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Area of Science:

  • Neurology
  • Biomarkers
  • Clinical Trials

Background:

  • Early identification of Alzheimer disease (AD) is crucial for management and therapeutic trials.
  • This study prospectively enriched a trial population with prodromal AD (PDAD) using cerebrospinal fluid (CSF) biomarkers and mild cognitive impairment (MCI) criteria.

Purpose of the Study:

  • To evaluate the safety of the γ-secretase inhibitor avagacestat in PDAD patients.
  • To determine if CSF biomarkers can identify PDAD before dementia diagnosis.

Main Methods:

  • A randomized, placebo-controlled phase 2 trial with a nonrandomized observational cohort.
  • Screened 1358 outpatients; 263 met MCI and CSF biomarker criteria for randomization.
  • 102 MCI, CSF biomarker-negative participants formed an observational cohort.

Main Results:

  • Avagacestat was relatively well tolerated at 50 mg/d, but higher doses caused adverse events.
  • Increased nonmelanoma skin cancer and reversible renal effects were noted with avagacestat.
  • PDAD patients showed faster progression to dementia and greater brain atrophy than the observational cohort.

Conclusions:

  • Avagacestat lacked efficacy and presented dose-limiting adverse effects.
  • PDAD patients, regardless of treatment, progressed more rapidly than biomarker-negative individuals.
  • CSF biomarkers and amyloid PET imaging correlate well for identifying cerebral amyloidopathy.