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lithium in treatment of motor neuron disease

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journal club on trials of lithium carbonate in treatment of amyotrophic lateral sclerosis

journal club on trials of lithium carbonate in treatment of amyotrophic lateral sclerosis

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  • Effects of lithium treatment on the lifespan and neurological symptoms of G93A mice. (a) Survival curve for saline- and lithium-treated G93A mice. Lithium carbonate (1 mEq/kg, daily, i.p.) treatment significantly increased the survival time of G93A mice compared with saline-treated mice. (b) Effects of lithium on specific symptoms, such as hind limb adduction, gait impairment, and the onset of severe paralysis. (c) Symptomatic effects and prolongation of the life span induced by lithium. Values represent the mean ± SEM of 10 mice per group in two different experiments (total N per group = 20). Comparison was made by using ANOVA with Sheffe's post hoc analysis. *, P ≤ 0.05 compared with G93A mice administered saline. **, P ≤ 0.001 compared with G93A mice administered saline.
  • Neuroprotective effects of lithium on medium-size lamina VII neurons. (a) Shows representative micrographs of those H&E-stained lamina VII neurons that were selected for the count based on size specificity (diameter ranging from 10 to 20 μm). (b) Graph indicates the severe loss of these neurons in G93A mice, which exceeded the loss of MN. Remarkably, the G93A mice treated with lithium showed a much higher number of lamina VII medium-size neurons even compared with saline-treated WT mice. (c–e) These results were confirmed by gephyrin immunostaining, as shown here and by all of the staining procedures summarized in SI Fig. 16. Counts represent the mean ± SEM of 62,000 cells per group (3,100 per mouse in groups of 20 mice). Comparison among groups was made by using one-way ANOVA. *, P ≤ 0.05 compared with WT saline-treated group. #, P ≤ 0.001 compared with G93A saline-treated groups. (Scale bars, 17 μm.)
  • Effects of lithium administration on motor neurons mitochondria in vivo. (a–h) Representative pictures of mitochondria (arrows) in MN from the spinal cord of WT mice treated with saline (a and b) or lithium (c and d) and from G93A mice treated with saline (e and g) or lithium (f and h). (g) In G93A mice treated with saline, TEM shows mitochondrial vacuolization (arrowheads). (f and h) This vacuolization is consistently absent in mitochondria of G93A mice treated with lithium. (d and h–j) Lithium decreases the size of mitochondria both in WT and G93A mice (d and h, respectively) both in the cervical (i) and lumbar (j) spinal cord. (k and l) Lithium increases the number of mitochondria both in cervical (k) and lumbar (l) MN both in WT and G93A. Values are the mean ± SEM. Comparison between groups was made by using one-way ANOVA. *, P ≤ 0.05 compared with saline-treated mice. **, P ≤ 0.01 compared with saline treated mice. (Scale bars: a, c, e, and g, 1.8 μm; b, d, f, and h, 0.25 μm.)
