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Given the acknowledged lack of success in Alzheimer’s disease (AD) drug development over the past two decades, the objective of this review was to derive key insights from the myriad failures to inform future drug development. A systematic and exhaustive review was performed on all failed AD compounds for dementia (interventional phase II and III clinical trials from ClinicalTrials.gov) from 2004 to the present. Starting with the initial ∼2,700 AD clinical trials, ∼550 trials met our initial criteria, from which 98 unique phase II and III compounds with various mechanisms of action met our criteria of a failed compound. The two recent reported phase III successes of aducanumab and oligomannate are very encouraging; however, we are awaiting real-world validation of their effectiveness. These two successes against the 98 failures gives a 2.0% phase II and III success rate since 2003, when the previous novel compound was approved. Potential contributing methodological factors for the clinical trial failures were categorized into 1) insufficient evidence to initiate the pivotal trials, and 2) pivotal trial design shortcomings. Our evaluation found that rational drug development principles were not always followed for AD therapeutics development, and the question remains whether some of the failed compounds may have shown efficacy if the principles were better adhered to. Several recommendations are made for future AD therapeutic development. The whole database of the 98 failed compounds is presented in the Supplementary Material.

In this chapter, we address portfolio optimization at a sub-portfolio level. Even a “mini” portfolio—such as a single molecule with numerous indication opportunities—can pose a significant challenge to an organization; there are many interdependencies, correlations, and synergies to consider, weigh, and trade off. Here we present a case study that considers the challenge of optimizing this sub-portfolio by determining the best sequence of three potential indications. The same methods can be applied to a molecule with even more indication opportunities, a group of related molecules, or an entire portfolio.

Animals prenatally exposed to ethanol typically exhibit hypothalamic-pituitary-adrenal (HPA) hyperresponsiveness to stressors. In contrast to previous studies that have investigated effects of prenatal ethanol exposure on HPA responses to acute or intermittent stressors, our study investigated HPA responses to a chronic continuous stressor, cold stress (4 degrees C for 0, 1, or 3 days). We tested the hypothesis that prenatal ethanol exposure would result in increased plasma corticosterone (CORT) and adrenocorticotropin (ACTH) responses and increased peptide [corticotropin-releasing factor and vasopressin] mRNA levels in the paraventricular nucleus (PVN) of the hypothalamus compared to that in control animals. In addition, CORT and ACTH responses were measured after exposure to an acute stressor (i.p. isotonic saline injection), superimposed during chronic cold exposure, to examine possible sensitization of the HPA response to the acute stress. Thus, blood samples were collected at the end of each of the three periods of cold exposure, either before (0 min) or 15 min after acute stress. The subjects were adult male and female Sprague-Dawley rat offspring from prenatal ethanol (E), pair-fed (PF), and ad libitum-fed control (C) treatment groups. Exposure to cold stress resulted in significant body weight loss in E males at 1 day and in both males and females of all prenatal treatment groups by 3 days of cold stress. Males in all prenatal groups also exhibited significant increases in adrenal weight:body weight ratios. Cold stress alone (0 min condition) increased CORT levels in E males and overall ACTH levels in E males and females compared to controls. ACTH levels were also higher overall in E compared to control males after acute stress (15 min condition). Sensitization of the CORT response to acute stress was observed in males but not females across all prenatal treatment groups. Corticotropin-releasing factor and vasopressin mRNA levels in the PVN were not significantly affected by prenatal treatment or chronic cold stress in either males or females. In contrast, both males and females displayed increases in PVN thyrotropin-releasing hormone (TRH) mRNA levels after cold stress. These data support and extend previous work demonstrating differential effects of prenatal ethanol exposure on HPA responsiveness of male and female offspring, and suggest that E males may be more vulnerable to the effects of chronic cold stress than E females.

Prenatal alcohol exposure has been shown to produce hyperresponsiveness of the hypothalamic-pituitary-adrenal (HPA) axis to immune challenges. Because cytokines, which are released in response to immune challenges, are known to activate the HPA axis, this study determined whether altered release of cytokines contribute to the HPA hyperresponsiveness to immune challenges observed after prenatal alcohol exposure. Pregnant dams were exposed to alcohol vapors (6-7 hr daily) between days 7 and 18 of gestation. At postnatal days 45 and 60, control (C) and prenatal alcohol-exposed (E) offspring were subjected to three different types of immune challenges: injections of interleukin-1beta or endotoxin (lipopolysaccharide), or turpentine-induced tissue injury. We observed the expected higher plasma adrenocorticotropic hormone and corticosterone levels in E compared with C rats, and this HPA hyperresponsiveness was greater in E females compared with E males. Plasma tumor necrosis factor-alpha or interleukin-6 responses were comparable in the C and E groups. Females exhibited significantly higher corticosterone, tumor necrosis factor-alpha, and interleukin-6 responses than males. These results indicate that (1) prenatal alcohol exposure produces HPA hyperresponsiveness to immune challenges; (2) prenatal alcohol treatment does not influence the release of cytokines to immune challenges; and (3) there are gender differences in the secretory pattern of corticosterone and cytokines to immune challenges. Therefore, these data do not support the hypothesis that cytokines play a role in the hyperresponsiveness of the HPA axis to immune challenges observed after prenatal alcohol exposure.

