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andrew west labAndrew WestFor more than five years, urine and cerebral-spinal fluid samples from patients with Parkinson’s disease have been locked in freezers in the NINDS National Repository, stored with the expectation they might someday help unravel the still-hidden course of this slow-acting neurodegenerative disease.

Now, research by Andrew West, Ph.D., and colleagues at the University of Alabama at Birmingham has revealed that the tubes hold a brand-new type of biomarker — a phosphorylated protein that correlates with the presence and severity of Parkinson’s disease. West and colleagues, with support from the National Institutes of Health, the Michael J. Fox Foundation for Parkinson’s Disease Research and the Parkinson’s Disease Foundation, are digging deeper into these biobanked samples, to validate the biomarker as a possible guide for future clinical treatments and a monitor of the efficacy of potential new Parkinson’s drugs in real time during treatment.

“Nobody thought we’d be able to measure the activity of this huge protein called LRRK2 (pronounced lark two) in biofluids since it is usually found inside neurons in the brain,” said West, co-director of the Center for Neurodegeneration and Experimental Therapeutics, and the John A. and Ruth R. Jurenko Professor of Neurology at UAB. “New biochemical markers like the one we’ve discovered together with new neuroimaging approaches are going to be the key to successfully stopping Parkinson’s disease in its tracks. I think the days of blindly testing new therapies for complex diseases like Parkinson’s without having active feedback both for ‘on-target’ drug effects and for effectiveness in patients are thankfully coming to an end.”

A biomarker helps physicians predict, diagnose or monitor disease, because the biomarker corresponds to the presence or risk of disease, and its levels may change as the disease progresses. Validated biomarkers can aid both preclinical trial work in the laboratory and future clinical trials of drugs to treat Parkinson’s. West and others are paving the way for an inhibitor drug that prevented neuroinflammation and neurodegeneration in an animal model of the disease, as reported last year by West and colleagues.

The new biomarker findings were published in Neurology in March and Movement Disorders in June. The biomarker, LRRK2, has been shown to play a role in hereditary Parkinson’s, and the most common of these mutations — called G2019S — causes the LRRK2 kinase to add too many phosphates to itself and other proteins. Why this leads to Parkinson’s disease is not yet clear.

The key to West’s biomarker approach was the recognition that LRRK2 can be purified from a new type of vesicle called exosomes found in all human biofluids, like urine and saliva. Cells in the body continually release exosomes that contain a mixture of proteins, RNA and DNA derived from different kinds of cells. West and colleagues were able to purify exosomes from 3- or 4-ounce urine samples donated by patients, and then measure phosphorylated LRRK2 in those exosomes.

The findings

In the Neurology study, they found that elevated phosphorylated LRRK2 predicted the risk for onset of Parkinson’s disease for people carrying a mutation in LRRK2, which is about 2-3 percent of all Parkinson’s disease patients. These findings were first tested with a preliminary, 14-person cohort of urine samples from the Columbia University Movement Disorders Center. That was followed by a larger replication study of 72 biobanked urine samples from the Michael J. Fox Foundation LRRK2 Cohort Consortium. All samples were provided to UAB in a blinded fashion to ensure the approach was rigorous.

“New biochemical markers like the one we’ve discovered together with new neuroimaging approaches are going to be the key to successfully stopping Parkinson’s disease in its tracks.”

—Andrew West

The follow-up Movement Disorders paper — the first study of its type — expanded the scope to people without LRRK2 mutations, which is most Parkinson’s disease patients. Using 158 urine samples from Parkinson’s disease patients and healthy controls enrolled in the UAB Movement Disorder Clinic as part of the NIH Parkinson’s Disease Biomarker Program, West and colleagues found that approximately 20 percent of people without LRRK2 mutations but with Parkinson’s disease also showed highly elevated phosphorylated LRRK2 similar to people with LRRK2 mutations, and this was not present in healthy controls. The study speculates that people with elevated phosphorylated LRRK2 may be particularly good candidates for future drugs that reduce phosphorylated LRRK2.