  • Effects of lithium on autophagy in vivo and in vitro. (a–d) MDC-positive small vacuoles in the lumbar spinal cord of WT (a and c, arrows) and G93A mice (b and d, arrows). (e) Representative picture of beclin immunostained vacuoles in the cytoplasm of alpha MN from a G93A lithium-treated mouse. The ImmunoGold particles (20 nm) are localized on both the membrane (that surround the core) and the electrondense core (arrows). (f) LC3 immunostaining is present on a larger membranous structure; the ImmunoGold particles (20 nm) are randomly localized (arrows). (g) The count of beclin immunostained structures shows a marked effect of lithium in MN both WT and G93A mice. (h) Likewise, LC3 immunopositive vacuoles increase significantly in G93A and WT mice administered lithium. (i–l) Phase-contrast microscopic images of lithium-induced accumulation of vacuoles in SH-SY5Y cells exposed or not for 72 h to 1 mM lithium (j), or lithium plus 50 mM asparagine (Asn) (a slight autophagy blocker acting downstream of lithium) (k), or 400 nM rapamycin (Rap) (l). Arrows point to cytoplasmic vacuoles that accumulate in cells treated with lithium or Rap (a known autophagy inducer). No vacuolization was observed in control (i) or lithium plus Asn-treated cells. (m–p) A parallel experiment was performed with transfected SH-SY5Y cells stably expressing the GFP-LC3 chimeric fluorescent protein. The images clearly show that both lithium (n) and rapamycin (p) change the cytoplasmic diffuse fluorescence pattern of GFP-LC3 to a punctuated pattern indicative of autophagosome formation. Asparagine (o) inhibited the effect of lithium on GFP-LC3 localization. *, P < 0.05 compared with saline. (Scale bars: a–d, 14 μm; e, 0.1 μm; f, 0.08 μm; i–l, 20 μm; m–p, 50 μm.)
  • Effects of lithium treatment on disease symptom progression and survival in patients with ALS. (a, b, d, and e) Symptoms progression (evaluated every 3 months) in controls (riluzole-treated) and treated patients (lithium plus riluzole-treated patients) expressed as raw data, using the Norris (a) and ALSFRS-R (b) rating scales and FVC (d) and MRC (e). There was no significant progression in the lithium-treated patients at any time interval apart from the last two evaluations using the MRC scale. In the riluzole-treated patients, symptoms progressed significantly starting at 3 or 6 months (depending on the scale). (c) Survival curve as normalized data shows the percentage of patients surviving over the 15 months of treatment in the riluzole and lithium groups. None of the patients died in the lithium-treated group; however, in the control group, although the patients had comparable disease severity at enrollment, ≈30% died. Intra- and intergroup analyses were performed by unpaired t test or ANOVA followed by the Bonferroni post hoc test. (f) Shows the breakdown between treated and control patients for FVC. (g) Shows the breakdown between groups for FVC (calculated at 1 month before death) in those patients affected by the bulbar form. *, P < 0.05, **, P < 0.01 compared with baseline value. #, P < 0.05; ##, P < 0.01 compared with control patients.