Prenatal ethanol exposure and stress have each been shown to have significant effects on the immune system. This study examined the possible interactive effects of prenatal ethanol exposure and exposure to stress later in life on the immune system. Differential vulnerability to these challenges in female and male offspring was assessed. At 5 to 6 months of age, female and male offspring from prenatal ethanol-exposed (E), pair-fed (PF), and ad libitum-fed control (C) conditions were exposed to 0, 1, or 3 days of cold (4°C). At the end of the cold period, the proliferative response of splenic lymphocytes to the mitogens concanavalin A (Con A) and pokeweed mitogen (PWM) was assessed. The data demonstrate a significant interactive effect between prenatal ethanol exposure and cold stress in female offspring. After 1 day of cold stress, E females had significantly increased PWM-induced lymphocyte proliferation compared with PF and C females, and significantly increased Con A-induced lymphocyte proliferation compared with PF females. There were no differences in PWM or Con A-induced lymphocyte proliferation among E, PF, and C females after 0 or 3 days of cold stress, nor among E, PF, and C males on any test day. Regardless of prenatal treatment, females exposed to 1 or 3 days of cold had significantly greater basal plasma corticosterone levels than females not exposed to cold. In contrast, only E males exposed to 1 or 3 days of cold had significantly increased basal plasma corticosterone levels, compared with E males not exposed to cold; PF and C males showed no significant change in basal corticosterone after cold stress. These data demonstrate that, in response to the challenge of cold stress, changes in lymphocyte proliferation to PWM and Con A may occur selectively in E females. Moreover, the interactive effects of prenatal ethanol and cold stress may result in enhanced rather than suppressed immune responsiveness.

We assessed the effect of an ascending-dose regimen on the development of tolerance to the anticonvulsant and ataxic effects of pentobarbital in four groups of amygdala-kindled rats. Each rat received 20 bidaily (one every 48 h) trials in which an intraperitoneal (IP) pentobarbital or vehicle injection was delivered l h before a convulsive amygdala stimulation. On each trial, the rats in the three pentobarbital groups received either a high dose (50 mg/kg), a low dose (10mg/kg), or ascending doses of pentobarbital that began at 10 mg/kg and increased to as high as 26 mg/kg by 1 mg/kg increments as tolerance developed to its anticonvulsant effect; the rats in the vehicle group received saline. The rats in the ascending-dose condition displayed significantly more tolerance to the anticonvulsant effect of pentobarbital than did the other rats; in contrast, the high-dose rats displayed more tolerance to the ataxic effect of pentobarbital than did the other rats. These findings extend previous reports of the facilitatory effect of ascending-dose regimens on the development of tolerance to the anticonvulsant effect of benzodiazepines, and show that the facilitatory effect of ascending-dose regimens does not extend to all drug effects.

The effects of early handling on physiological and hormonal responses of rats exposed to ethanol prenatally were studied. Male and female Sprague-Dawley rats from prenatal ethanol (E), pair-fed (PF), and ad lib-fed control (C) prenatal treatment groups were either handled (H) or nonhandled (NH) during the preweaning period and tested in adulthood. Early handling eliminated the deficit in preweaning weight gain observed in E compared to PF and C offspring. In adulthood, early handling eliminated the increased hypothermia observed in E and PF compared to C males following an ethanol challenge (2.0 g/kg, IP). In addition, H males displayed marginally less hypothermia overall than NH males. In contrast, handling accelerated the return to preinjection temperature in PF and C females but had no effect on E females. There were no significant differences among E, PF, and C rats in corticosterone (CORT) responses to ethanol challenge (1.5 g/kg, IP), but both males (marginally) and females in the H condition displayed higher CORT levels overall than NH rats. Early handling also eliminated the increased peak CORT response to restraint stress in E compared to C females, but did not affect the more prolonged elevation of CORT in E compared to PF and C females. There were no differences among E., PF, and C females in hippocampal type I and type II glucocorticoid receptor density or affinity. However, binding affinity of type II receptors was slightly but significantly increased in H compared to NH females. Together, these data indicate that early handling may modulate or attenuate some, but not all, of the adverse effects of fetal ethanol exposure on offspring growth and physiological responsiveness.