Next steps

Questions remain for this evidence of biochemical changes in LRRK2 in idiopathic Parkinson’s disease. One is finding out where the urinary exosomes come from. Given a suspected role for inflammation in Parkinson’s disease, it is interesting that LRRK2 is highly expressed in cells of the innate immune system. A possible explanation for the phosphorylated LRRK2 in patients with more severe disease may be an increased inflammation in those patients who have aggressive progression of disease.

In May, West was awarded a new U01 collaborative grant from the National Institute of Neurological Disorders and Stroke to further explore urinary exosomes and extend the observations to cerebral-spinal fluid as a marker for disease prediction and prognosis.

Besides West, authors of the Neurology paper, “Urinary LRRK2 phosphorylation predicts parkinsonian phenotypes in G2019S LRRK2 carriers,” are Kyle B. Fraser and Mark S. Moehle, of the Center for Neurodegeneration and Experimental Therapeutics and Department of Neurology, UAB School of Medicine; and Roy N. Alcalay, M.D., Columbia University Department of Neurology.

Besides West, authors of the Movement Disorders paper, “Ser(P)-1292 LRRK2 in urinary exosomes is elevated in idiopathic Parkinson’s disease,” are Fraser, Ashlee B. Rawlins, Rachel G. Clark and David G. Standaert, M.D., Ph.D., of the UAB Center for Neurodegeneration and Experimental Therapeutics and Department of Neurology; Alcalay; and Nianjun Liu, Ph.D., Department of Biostatistics, UAB School of Public Health.

Standaert is the John N. Whitaker Professor and chair of the Department of Neurology at UAB.

The MJFF LRRK2 Cohort Consortium provided samples and is coordinated and funded in part by the Michael J. Fox Foundation for Parkinson’s Disease Research. The Parkinson’s Disease Foundation supported the collection of samples from Columbia University. Financial support for the study was provided by National Institutes of Health grants U18 NS082132, R01 NS064934, F31 NS081963, K02 NS0915 and T32 GM008111.

cynthia brownCynthia BrownTwo members of the School of Medicine faculty have been selected as fellows for the Hedwig van Ameringen Executive Leadership in Academic Medicine® for 2016-2017. Cynthia J. Brown, M.D., MSPH, and Nita A. Limdi, PharmD, MSPH, Ph.D., both met the extensive requirements to be accepted into this elite program – two of only 54 members accepted nationwide.

ELAM is a year-long, part-time fellowship for women faculty in schools of medicine, dentistry and public health. The 2016-2017 class will be the 22nd incoming class for ELAM, which remains the only program in North America committed to preparing women for senior leadership roles in academic health science institutions.

Brown, who serves as the director of UAB’s Division of Gerontology, Geriatrics and Palliative Care and the UAB Comprehensive Center for Healthy Aging, completed her medical degree at the University of North Carolina at Chapel Hill. She served her internship and residency in the Primary Care Internal Medicine Program at Yale University School of Medicine, where she also completed a fellowship in geriatrics and clinical epidemiology. She obtained a Master’s of Science in Public Health at UAB in 2006. Limdi, who followed her PharmD from Samford with a MSPH in Clinical Research in 2005 and a doctorate in Epidemiology in 2007 (both from UAB), is a professor of Neurology and interim director of the UAB Hugh Kaul Personalized Medicine Institute.

While already boasting professional credential rich in leadership, both saw ELAM as a means to further their professional development and cultivate new avenues for growth.

“As a relatively new division director, I recognize that I have much to learn about being a leader,” Brown said. “When I took the job as division director, I shared with my chair that being recommended for this prestigious program was on my personal wish list. The program is rich with opportunities.”

Nita LimdiNita LimdiLimdi’s sentiments are similar. “I believe that participating in the ELAM experience will shape my professional goals and give me the tools, confidence and support to achieve them,” she said. “I am a chronic student. I always say, ‘What’s next? What can I do better?’ My goals are to further advance in research and implementation, teaching and mentorship – but also to inform policy. You can’t just stay in your lab, or people who know less than you will be the ones forming policy.”