 lithium in treatment of motor neuron disease lithium in treatment of motor neuron disease Presentation Transcript

  • Lithium delays progression of amyotrophic lateral sclerosis Francesco Fornai*†‡, Patrizia Longone§, Luisa Cafaro†, Olga Kastsiuchenka*, Michela Ferrucci*, Maria Laura Manca¶, Gloria Lazzeri*, Alida Spalloni§, Natascia Bellio, Paola Lenzi*, Nicola Modugno†, Gabriele Siciliano¶, Ciro Isidoro, Luigi Murri¶, Stefano Ruggieri†, and Antonio Paparelli* *Department of Human Morphology and Applied Biology, and ¶Department of Neuroscience, Clinical Neurology, University of Pisa 56100 Pisa, Italy; PNAS February 12, 2008 vol. 105 no. 6 2055
    • ALS is a devastating neurodegenerative illness with no effective treatment
    • Survival rates of 3-5 yrs from disease onset(11months for bulbar forms)
    • 90% sporadic 10% FALS
    • Cu/Zn superoxide dismutase (SOD1)
    • Transgenic mice-SOD mutation similar phenotype as ALS
    • Motorneurons, interneurons, glial cells
    • Lithium-mood stabiliser, neuropotective in animal model-brain ischemia, kainate toxicity, promotes autophagy through IMP1
    • Autophagy- keyrole in neurodegeneration
    • Study proposed to test neuro protective effect of lithium in transgenic mice G93A ALS models
    • Based on promising results, a clinical trial was also conducted
  • Study 1
    • In vivo
    • Control miceWT,G93A mice
    • Breeding protocol
    • Treatment saline/lithium
    • Tissue preparation,Electron microscopy
    • In vitro-Primary neuronal cultures,immunocytochemistry,cell lines
    • Effect of lithium on disease duration and survival in mice
    • Mean survival time110.8 to 148 days
    • Disease duration 9days to >38 days
    • Delayed onset of paralysis and motor deficits
  • Effects of lithium treatment on the lifespan and neurological symptoms of G93A mice Fornai F. et.al. PNAS;2008;105:2052-2057 ©2008 by National Academy of Sciences
    • Effect on motor neuron survival(lamina1X of lumbar, cervical spinal cord and brainstem motor nuclei)
    • Preservation of size and number of motor neuron
    • Decreased astrocytosis
    • Increased lamina vii interneuron number
  • Neuroprotective effects of lithium on medium-size lamina VII neurons Fornai F. et.al. PNAS;2008;105:2052-2057 ©2008 by National Academy of Sciences
    • Lithium treatment rescues spinalcord mitochondria and facilitates clearance of alpha synuclein,ubiquitin and SOD1
    • Increases the number and normalises size of mitochondria
  • Effects of lithium administration on motor neurons mitochondria in vivo Fornai F. et.al. PNAS;2008;105:2052-2057 ©2008 by National Academy of Sciences
    • Lithium increases the number of autophagic vacuoles both in vitro and in vivo.
    • Decreased Autophagy is postulated mechanism in neurodegeneration
  • Effects of lithium on autophagy in vivo and in vitro Fornai F. et.al. PNAS;2008;105:2052-2057 ©2008 by National Academy of Sciences
  • Study 2-clinical trial
    • 15 month
    • Parallel randomized study
    • IRCSS ethical comitee
    • Informed consent
    • Statistical significance required minimum 40 patients
    • N=44 male-20.female-24
    • El escorial diagnostic criterian
    • Disease duration<5 years
    • No familial case
    • 33 patients classical onset,11 presented with bulbar symptoms
    • groupA-16 patients(M-8,F-8),4 of them had bulbar
    • Riluzole 100mg/day +lithium carbonate 300mg/day
    • groupB-38(m-12,f-16),7 of them had bulbar
    • Riluzole only
    • Treating physician-not blind, administers and monitors lithium concentration and adjusts to 0.4-0.8meq/l
    • Evaluating physician-clinical evaluation, measurement of FVC, data analysis
    • Compliance and adverse effects were monitored through out the study period
    • Asessment 6 times,at baseline and every 3 months until 15months
    • Primary end point-survival rate
    • Secondary outcome- change in global function, ALSFRS-R(n-48) &Norris ALS scale(n-100) ,(functioning of upper and lower limbs, bulbar function)
    • Quality of life SF-36
    • Objective measures-MRC & FVC
    • ANOVA
    • Kolmogorov-sminrnov
    • Kaplameier curves
    • Unpaired t test
  • results
    • Demographic variables and baseline ratings are well distributed among study and control groups
    • All patients treated with lithium were alive at the end of the study vs 30% mortality in riluzole only group
    • FVC did not progress significantly(89…75)
    • No significant decrement in short form health survey-sf 36 scale
    • MRC progressed ony at end of the follow up(138.5…113.4)
    • In riluzole only group,Norris scale significantly decreased (86.6…..55.3)
    • ALSFRS score significantly decreased(40.2….24.2)
    • FVC significantly decreased(91…..58)
    • MRC scale from 140…..92
    • At the end of the follow up,mean decrement in in Norris score was 46.1% in riluzole only group vs 10.6% in lithium group.
    • ALSFRS was 39.8% vs 14.35
    • MRC..34.6% decrease in riluzole group vs 18% in lithium group.
  • Effects of lithium treatment on disease symptom progression and survival in patients with ALS Fornai F. et.al. PNAS;2008;105:2052-2057 ©2008 by National Academy of Sciences
  • conclusion
    • This study indicates that lithium delays progression in human patients.
    • All persons on lithium were alive at the end of the study
    • MRC-minimal progression and FVC –preservation
    • Lithium affects multiple targets
    • Thank you
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