The effect of convulsive stimulation during periods of drug exposure on the development of tolerance to the anticonvulsant effects of carbamazepine (CBZ), diazepam (DZP), or sodium valproate (VPA) was studied in three similar experiments. In each experiment, amygdala-kindled rats were assigned to one of three groups: one group received a drug injection (CBZ, 70 mg/kg, IP; DZP, 2 mg/kg, IP; VPA, 250 mg/kg, gavage) 1 h before each of a series of 10 bidaily (one every 48 h) convulsive stimulations, a second group received the same dose of the drug 1 h after each of the 10 stimulations, and a third group served as a vehicle control. The drug tolerance test occurred in each experiment 48 h after the 10th tolerance-development trial; every rat received the appropriate dose of CBZ, DZP, or VPA 1 h before being stimulated. In each experiment, only the rats from the drug-before-stimulation group displayed a significant amount of tolerance to the drug's anticonvulsant effect. Thus the development of tolerance to the anticonvulsant effects of CBZ, DZP, and VPA was not an inevitable consequence of drug exposure; the development of tolerance was contingent upon the occurrence of convulsive stimulation during the periods of drug exposure. These results support the idea that functional drug tolerance is an adaptation to a drug's effects on ongoing patterns of neural activity, rather than to drug exposure per se.

We tested the hypothesis that nitric oxide and carbon monoxide, which are produced in the brain by nitric oxide synthase (NOS) and heme oxygenase (HO), modulate the hypothalamic-pituitary-adrenal response to physico-emotional stressors by acting at the hypothalamus. Accordingly, we determined 1) whether the intracerebroventricular (icv) injection of NOS or HO inhibitors at doses that were confined to the brain attenuated electroshock-induced ACTH release; and 2) whether the decreases in this ACTH response were concurrent with decreases in NOS or HO activity levels at the hypothalamus. Icv injection of the NOS inhibitor Nω-nitro-l-arginine-methylester (L-NAME; 50 μg) or the HO inhibitor tin protoporphyrin (SnPP; 20–25μ g) significantly blunted the plasma ACTH response to a 45-min session of intermittent electroshocks. Importantly, in these same animals there were concurrent decreases in hypothalamic NOS or HO activities, respectively. There were little or no effects of these inhibitors on anterior pituitary NOS or HO activities, indicating that there was only minimal leakage of the drug from the brain after icv administration. The specificity of action of these inhibitors was confirmed by the fact that SnPP did not affect NOS activity, and L-NAME did not affect HO activity. Finally, L-NAME produced no effect, whereas SnPP produced only transient increases in blood pressure, suggesting that these inhibitors do not affect activity indirectly through alterations in blood pressure. These data support the hypothesis that in the whole animal, both NO and CO exert a stimulatory influence on the acute ACTH response to physico-emotional stressors, and that the hypothalamus is the critical site of their actions.

We investigated the effect of the intracerebroventricular injection of the nitric oxide (NO) donor 3-morpholino-sydnonimine (SIN-1) on the release of adrenocorticotropin hormone (ACTH) and the neuronal response of hypothalamic neurons responsible for this release. Rats that were administered SIN-1 showed significant elevations in plasma ACTH levels, a response that was virtually abolished by antibodies against corticotropin-releasing factor (CRF) and significantly blunted by vasopressin (VP) antiserum. SIN-1 also upregulated heteronuclear (hn) transcripts for CRF and VP and messenger RNA (mRNA) levels for the immediate early gene NGFI-B and for CRF receptor type 1 (CRF-R(1)) in the parvocellular portion of the paraventricular nucleus (PVN) of the hypothalamus. Blockade of prostaglandin synthesis with ibuprofen did not alter the ACTH or the PVN response to SIN-1. The central nucleus of the amygdala and the supraoptic nucleus, regions that are involved in autonomic adjustments to altered cardiovascular activity, also responded to SIN-1 with elevated NGFI-B mRNA levels. However, the only change in mean arterial blood pressure caused by this NO donor was a transient and modest increase. To our knowledge, this is the first demonstration that in the intact rat NO stimulates the activity of PVN neurons that control the hypothalamic-pituitary-adrenal axis. It must be noted, however, that our results do not allow us to determine whether this effect was direct or mediated through PVN afferents. This study should help resolve the controversy generated by the use of isolated brain tissues to investigate the net effect of NO on hypothalamic peptide production.