Limdi explains that she looks forward to enhancing her leadership skills. “As scientists, we tend to stay focused on the science. But we need to develop this new facet to our skills in order to get people and organizations to understand our research and see its value. It’s about how to build and challenge teams to be transformative.”

The one-year fellowship will finish in April 2017 and include online assignments, community-building activities, and three week-long in-residence sessions.  Brown and Limdi join other notable ELAM participants from UAB, including last year’s participants Robin G. Lorenz, M.D., Ph.D., assistant dean for Physician-Scientist Education and Mary T. Hawn, M.D., who is now chair of surgery at Stanford. Beyond UAB, roughly 1,000 ELAM alumnae fill leadership roles in institutions across the globe, including women who hold positions as department chairs, research center directors, deans, college presidents and chief executives in health care and accrediting organizations.

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By Jeff Hansen
UAB Media Relations



   Results show that JAK/STAT pathway inhibitors may be a new class of therapeutic treatments for patients with Parkinson’s disease. Acting by reducing inflammation, they prevent neurodegeneration in animal models and may be an important new approach to slow progression of the disease.

news etty benvenisteEtty “Tika” Benveniste

University of Alabama at Birmingham researchers report the first documentation that suppressing a key cell-signaling pathway in a rat model of Parkinson’s disease reduces pathogenesis. Oral administration of AZD1480 — one of the JAK/STAT pathway inhibitors generally known as Jakinibs — lessened the destructive inflammation and nerve cell degradation in the area of the brain affected by Parkinson’s.

At present, there are no therapies available to patients to prevent progression of Parkinson’s disease, the chronic neurodegenerative movement disorder marked by profound loss of dopamine-producing neurons in the brain.

“We believe Jakinibs may become a viable therapeutic option for Parkinson’s disease patients,” said Etty “Tika” Benveniste, Ph.D., professor in the Department of Cell, Developmental and Integrative Biology and lead author of a paper published May 4 in The Journal of Neuroscience. “They are already being studied for other conditions, are orally bioavailable, seem to be well-tolerated, and do not promote troublesome immunosuppression. Furthermore, there may also be other ways of targeting the JAK/STAT pathway as a neuroprotective therapy for neurodegenerative disease.”

A variety of Jakinibs are in Phase I, II or III clinical trials for several other diseases. The current UAB study, funded by the Michael J. Fox Foundation for Parkinson Research and the National Institutes of Health, is the first to show that disrupting the JAK/STAT pathway prevents the neuroinflammation and neurodegradation specific to Parkinson’s disease.

“This is a very important advance,” said David Standaert, M.D., Ph.D., professor and chair of the UAB Department of Neurology and a collaborator on the project. “It shows that anti-inflammatory strategies have real potential. The next steps will be to validate some of the inflammatory changes seen in the animals in patients with Parkinson’s disease, which in turn will enable planning of clinical studies of anti-inflammatory therapies in patients with Parkinson’s.”

“This is a very important advance. It shows that anti-inflammatory strategies have real potential. The next steps will be to validate some of the inflammatory changes seen in the animals in patients with Parkinson’s disease, which in turn will enable planning of clinical studies of anti-inflammatory therapies in patients with Parkinson’s.” — David Standaert, M.D., Ph.D.

Benveniste and Standaert are part of an interdisciplinary UAB team focusing on neuroinflammatory mechanisms in Parkinson’s disease. The group — co-led by Benveniste, Standaert and Andrew West, Ph.D., associate professor of neurology — seeks to understand how the body’s immune system contributes to the pathology seen in the brains of Parkinson’s disease patients and to the development and progression of the disease. Only recently have researchers begun to suspect an important role for inflammation in the disease, and this is still largely uncharted territory.For the current paper, UAB researchers, led by Hongwei Qin, Ph.D., associate professor of cell, developmental and integrative biology, either challenged rat immune cells in vitro with aggregated human α-synuclein, or induced overexpression of α-synuclein carried by a virus vector in brains of rats. Untreated, this in vivo model leads to neuroinflammation in the brain and degradation of dopamine-producing neurons in the substantia nigra, the portion of the midbrain marked by cell death in Parkinson’s patients. Accumulation of α-synuclein in the brains of patients is a core feature of Parkinson’s disease, and this leads to the activation of the brain immune cells called microglia, the production of inflammatory signaling chemicals, and ultimately, neurodegradation.

