Rebounds leave basketball fans on the edge of their seats. They can also leave drug developers with bated breath—rebounds of the Aβ kind, that is. Research shows that withdrawal of γ-secretase inhibitors (GSIs) unleashes a sudden spike in Aβ production, at least outside of the central nervous system. What happens inside the brain is not clear, though extensive Aβ rebound could spell trouble for Alzheimer disease (AD) therapy. Now, new data from non-human primates suggest that may not be such a concern. “I think we’ve very clearly shown that the CNS does not have that same rebound effect at all,” said Randall Bateman, Washington University, St. Louis, Missouri, who led the study. “The reason appears to be that there is some alternative metabolic processing of APP before it can be converted to Aβ,” he added. The results, which appeared May 12 in the Journal of Neuroscience, strengthen the case for using γ-secretase as a therapeutic target in AD, suggest the researchers.

Aβ rebounds in the plasma in both humans and animal AD models when administration of GSIs is stopped (see, e.g., Siemers et al., 2006; Lanz et al., 2006; ARF related news story). In fact, you can end up with more Aβ than if you never gave the inhibitor to begin with, noted Bateman. That would obviously be a concern if it happened in the brain. “The other concern is that a rapid change in concentration, especially a spike, may, on theoretical grounds anyway, increase the likelihood of Aβ to fibrillize and seed,” he said.

Bateman, together with joint first authors Jacquelynn Cook from Merck Research Laboratories, West Point, Pennsylvania, and Kristin Wildsmith from WashU, used a rhesus monkey model to test for rebound in cerebrospinal fluid (CSF). In this model, the fluid is sampled through a port and catheter permanently inserted into the cisterna magna at the base of the brain. This allows the researchers to study a single animal longitudinally with repeat sampling, without the need for multiple lumbar punctures, as would be done in humans.

Following an intravenous pulse of carbon-13-labeled leucine, Cook and colleagues found that brain Aβ synthesis and clearance were not significantly different. Analyzing for the γ-secretase inhibitor MK-0752, they found that after giving it orally (at either 60 or 240 mg/Kg), the drug rapidly appeared in the plasma and CSF and then slowly dissipated, being totally cleared from both fluids by 36 hours. During the initial few hours, plasma Aβ levels fell, but by 27 hours rose to baseline levels in three monkeys given the lowest dose, and continued to rebound slightly higher than baseline over the next two days. The rebound in three other animals given the high dose of MK-0752 took longer but was greater, reaching 150 percent of baseline levels and remaining there for at least seven more days. There was no such rebound in the CSF.

The lowest dose of the GSI substantially blocked Aβ production in the brain, and the highest dose almost completely blocked it, such that within 18 hours, CSF Aβ was halved and almost fully eliminated, respectively. Though the levels eventually crept back up to baseline, they never rose higher.

This acute study suggests that Aβ rebound does not occur in the CSF in rhesus monkeys, and by extrapolation might not in humans, who have similar Aβ synthesis and clearance rates in the brain. What happens after withdrawal of chronically administered drug is not clear, said Bateman. Because of time and cost restraints, he does not plan to investigate this. But he suggested that chronic withdrawal may, in fact, closely mimic reality. “If the concentration of the drug falls below the EC50 before you take the next dose, effectively you are withdrawing every day,” he said. And since GSIs, unless they spare Notch, have known and serious side effects, you don’t want round-the-clock inhibition, said Bateman.

The lack of rebound indicates that APP fragments are not accumulating in the brain when γ-secretase is blocked. That, in turn, suggests the precursor protein is being metabolized by some other pathway. Strong evidence has emerged from in-vitro studies, animal models, and from analysis of human CSF that α-secretase may take up the slack. Researchers led by Erik Portelius and Kaj Blennow at the University of Gothenburg, Sweden, identified small Aβ fragments (Aβ1-14, 1-15, and 1-16) in the CSF of patients enrolled in Ely Lilly’s Phase 2 GSI trial (see ARF related news story). These fragments are consistent with β- followed by α- rather than γ-secretase cleavage of APP. Now Bateman and colleagues report a similar finding, with a two- to threefold jump in synthesis of Aβ1-14, Aβ1-15, and Aβ1-16 in the brain within a few hours of giving MK-0752 to the monkeys. “This is exactly what we saw in humans treated with a GSI,” wrote Blennow’s colleague Henrik Zetterberg, University of Gothenberg, in an e-mail to ARF (see full comment below). In contrast, CSF Aβ1-17, a likely cleavage product of Aβ42, drops in parallel with the latter.

The results suggest that some GSIs, if given at just the right dose, not only block production of Aβ42, but also divert APP processing toward non-amyloidogenic pathways. Slam-dunk for GSI development—eventually?—Tom Fagan


  1. This is exactly what we saw in humans treated with GSI as reported in our recent Alzheimer's Research & Therapy paper (Portelius et al., 2010). Similar results have also been seen in cell lines (Portelius et al., 2009), mice (Portelius et al., 2009), and dogs (Portelius et al., Journal of Alzheimer's Disease, 2010, in press) treated with GSIs. The results speak strongly for a third APP processing pathway involving concerted β- and α-cleavages on the same APP molecule, and that this pathway is upregulated in response to γ-secretase inhibition. When seeing the increases in Aβ1-14, 1-15, and 1-16, it may be comforting to remember that these molecules do not appear to be synaptotoxic (Portelius et al., 2010).


    . A novel Abeta isoform pattern in CSF reflects gamma-secretase inhibition in Alzheimer disease. Alzheimers Res Ther. 2010;2(2):7. PubMed.

    . A novel pathway for amyloid precursor protein processing. Neurobiol Aging. 2011 Jun;32(6):1090-8. PubMed.

    . Effects of gamma-secretase inhibition on the amyloid beta isoform pattern in a mouse model of Alzheimer's disease. Neurodegener Dis. 2009;6(5-6):258-62. PubMed.

    . Distinct cerebrospinal fluid amyloid beta peptide signatures in sporadic and PSEN1 A431E-associated familial Alzheimer's disease. Mol Neurodegener. 2010;5:2. PubMed.

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News Citations

  1. DC: New γ Secretase Inhibitors Hit APP, Spare Notch
  2. Sweet 16: Novel APP Processing Pathway and a New Biomarker?

Paper Citations

  1. . Effects of a gamma-secretase inhibitor in a randomized study of patients with Alzheimer disease. Neurology. 2006 Feb 28;66(4):602-4. PubMed.
  2. . Concentration-dependent modulation of amyloid-beta in vivo and in vitro using the gamma-secretase inhibitor, LY-450139. J Pharmacol Exp Ther. 2006 Nov;319(2):924-33. PubMed.

Further Reading

Primary Papers

  1. . Acute gamma-secretase inhibition of nonhuman primate CNS shifts amyloid precursor protein (APP) metabolism from amyloid-beta production to alternative APP fragments without amyloid-beta rebound. J Neurosci. 2010 May 12;30(19):6743-50. PubMed.