We determined whether the gas carbon monoxide (CO) altered the adrenocorticotropin hormone (ACTH) response to mild inescapable electrofootshocks, and whether it interacted with nitric oxide (NO). Peripheral injection of the NO synthase (NOS) inhibitor Nwnitro-L-arginine-methylester (L-NAME), a compound which readily crosses the blood-brain barrier, produced the expected blunting of the ACTH response to the shocks. This effect was mimicked by other arginine analogues such as L-nitroarginine (L-NNA) and NG-methyl-L-arginine (NMMA). The subcutaneous (s.c.) administration of the heme oxygenase (HO) blockers tin mesoporphyrin (SnMP) or tin protoporphyrin (SnPP) significantly decreased brain HO levels, indicating that both compounds had penetrated the brain. Blood pressure showed a modest increase in response to SnMP, and no change after SnPP. SnMP and SnPP both decreased shock-induced ACTH release, though the magnitude of this effect was slightly less than that of L-NAME. The influence of SnPP was further augmented in rats with concomitant blockade of NO formation, which suggests that both NO and CO are necessary for the full response of this axis to electrofootshocks. Finally, the ability of SnPP to significantly blunt the expression of the mRNA for the immediate early gene NGFI-B in the paraventricular nucleus (PVN) of rats exposed to shocks, indicates that the influence of CO was exerted on hypothalamic neuronal activity. Collectively, our results show that NO and CO exert a stimulatory effect on the HPA axis response to mild electrofootshocks, and that at least part of this influence takes place on hypothalamic neurons and/or their afferents.

The kindled-convulsion model of epilepsy was used to study contingent tolerance to ethanol's (1.5 g/kg; IP) anticonvulsant, hypothermic, and ataxic effects in adult male rats. In the present experiments, three groups of amygdala-kindled rats received a series of bidaily (one every 48 h) convulsive stimulations: one group received ethanol 1 h before each stimulation; one group received ethanol 1 h after each stimulation; and another group served as the saline control. Tolerance to ethanol's anticonvulsant effect (Experiments 1 and 2) was greatest in those rats that received ethanol before each convulsive stimulation; whereas, tolerance to ethanol's hypothermic (Experiments 1 and 2) and ataxic (Experiments 2) effects developed in both groups that received ethanol. These results were predicted on the basis of the drug-effect theory of drug tolerance: the theory that functional drug tolerance is an adaptation to the disruptive effects of drugs on concurrent patterns of neural activity, not to drug exposure per se.

The present experiments assessed the effects of prenatal ethanol exposure on the susceptibility to convulsions and on the anticonvulsant effect of ethanol using the electrical kindling model of epilepsy in rats. Adult male Sprague-Dawley rats from prenatal ethanol (E), pair-fed (PF), and ad libitum-fed control (C) treatment groups were tested following the implantation of a stimulation electrode in the left amygdala complex. The same rate viete tested in tout consecutive experiments. Both E and PF rats showed a slightly slower rate of kindling than C rats, as measured by convulsion class but not as measured by forelimb clonus duration (experiment 1). However, the groups did not differ significantly in the electrical stimulation threshold for kindled convulsions (experiment 2). Furthermore, prenatal ethanol exposure had no significant effect on the dose-response curve for ethanol's (0, 0.9, 1.1, 1.3, and 1.5 g/kg, ip) anticonvulsant effect (experiment 3), or on the rate of tolerance development to ethanol's (1.5 g/kg, ip) anticonvulsant effect (experiment 4) on kindled convulsions. Thus, prenatal exposure to ethanol does not appear to have long-term effects on the susceptibility to convulsions or on the anticonvulsant effect of ethanol in adult male rats in the kindling model as used in the present experiments.

In Experiment 1, two groups of kindled rats received a pentobarbital injection (15 mg/kg, IP) and a convulsive amygdala stimulation once every 48 h. In one group, pentobarbital was injected 1 h before each stimulation; in the other, it was injected 1 h after each stimulation. Only the rats that received pentobarbital before each stimulation became tolerant to pentobarbital's anticonvulsant effect. Cross tolerance to the anti-convulsant effect of ethanol (1.5 g/kg, IP) was also found to be greater in the pentobarbital-before-stimulation rats. Experiment 2 was designed to assess the transfer of tolerance in the opposite direction, that is, from ethanol to pentobarbital, and the results mirrored those of Experiment 1: convulsive stimulation during the periods of ethanol exposure facilitated the development of tolerance to the anticonvulsant effect of ethanol and its transfer to pentobarbital. These results support the theory that functional drug tolerance and cross tolerance are adaptations to the effects of drugs on concurrent patterns of neural activity rather than to drug exposure per se.

