Biomarkers For Alzheimer's Disease, NRDD 2010

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biomarkers
Biomarkers for Alzheimers disease: academic, industry and regulatory perspectives

Harald Hampel*, Richard Frank, Karl Broich, Stefan J. Teipel||, Russell G. Katz#, John Hardy**, Karl Herholz, Arun L. W. Bokde, Frank Jessen||||, Yvonne C. Hoessler, Wendy R. Sanhai##, Henrik Zetterberg***, Janet Woodcock and Kaj Blennow***
Abstract | Advances in therapeutic strategies for Alzheimers disease that lead to even small delays in onset and progression of the condition would significantly reduce the global burden of the disease. To effectively test compounds for Alzheimers disease and bring therapy to individuals as early as possible there is an urgent need for collaboration between academic institutions, industry and regulatory organizations for the establishment of standards and networks for the identification and qualification of biological marker candidates. Biomarkers are needed to monitor drug safety, to identify individuals who are most likely to respond to specific treatments, to stratify presymptomatic patients and to quantify the benefits of treatments. Biomarkers that achieve these characteristics should enable objective business decisions in portfolio management and facilitate regulatory approval of new therapies.
Basic and clinical research advances over the past decades have provided detailed knowledge of the molecular mechanisms and clinical course of Alzheimers disease. Alzheimers disease is a complex progressive condi tion that involves sequentially interacting pathological cascades, including the interaction of amyloid- (A) aggregation with plaque development, and the hyper phosphorylation and aggregation of tau protein with formation of tangles. Together with associated pro cesses, such as inflammation and oxidative stress, these pathological cascades contribute to loss of synaptic integrity and progressive neurodegeneration1. These advances in research have been translated into several new drug candidates with diseasemodifying poten tial, many of which are now being evaluated in clinical trials2. Studies in transgenic mouse models of Alzheimers disease suggest that the majority of these new types of diseasemodifying drugs may be most effective early on in the process of A aggregation, and be less effective in later stages when there is severe plaque pathology and neurodegeneration35. However, the current diagnostic criteria (DSM-IV, ICD-10 and NINCDS-ADRDA) that are used to identify patients with Alzheimers disease who have overt dementia correspond to neuropathologically advanced disease. Consequently, early recognition of the disease needs to be improved; indeed, it is estimated that interventions that could delay the clinical onset of dementia by 1 year would reduce the prevalence in 2050 by 9 million cases6. The primary end points in current clinical trials for Alzheimers disease measure the symptoms of the dis ease, such as cognitive and functional impairment. However, performance in these tests is determined by multiple factors other than key pathological events, which lead to neurodegeneration. As a result, drug trials that use clinical rating scales as outcome measures will fail to define the impact of new drugs on Alzheimers disease pathology. There is a growing need for biomarkers of Alzheimers disease pathology to improve drug development related to the disorder. Animal models of Alzheimers disease have low predictive power for determining the efficacy of treatments in patients with sporadic Alzheimers disease1. Human biomarkers that facilitate the identification of the biochemical effects of a drug in shortterm pilot studies may identify those drug candidates derived from animal
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Amyloid-
(A). An aggregation-prone peptide derived from the amyloid precursor protein. The 42 amino acid isoform of the peptide is the main component of plaques in Alzeimers disease.
*Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Johann Wolfgang Goethe-University, Heinrich-Hoffmann-Str. 10, 60528 Frankfurt/Main, Germany. Correspondence to H.H. e-mail: harald.hampel@med. uni-frankfurt.de doi:10.1038/nrd3115
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author addresses
Global Medical Affairs and Clinical Strategy, GE Healthcare, 101 Carnegie Center, Princeton, New Jersey 08540, USA. Federal Institute for Drugs and Medical Devices (BfArM), Kurt-Georg-Kiesinger-Allee 3, D-53175 Bonn, Germany. || Department of Psychiatry, University of Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany. DZNE, German Center for Neurodegenerative Disorders, Gehlsheimer Str. 20, 18147 Rostock, Germany. # Division of Neurology Products, Center for Drug Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, Maryland 20993, USA. **Department of Molecular Neuroscience and Reta Lila Weston Laboratories, Institute of Neurology, University College, Queen Square House, Queen Square, London WC1 3BG, UK. Wolfson Molecular Imaging Centre, University of Manchester, 27 Palatine Road, Manchester M20 3LJ, UK. School of Medicine and Trinity College Institute of Neuroscience, Trinity College Dublin, Trinity Centre for Health Sciences, The Adelaide and Meath Hospital Incorporating The National Childrens Hospital, Tallaght, Dublin 24, Ireland. |||| Department of Psychiatry, Rheinische Friedrich-Wilhelm University Bonn, SigmundFreud-Strasse 25, 53105 Bonn, Germany. Department of Psychiatry, Alzheimer Memorial Center, Ludwig-Maximilian University, Nussbaumstr. 7, 80336 Munich, Germany. ## Senior Scientific Advisor, Office of the Commissioner, Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, Maryland 20993, USA. ***Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, S-431 80 Mlndal, Sweden. Center for Drug Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, Maryland 20993, USA.
