Pre-clinical and clinical data suggest that the development of a safe and effective anti-amyloid-beta (Aβ) immunotherapy for Alzheimers disease (AD) will require therapeutic levels of anti-Aβ antibodies, while avoiding proinflammatory adjuvants and autoreactive T cells which may increase the incidence of adverse events in the elderly population targeted to receive immunotherapy. The first active immunization clinical trial with AN1792 in AD patients was halted when a subset of patients developed aseptic meningoencephalitis. The first passive immunotherapy trial with bapineuzumab, a humanized monoclonal antibody against the end terminus of Aβ, also encountered some dose-dependent adverse events during the Phase II portion of the study, vasogenic edema in 12 cases, which were significantly over represented in ApoE4 carriers. The proposed remedy is to treat future patients with lower doses, particularly in the ApoE4 carriers. Currently there are at least five ongoing anti-Aβ immunotherapy clinical trials. Three of the clinical trials use humanized monoclonal antibodies, which are expensive and require repeated dosing to maintain therapeutic levels of the antibodies in the patient. However, in the event of an adverse response to the passive therapy antibody delivery can simply be halted, which may provide a resolution to the problem. Because at this point we cannot readily identify individuals in the preclinical or prodromal stages of AD pathogenesis, passive immunotherapy is reserved for those that already have clinical symptoms. Unfortunately those individuals have by that point accumulated substantial neuropathology in affected regions of the brain. Moreover, if Aβ pathology drives tau pathology as reported in several transgenic animal models, and once established if tau pathology can become self propagating, then early intervention with anti-Aβ immunotherapy may be critical for favorable clinical outcomes. On the other hand, active immunization has several significant advantages, including lower cost and the typical immunization protocol should be much less intrusive to the patient relative to passive therapy. However in the advent of Aβ-antibody immune complex-induced adverse events the patients will have to receive immuno-suppressive therapy for an extended period until the anti-Aβ antibody levels drop naturally as the effect of the vaccine decays over time. Obviously, improvements in vaccine design are needed to improve both the safety, as well as the efficacy of anti-Aβ immunotherapy. The focus of this review is on the advantages of DNA vaccination for anti-Aβ immunotherapy, and the major hurdles, such as immunosenescence, selection of appropriate molecular adjuvants, universal T cell epitopes, and possibly a polyepitope design based on utilizing existing memory T cells in the general population that were generated in response to childhood or seasonal vaccines, as well as various infections. Ultimately, we believe that the further refinement of our AD DNA epitope vaccines, possibly combined with a prime boost regime will facilitate translation to human clinical trials in either very early AD, or preferably in preclinical stage individuals identified by validated AD biomarkers.
Immunotherapy, AN1792, polysorbate-80, bapineuzumab, immuno-conjugate, immunosenescence, thymic involution, PADRE, molecular adjuvant, macrophage-derived chemokine
ADRC Neuropathology Core, Department of Neurology, Institute for Memory Impairments and Neurological Disorders, 1111 Gillespie NRF, University of California, Irvine, CA 92697-4540, USA.