In vitro and in vivo experiments showed AZD1480 inhibited JAK/STAT activation and downstream gene induction after a challenge by α-synuclein. The genes that are induced by α-synuclein, but not induced in the presence of α-synuclein and AZD1480, are associated with the proinflammatory phenotype. The inhibition by AZD1480 dampened both innate and adaptive immune responses.

Altogether, the researchers say, the results show the potential of Jakinibs to protect against the degradation of dopamine-producing neurons.

Details

For the in vivo neuroinflammation experiments, α-synuclein overexpression was induced, and two weeks later rats were given AZD1480 by oral gavage for 14 days. Then the researchers analyzed the inflammatory response in the substantia nigra of the midbrain for AZD1480-treated and -untreated animals. AZD1480 prevented the increased numbers of microglia and macrophages seen after α-synuclein overexpression. AZD1480 also prevented inflammatory activation of the microglia, as measured by Iba1-positive cells, and it prevented upregulation of genes for the proinflammatory markers TNF-α, iNOS, IL-6 and CCL2.

AZD1480 also prevented neurodegradation. For the in vivo neurodegradation experiments, α-synuclein overexpression was induced, and four weeks later — at the peak of neuroinflammation — rats were given a four-week treatment of AZD1480 oral gavage. At 12 weeks, the brains were analyzed for nigral neurons of the substantia nigra. Benveniste and colleagues found that overexpression of α-synuclein caused a 50 percent loss of nigral neurons at three months. But when the α-synuclein rats were also treated with AZD1480, that loss was prevented, and the numbers of nigral cells were similar to those of the controls.

In Parkinson’s disease, chronic inflammation in the brain makes the blood-brain barrier more permeable, allowing immune system T-cells to infiltrate into the brain from the bloodstream, potentially adding to neuroinflammation. In the rat model, α-synuclein overexpression increased the infiltration of CD4+ T-helper cells and induced activation of the STAT3 signaling protein. AZD1480 treatment inhibited both of these immune responses. AZD1480 also inhibited induction of two genes for proinflammatory markers, CIITA and MHC Class II.

The UAB researchers further found that α-synuclein overexpression significantly upregulated 186 genes in the midbrains of rats, while AZD1480 treatment of α-synuclein-overexpression rats inhibited the expression levels of 59 genes, the majority being genes that were induced by α-synuclein. Genes induced by α-synuclein overexpression include many that are implicated in cell signaling, inflammatory and neurological diseases, and antigen presentation (a step in the adaptive immune response).

Besides Benveniste, Qin and Standaert, authors of the paper, “Inhibition of the JAK/STAT pathway protects against α-synuclein-induced neuroinflammation and dopaminergic neurodegeneration,” are Jessica A. Buckley, Yudong Liu, Thomas H. Fox III, Gordon P. Meares, Hao Yu and Zhaoqi Yan, all of the UAB Department of Cell, Developmental and Integrative Biology; Xinru Li and Ashley S. Harms, UAB Department of Neurology; and Yufeng Li, UAB Department of Medicine.

At UAB, Benveniste holds the Charlene A. Jones Endowed Chair in Neuroimmunology, and Standaert holds the John N. Whitaker Endowed Chair in Neurology. West holds the John A. and Ruth R. Jurenko Endowed Professorship in Neurology.

Research support came from the M.J. Fox Foundation, and from NIH grants RO1 NS57563-05, P20 NS095230, P30 AR48311, P30 NS47466, P30 CA13148 and P30 AI027767.