Tau protein
A microtubule-associated protein located in the neuronal axons. Hyperphosphorylated tau is the main component of neurofibrillary tangles in Alzheimers disease.
DSM-IV
(Diagnostic and Statistical Manual of Mental Disorders, Fourth edition). This manual outlines diagnostic criteria for psychiatric disorders and is published by the American Psychiatric Association.
ICD-10
(International Statistical Classification of Diseases, Tenth edition). This book outlines diagnostic criteria for human diseases and is published by the World Health Organization.
models that affect the disease process in patients. In clin ical academic research, when qualified for use (BOX 1) in a specific patient population, biomarkers should aid in population selection and assessment of drug effects on disease progression. In industryled drug discovery and development, biomarkers should facilitate selection of drug candidates, verify the mechanism of action, define dose effects and enable clinical trials to be shortened and run with reduced sample size. Biomarkers could serve as surrogate end points (discussed in more detail below) for clinical outcomes, and so could increase objectivity and efficiency in regulatory decisionmaking. These could include, for example, labelling decisions in which a drug could be labelled as disease modifying rather than just providing symptomatic treatment 7. In addition to this, biomarkers should serve as diagnostic tools in clinical practice to allow early and presymptomatic identifica tion of patients with Alzheimers disease, and to aid treatment decisions and monitoring in individualized care. Finally, biomarkers could serve as screening tools for disease prevention programmes. To qualify for these purposes, a biomarker must be measured by reliable and validated methods, must be sen sitive and specific when used as diagnostic markers, must be sensitive to the effects of a drug, and must be predictive of clinical outcomes8,9. In clinical trials, biomarkers that are indicators of the central or downstream elements of Alzheimers disease pathogenesis could serve at least three different purposes:
as diagnostic biomarkers, to detect and monitor effects of drug candidates on the disease process, and as safety markers to detect and monitor potential side effects of drug candidates at an early stage. The last item may be of particular importance in clinical trials of novel drugs against Alzheimers disease, given the risk of encephali tis associated with monoclonal antibodies10. Biomarkers can be compounds obtained from bodily fluids or tissue, such as cerebrospinal fluid (CSF) assays11, or technically derived correlates of Alzheimers disease pathology, such as brain imaging markers. In particular, neuroimaging techniques12 have been developed that provide evidence for A deposition, tau aggregation and neurodegen eration already at very early clinical disease stages13. However, the current generation of biomarkers are not yet robust against standard criteria that biomarkers in other branches of medicine fulfil. Also, the reporting of studies involving diagnostic biomarkers in Alzheimers disease needs to follow strict quality criteria, such as the quality assessment of diagnostic accuracy studies (QuADAS) criteria14. Here, we review the current status of multimodal core biomarker candidates derived from structural, functional and metabolic neuroimaging, and from neurochemistry and genetic studies of Alzheimers disease. We also provide the converging perspectives of industry stake holders and regulatory agencies on biomarker discovery and development. In our opinion, the integration of scientific knowledge and united international and inter disciplinary research efforts by academic institutions, the pharmaceutical industry and the regulatory agencies will accelerate the discovery and codevelopment of new and more informative biomarkers for broad clinical diagnostic use, as well as for the many trials of innovative treatments in neurodegenerative diseases and Alzheimers disease.