The kindled-convulsion model was used to assess the development of tolerance and cross tolerance to the anticonvulsant effects of antiepileptic drugs. In Experiment 1, tolerance developed to the anticonvulsant effects of bidaily (one every 48 h) IP injections of phenobarbital, trimethadione, and clonazepam on convulsions elicited 1 h after each injection in kindled rats by amygdala stimulation. In Experiment 2, kindled rats that were tolerant to the anticonvulsant effects of phenobarbital, trimethadione, or clonazepam received bidaily IP injections of carbamazepine, each followed 1 h later by a convulsive amygdala stimulation. There was a statistically significant transfer of tolerance from phenobarbital to carbamazepine, but not from either trimethadione or clonazepam to carbamazepine. Apparently, tolerance to anticonvulsant drugs is most likely to transfer between drugs that are effective against similar kinds of clinical and experimental seizures and have similar putative mechanisms of action.

We assessed the development of tolerance to the anticonvulsant effects of carbamazepine (CBZ), diazepam (DZP), and sodium valproate (VPA) on convulsions elicited by amygdala stimulation in kindled rats in three similar experiments. In each experiment, amygdala-kindled rats were assigned to a drug group or to a corresponding vehicle control group. The rats in the three drug groups received a total of 10 bidaily (one every 48 h) IP injections of CBZ (70 mg/kg), DZP (2 mg/kg) or VPA (250 mg/kg) at a dose that initially blocked the forelimb clonus elicited by an amygdala stimulation (400 microA, 60 Hz, 1 s) administered 1 h after the injection. The rats in the three vehicle control groups were similarly treated except that they received injections of the saline vehicle. The drug tolerance test occurred 48 h after the final tolerance-development trial; the rats from each drug group and the corresponding vehicle control group received an injection of the appropriate drug followed 1 h later by the administration of a convulsive stimulation. The drug tolerance test revealed almost total tolerance in each of the three drug groups but no tolerance in any of the three vehicle control groups. Such large tolerance effects are inconsistent with the less dramatic effects reported in previous studies; possible reasons for this inconsistency were considered.

At the Kindling 3 Conference in 1985, we reported that the development of tolerance to ethanol’s anticonvulsant effect on kindled convulsions elicited in rats by amygdalar stimulation is greatly influenced by the temporal relation between the administration of ethanol and the convulsive stimulation (18). We reported that substantial tolerance developed to ethanol’s anticonvulsant effect if the kindled rats were stimulated following each of five bidaily (once every 48 hr) intraperitoneal ethanol injections, but not if they were stimulated before each injection (see also 16). The fact that both groups of rats received the same exposure to ethanol and the same number of stimulations suggested that the critical factor in the development of the tolerance was the administration of convulsive stimulation during the periods of ethanol exposure. On the basis of this and similar observations (e.g, 13;17;20), we have proposed a theory of tolerance that emphasizes the idea that functional drug tolerance is a reaction to the expression of a drug’s effect rather than to the mere presence of the drug in the system (19). Although a drug’s effects are often an inevitable consequence of drug exposure, in some instances they may not be fully expressed unless the nervous system (or other target tissue) is involved in a specific pattern of neural activity during periods of drug exposure (cf., 4).

Tolerance to the anticonvulsant effect of pentobarbital (15 mg/kg, i.p.) was developed in amygdala-kindled rats; it was found to be contingent upon the rats' receiving convulsive stimu­ lations during the bidaily (once every 48 h) periods of pentobarbital exposure (Experiment IB; contingent tolerance). Furthermore, the subjects that received convulsive stimulations while un­ der the influence of the bidaily pentobarbital injections subsequently displayed a greater degree of cross-tolerance to the anticonvulsant effect of 1.5 g/kg of ethanol than those that had received the drug after the stimulations (Experiment 2; contingent cross-tolerance). Finally, contingent tolerance to the anticonvulsant effect of ethanol was maintained when kindled rats received con­ vulsive stimulations during, but not before, bidaily periods of pentobarbital exposure (Experi­ ment 3; contingent cross maintenance of tolerance). These results suggest that the repeated manifestation of particular drug effects-anticonvulsant effects in this case-play an important role in the development of some forms of drug tolerance and in their transfer to other drugs.