Bob Shepard
UAB Media Relations

CBD Oil graphic 2

Investigators with the University of Alabama at Birmingham Cannabidiol Program will present the first results drawn from the CBD oil studies underway at UAB and Children’s of Alabama. Three abstracts will be presented at the annual meeting of the American Academy of Neurology in Vancouver, Canada.The abstracts describe results from the first 51 subjects enrolled in the studies. Among other findings, the researchers report that approximately 50 percent of the subjects responded to the CBD oil therapy with overall sustained improvement inseizure control over a six-month period. Seizures declined between 32 and 45 percent in the responders, depending on the CBD dose. Two patients were seizure-free, and nine dropped out due to side effects or lack of efficacy.

UAB launched the studies of CBD oil as a treatment for severe, intractable seizures in April of 2015. The studies, an adult study at UAB and a pediatric study at Children’s of Alabama, were authorized by the Alabama Legislature in 2014 by legislation known as Carly’s Law.

The studies are designed to test the safety and tolerability of CBD oil in patients with intractable seizures. CBD oil, a derivative of the cannabis plant, is delivered orally as an oily liquid.

“The studies are ongoing, and we have a lot more to learn; but these preliminary findings are encouraging,” said Jerzy Szaflarski, M.D., Ph.D., professor in the Department of Neurology, principal investigator of the adult study. “Among our goals was to determine the safety of CBD oil therapy, and it appears that, in many cases, patients tolerate the oil quite well. The evidence of seizure reduction gives us hope that, the more we learn about CBD oil, the better we will be able to tailor this therapy to provide relief for those with severe epilepsy.”

The oil used in the studies is produced under stringent requirements of the United States Food and Drug Administration by a licensed pharmaceutical company. It contains only traces of THC, the psychoactive component of marijuana. The process developed by GW Pharmaceuticals guarantees the consistency of the product that is provided to study participants.

“Some patients respond well, but others either have no improvement or experience significant side effects. CBD is not a panacea, and it’s not for everyone. But many patients do have a reduction in seizure activity, and we hope our efforts will further define how to best utilize CBD oil for maximum benefit to the appropriate patient population.”
“The studies thus far show that the administration of CBD oil is a complex undertaking,” said Martina Bebin, M.D., professor of neurology and principal investigator for the pediatric study. “Some patients respond well, but others either have no improvement or experience significant side effects. CBD is not a panacea, and it’s not for everyone. But many patients do have a reduction in seizure activity, and we hope our efforts will further define how to best utilize CBD oil for maximum benefit to the appropriate patient population.”

Tyler Gaston, M.D., a clinical neurophysiology fellow, led a study of potential interactions between CBD and clobazam, a commonly prescribed anti-epileptic medication. The investigators suspected that CBD treatment might cause an increase in the blood levels of clobazam and its metabolite, N-desmethylclobazam, leading to adverse events including sedation. Seventeen patients in the studies were taking clobazam, and investigators found clear evidence for an interaction, with rising clobazam levels during CBD therapy. This finding highlights the importance of monitoring clobazam and N-desmethylclobazam levels when treating patients with CBD, and the results underscore the importance of the new knowledge gained through the UAB CBD program.

A study headed by Leslie Perry, M.D., also a clinical neurophysiology fellow, looked at the effect of CBD oil therapy on electroencephalography, or EEG. EEG is the standard test to measure electrical activity in the brain. The same cohort of 51 patients received EEG tests prior to beginning CBD therapy and then again after CBD therapy had begun. The investigators report that CBD does not appear to have a negative effect on standard EEG parameters. However, the authors acknowledge that the conclusion is limited by the relatively short duration of both the EEG and the length of time from the tests done prior to beginning CBD therapy and then during therapy.  

Another abstract, led by Jane Allendorfer, Ph.D., assistant professor of neurology, will be presented at the annual meeting of the Organization for Human Brain Mapping in Geneva, Switzerland. In her work, she evaluated the effects of CBDtreatment on attention circuits in the brain using functional MRI. Eight patients underwent fMRI before treatment with CBD and while taking CBD. Their scanning showed improved activation of brain regions important for attention. The authors conclude that these preliminary results are promising and illustrate the potential of CBD treatment to improve not only seizure control but also cognition in patients with poorly controlled epilepsy.  

The ongoing UAB CBD studies currently have 40 children and 39 adults enrolled.