imaging as an end point in clinical trials Four imaging modalities have been used as secondary end points in clinical trials on Alzheimers disease: struc tural magnetic resonance imaging (mRI), functional mRI (fmRI), magnetic resonance spectroscopy (mRS) and positron emission tomography (PeT). In structural mRI studies, there are correlations between mRIbased volume and neuron numbers in specific brain regions15. The blood oxygendependent level (BolD) fmRI signal is primarily a measure of the input and processing of neuronal information within a brain region16. mRS rep resents changes in the biochemical composition of the brain tissue. PeT using 18F2fluoro2deoxydglucose (FDG) is thought to represent neuronal glucose con sumption as the main determinant of neuronal metabo lism17. PeT using tracers for A is thought to represent accumulation of the pathognomonic sign of Alzheimers disease, that is, A plaques18. The validity of a biomarker with respect to a sup posed neurobiological substrate will be relevant for the evaluation of diseasemodifying treatments. The imaging techniques provide information on the regional distribu tion of changes on a macroscopic (fmRI, PeT, mRS) or a mesoscopic (mRI) scale. Such knowledge on the spatial distribution and temporal dynamic changes of the brain
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Box 1 | Validation and qualification of biomarkers
To facilitate communication among stakeholders it is useful to distinguish between the words validation and qualification. Validation is often used to mean the determination of the performance characteristics of an assay for example sensitivity and specificity in measuring a particular analyte. Validation also has a jargonized use in the context of regulatory approval to market kits for commercial use as clinical diagnostics. Qualification is often used to mean the establishment of the credibility of that assay in its application to questions relevant to drug development. Such questions include does the drug hit the target, and if so to what extent?, does the drug alter the mechanism by which it is intended to act or does the drug change pathophysiology in a clinically relevant way? Qualification requires specific patient populations and a specific therapeutic intervention. For example, a validated assay may be qualified as an Alzheimers disease biomarker for intervention with amyloid- (A) production but not in non-A mechanisms. So, it could be said that the assay which was validated for quantification of A plaques (or A oligomers or A monomers) in the brain or in CSF is qualified for use as a biomarker in Alzheimers disease for drugs that inhibit -site amyloid precursor protein-cleaving enzyme 1 (BACE1). However, as well as the assay validation data, additional clinical data are required to support such qualification. A validated assay might not be qualified for use as a biomarker, hence the distinction between validation and qualification (for use). The ultimate use of a biomarker is as a surrogate end point, which requires that the biomarker has been qualified to substitute for a clinical standard of truth such that the biomarker reasonably predicts the clinical outcome and therefore can serve as a surrogate.
However, more recent approaches use automated spatial transformation of mRI volumes in a common standard space and derive univariate or multivariate statistics from maps of cortical grey matter density, cortical thickness, white matter density or highresolution spatial transformation maps. These approaches are less labour intensive than manual volumetric analyses and so far have been applied as secondary outcomes in few clinical trials. However, the multicentre reliability of these techniques has yet to be determined. Pharmacological fMRI. Studies of memory in patients with Alzheimers disease using fmRI discovered a pattern of altered activation in the medial temporal lobes and parietal lobes, which were consistent with structural mRI results. Based on initial singlecentre studies, specific effects of treatment on regional brain activation could be detected in Alzheimers disease23 (FIG. 2; TABLE 1; see Supplementary information S1 (table)). multicentre and longitudinal studies using fmRI in patients with Alzheimers disease have yet to be done, which will be a major step in the further development of fmRIbased biomarkers. Proton-MRS. ProtonmRS (1HmRS) provides quan titative biochemical measures of compounds in brain tissue. The best established 1HmRS marker is the amino acid Nacetyl aspartate (nAA), which reflects the functional status of neuronal mitochondria24. A reduc tion of nAA levels independent of brain atrophy is a consistent finding in Alzheimers disease. Preliminary singlecentre studies have demonstrated that nAA levels are responsive to pharmacological treatment, and multicentre application of this technique has been demonstrated (TABLE 1; see Supplementary information S1 (table)). However, largescale applications in clini cal trials are still pending. In addition to nAA, several other metabolites such as cholinecontaining com pounds, creatine and phosophocreatine, myoinisitol, and gluatmate and glutamine are detectable with 1 HmRS, but their potential as biomarker candidates in Alzheimers disease is controversial and requires refined investigations25. FDG-PET. FDGPeT measures local glucose metabo lism as a proxy for neuronal activity at a resting state without the need for cognitive activation. In Alzheimers disease, neuronal activity is impaired, as FDG uptake is reduced, predominantly in temporoparietal association areas including the precuneus and posterior cingulate cortex. These changes are closely related to cognitive impairment as demonstrated in crosssectional and longitudinal studies. The changes in FDG uptake can be measured objectively with smaller coefficients of vari ance than standard neuropsychological measures, thus increasing the power of studies26,27. Alterations in FDG uptake are usually attributed to pharmacodynamic drug effects but will also reflect disease progression, espe cially when measured after several months of followup. This technique has been used as a secondary outcome parameter in some clinical trials2831.
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NINCDS-ADRDA
(The National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimers Disease and Related Disorders Association). This outlines criteria for diagnosing Alzheimers disease.
in Alzheimers disease is important. This is because a systematic brain disease that follows a specific pattern of progression through the brain may lead to differences in the extent of pathological changes depending on the stage of the disease. Additionally, imaging biomarkers have been used as predictive markers of the progression of dementia in defined risk groups of patients. For example, biomar kers can increase the accuracy of predicting the conver sion of mild cognitive impairment a clinically defined risk syndrome in which normal cognition and dementia cannot be sharply separated to dementia19,20. Structural MRI. In Alzheimers disease, structural mRI typically shows a pattern of decreased grey matter in the parahippocampal gyrus, the hippocampus, the amyg dala, the posterior association cortex and the subcortical nuclei including the cholinergic basal forebrain. In longitudinal studies mRI can be used as a potential marker to dis criminate between diseasemodifying and symptomatic treatment effects by determining the rate of atrophy of brain regions (FIG. 1). TABLE 1 and Supplementary infor mation S1 (table) outline the characteristics of different mRIbased disease markers. The reliability of volumetric measures obtained from repeated mRI scans is generally high21, which is an important prerequisite for its use as a disease progression marker. Additionally, multicentre variability of manual and automated volumetric measures across 12 different mRI scanners was below 5% in one study 22. To reduce the variability of mRI measures between different scan ners in clinical trials, a phantom test is required to ensure that participating centres meet a set of minimal criteria for scanner quality. The most commonly mRIderived measure is hippocampus volume, which is measured by visual inspection or manual drawing on mRI slices.
Primary end point

A primary end point is defined as the single main question to be answered in a given clinical trial.
Biomarker
An objective measure of a biological or pathogenic process that can be used to evaluate disease risk or prognosis. It can be used to guide clinical diagnosis or to monitor therapeutic interventions.
Surrogate end point

A substitute for a clinical end point in a clinical trial.
Secondary end point

An end point in a trial that provides additional characterization of treatment effect, but is not sufficient by itself to fully characterize the benefit or to support a claim for a treatment effect.
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a Neuropsychology
Cognitive function Treatment withdrawal
choline esterase, cholinergic receptors and transporters have been used in human studies ( TABLE 1 ; see Supplementary information S1 (table)), but have not yet been qualified as biomarkers. Imaging biomarkers: future challenges. Presently, clini cal trials include imaging end points on a projectby project basis. The standardization of imaging protocols and analysis techniques is paramount for acceptance in multicentre trials. In addition, regulatory authorities require proof that imaging outcomes are of relevance to drug safety or efficacy. A biomarker would serve as a surrogate end point if it reflects clinically relevant outcomes such as cognitive decline or health economic outcomes such as institutionalization. For instance, hip pocampal atrophy could serve as a surrogate end point if hippocampus atrophy reflects the clinically relevant outcome of memory loss. This association needs to be further established in future studies. nevertheless, an imaging marker could be used as a primary prespecified outcome measure in a proof ofconcept study if the imaging marker reflects an underlying disease process. Hippocampus atrophy as determined by mRI correlates with hippocampal neu ronal loss as shown in numerous clinical pathological studies15,38. Thus, hippocampus atrophy could be used to assess the mechanism of action of a new compound that claims to reduce neurodegeneration in Alzheimers disease. Therefore, imaging markers may be used to assess the presumed mechanism of action of a new com pound in proofofconcept studies. For example, in the AN1792 vaccination trial39, as well as in the AlZHemeD Phase III trial40, there were higher rates of brain and hippocampus atrophy in the treated subjects than in the untreated controls. However, treated subjects showed no evidence of more rapid cognitive decline compared with the placebo groups. These examples illustrate that imaging end points can lead to unexpected findings that help to critically evaluate our primary assumptions on the mode of action of new compounds.
Disease modifying Symptomatic Placebo Time
b Atrophy
Cognitive function
Treatment withdrawal
Disease modifying Symptomatic Placebo Time
Figure 1 | Detection of disease-modifying treatment effects. a | The solid red line indicates the course of cognitive decline (assessed by cognitive testing) during Nature Reviews | decline seen disease-modifying or symptomatic treatment compared with the course ofDrug Discovery with placebo (green line). Only after withdrawal from drug treatment in the second half of the trial does the disease-modifying treatment effect (upper dashed red line) differentiate from the symptomatic treatment effect (lower dashed orange line). b | The upper solid blue line indicates the course of atrophy in the brain (as measured by magnetic resonance imaging) with a disease-modifying compound compared with a symptomatic treatment (lower pale blue line) and placebo (green line). This difference is maintained after withdrawal of the drug, but the withdrawal phase of the trial would not be required to differentiate the disease-modifying effect from the symptomatic treatment effect based on a volumetric outcome.
Longitudinal study
A research study with repeated observations of the same patients over long periods of time.
Phantom test
A plastic cylinder with standardized measures and density used for calibration of magnetic resonance imaging devices.
Transformation map
A spatially extended vector field that describes the spatial warps that are needed to align a three-dimensional image of the brain into a common standard space.
Classical plaque
A dense aggregation of amyloid- protein with classical amyloid characteristics, which is surrounded by swollen neuritis and reactive glial cells.
Amyloid-PET. Several studies have shown that selective binding of a11Clabelled thioflavin analogue known as Pittsburgh compound B (11CPIB)32 to A can be visual ized in PeT scans of patients with Alzheimers disease (TABLE 1; see Supplementary information S1 (table)). These amyloidPeT scans have provided information regarding the A plaque burden that is independent from structural changes in brain anatomy 33.11CPIB binding sites in the brain are associated with A sheets in classical plaques and diffuse plaques, as well as cere brovascular amyloid angiopathy 18,34. It does not bind to soluble and oligomeric amyloid. Increased cortical uptake of 11CPIB is seen in 2 out of 3 of patients with mild cognitive impairment with probable progression to Alzheimers disease35,36. However, a significant propor tion of elderly subjects without mild cognitive impairment show increased 11CPIB uptake with as yet unknown prognostic implications33,35. Currently, Phase II trials have been initiated with amyloid tracers that can be labelled with 18F isotopes, which have a longer halflife and wider availability compared with 11CPIB37. Cholinergic neurotransmission. Cholinergic projections from the basal forebrain to cortical areas degenerate in Alzheimers disease, and treatment with choline esterase inhibitors has modest but proven efficacy. ligands for
Genetic analysis in biomarker research The use of all the biomarkers discussed in this paper and indeed all biomarkers for any disease are limited in part by variability between cases of disease and vari ability between controls. This variability increases the sample sizes that are needed to achieve statistical signifi cance and is notably higher, for many reasons including genetic variability, in humans compared to animal studies. So, genetic analysis of individuals is beneficial in four broad ways. First, some biomarkers (such as A42) came directly from genetic analysis of kindreds with the condition. As other genetic risk factors for Alzheimers disease are identified, it will be appropriate to assess their pro tein products, and other proteins, in the same pathway. Recent studies using large whole genome scans for Alzheimers disease41,42 identified clusterin (CLU; also known as apolipoprotein j) and complement receptor 1 (CR1) as risk loci, suggesting that these proteins them selves may be useful biomarkers for Alzheimers disease
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Table 1 | imaging biomarkers for alzheimers disease
Method
Magnetic resonance imaging (MRI)
Measures
Visual rating of hippocampus
Manual volumetry of hippocampus
Automated whole brain volumetry
cross-sectional findings High discrimination between Alzheimers disease versus control groups104 High discrimination between Alzheimers disease versus control groups105,106; prediction of Alzheimers disease in MCI with 7080% accuracy107 Main application for longitudinal evaluation
Consistent pattern of cortical and subcortical atrophy
Longitudinal findings
Poor detection of atrophy over time104
Perspectives
The best-established structural imaging markers are hippocampus and whole brain volume, which already have been applied in clinical trials Other imaging markers may carry more comprehensive regional information, but require multicenter assessment before application in clinical trials
Atrophy rates of 37% per year in patients with Alzheimers disease compared with 0.9% in healthy controls
Atrophy rate of 2.5% per year in patients with Alzheimers disease compared with 0.40.9% in healthy controls108 Spread of atrophy throughout the brain in Alzheimers disease; effect sizes for application in clinical trials are difficult to derive Specific effects of cholinergic treatment on regional brain activation in Alzheimers disease110112 Increase of NAA during cholinergic treatment in Alzheimers disease114 Promising secondary end point owing to wide availability Initial studies on multicenter fMRI are positive MRS marker provides complementary information to structural MRI and fMRI Has been evaluated in a first multicenter study
Automated measures of regional cerebral atrophy patterns Functional magnetic resonance imaging (fMRI) Magnetic resonance spectroscopy (MRS) Blood oxygendependent level signal imaging during activation Single voxel proton spectroscopy of NAA
Reliability of fMRI data is high within subjects between imaging sessions109 NAA in the hippocampus is reduced in Alzheimers disease and at the MCI stage in those subjects who later decline to dementia113 Typical pattern of parieto-temporal cortical hypometabolism; low variability between multiple centers115 High sensitivity in detecting amyloid plaques and vascular amyloid in human brains in vivo116 Average reduction of cerebral acetylcholine esterase activity is in the range of 3040%
Positron emission tomography (PET)
Glucose (FDG) consumption
Effects of cholinergic treatment on cortical metabolism in Alzheimers disease117,118
Amyloid (11C- PIB)
Little further increase of 11C-PIB uptake during progression of Alzheimers disease119 Degree of acetylcholine esterase inhibition correlated with clinical improvement of cognition in Alzheimers disease120
FDG-PET is a stable and valid multicenter marker, but use is limited due to costs and availability The potential use of amyloid imaging with 11C-PIB and cholinergic imaging as surrogate end points is not clear Feasibility of both FDG-PET and 11C-PIB in multicenter studies has been demonstrated
Acetylcholine esterase
11 C- PIB, 11C-labelled Pittsburgh compound B; FDG, 18F-2-fluoro-2-deoxy-d-glucose; MCI, mild cognitive impairment; NAA, N-acetyl aspartate.
Diffuse plaque
An aggregation of amyloid- protein that can only be detected using immunohistochemistry.
AN1792 vaccination trial

The first clinical trial on active amyloid- immunotherapy in Alzheimers disease.
(although admittedly apolipoprotein e (APOE) has not proved useful in this regard). These results also suggest that the complement cascade, of which both Clu and CR1 are a part of, should be investigated. Second, it is well known that those who are either amyloid precursor protein (APP) or presenilin (PSEN) mutation carriers, or who have Downs syndrome or are APOE 4 allele homozygotes, have an extremely
high risk of developing Alzheimers disease at relatively welldefined ages. These defined populations offer the possibility of following the presymptomatic changes in biomarker levels and therefore correlating their behaviour with clinical state. This approach has been particularly informative and useful in the analysis of brain imaging biomarkers4345, but also offers potential in the assessment of blood and CSF biomakers46.
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A likely outcome of these endeavours is that these predictive tests will classify individuals at risk of develop ing Alzheimers disease into three groups. The first group includes individuals who are APOE 4 homozygotes at high risk of developing Alzheimers disease. This risk is modulated by other genes and the polymorphisms of the APOE promoter (about 3% of the population). The second group includes individuals who are APOE 4 heterozygotes who are at modest risk of developing Alzheimers disease. For this group, the precise risk is modulated by other APOE alleles (2 being less risky than 3) and by the polymorphisms of the APOE pro moter, as well as by the other genomewide association study hits. The third group includes individuals who do not carry an APOE 4 allele and are therefore at low risk of developing Alzheimers disease. The interpretation of these data will need the development of a sophisti cated risk chart, and their explanation to lay people will present a challenge. Although still to be investigated, it is expected that the adjunct use of these genetic tests will help considerably in the identification of individ uals with mild cognitive impairment who will later be diagnosed with Alzheimers disease54. As our understanding of the genetic architecture of Alzheimers risk increases through the identification of relatively common risk variants such as CLU, C1R and PICALM (phosphatidylinositol binding clathrin assembly protein), and the later identification of individually rare highrisk variants, we will be able to asymptotically con struct a predictive algorithm of Alzheimers disease risk. Although this will considerably improve on what can be currently achieved, it is unlikely that this algorithm will be amenable for screening large atrisk populations (as indicated in our proposed diagnostic flow model depicted in FIG. 3).
Figure 2 | Detection of effects of cholinergic treatment on cortical activation in patients with Alzheimers disease using functional magnetic resonance imaging. Nature Reviews | Drug Discovery Regions of decreased activation (shown in blue) during a visual perception task in a group of patients with Alzheimers disease after 3 months of open-label treatment with an acetylcholinesterase inhibitor compared with activation before treatment. The visual perception task recruits parietal areas in healthy controls and the decrease in activation after treatment (blue areas) occurred in the cognitively relevant brain regions. Left side of image is left brain.
Huntingtons protocol
Individuals who have family members with Huntingtons disease are offered genetic counselling, which includes the possibility of presymptomatic DNA testing. However, this is only offered after a series of careful counselling sessions to ensure that the individual understands the issues involved in knowing their genetic status.
Third, one of the problems of biomarker research is normal variability in the level of the biomarker between individuals. At least some of this variability is genetic and can be factored out through genetic analysis. For example, expression levels of microtubuleassociated protein tau (MAPT) in the brain47 and tau levels in the CSF48,49 have been suggested to be influenced by the MAPT haplotype. This phenomenon is true of many proteins for which blood (and CSF) levels are directly influenced by genetic variability 50. Fourth, the incorporation of data relating to an individuals response to a drug and to how the drug is metabolized (which can vary between individuals) into biomarkers and in clinical studies will be helpful51. Genetic tests and Alzheimers risk. Genetic tests are available for individuals who have family members with earlyonset familial Alzheimers disease, and are offered using the Huntingtons protocol. These genetic screens include testing for PSEN1, PSEN2, APP and APOE mutations; however, as APP or PSEN2 mutations are rare, screening for these mutations currently has to be organized on an ad hoc basis. Although genetic testing of APOE and predictive testing in typical late onset disease had been discouraged 52, the predictive value of APOE 4 homozygosity is as high as for many other mendelian diseases. Indeed, it seems that atti tudes to APOE genotyping are changing 53, and it is likely that the predictive potential of genetic analysis will be considerably increased. This is in part due to a growing appreciation of the increase in predictive value given by genotyping the whole APOE locus (including the TOMM40 region of the APOE promoter), together with hits from the recent genomewide association studies41,42.
TOMM40
A gene encoding a mitochondrial protein that is located on chromosome 19 adjacent to the apolipoprotein E gene.
Risk chart
A graph illustrating the risk of developing Alzheimers disease by age. This risk is modified by genetic status, especially by apolipoprotein E genotype status. Other genes will have a smaller effect on this chart (except in families with amyloid precursor protein and presenilin mutations).
biochemical biomarkers for use in clinical trials There are two main types of biochemical (that is, other than genomic or imaging) biomarkers. The first are core biomarkers that mirror fundamental pathogenic events in Alzheimers disease; for example, the deregulated metabolism of APP and A. The second are downstream biomarkers that reflect secondary phenomena, such as axonal degeneration. Compared with CSF biomarkers, efforts to discover reliable biomarkers for Alzheimers disease in peripheral blood have been of limited success. Indeed, although there are many publications on poten tial candidate blood biomarkers, followup studies by other research groups are either lacking, or have failed to confirm a solid diagnostic value. nevertheless, a recent pilot study reported diagnostically useful patterns of 18 different signalling, acute phase and inflammatory proteins in plasma that warrant further investigation55. Plasma A40 and A42 can be measured in peripheral blood, but do not contribute to the identification of Alzheimers disease in a reproducible manner 56, and are unlikely to reflect A processing in the brain57. Instead, most research has focused on CSF biomarkers, which more directly reflects brain neurochemistry, and can be obtained through lumbar puncture without significant side effects58.
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New candidates Or
No Hits target Enrich Diagnose Yes No Alters mechanism Confirm Characterize Yes No Affects pathophysiology Monitor Individualize Yes Outcomes Surrogate Clinical diagnosis Treatment New target or indication Enhanced exposure
of the neurodegenerative process11. The combination of elevated levels of total tau and phosphorylated tau together with reduced levels of A42 or reduced A42/A40 ratio in CSF is a consistent finding in biomarker studies of patients with different stages of Alzheimers disease, including mild cognitive impairment 11 (TABLE 2). A high diagnostic performance of these CSF biomarkers has been verified in three large multicentre studies, including the Alzheimers disease neuroimaging Initiative (ADnI) study 63, the DeSCRIPA study 64, and the Swedish Brain Power project 65. Potential CSF biomarkers. There are numerous other candidate biomarkers that reflect either elements of the primary pathogenic process in Alzheimers disease or secondary events of the disease. Biomarkers that mirror the pathogenic process include, for example, A oligo mers, site amyloid precursor proteincleaving enzyme 1 (BACe1) activity and concentration, secreted isoforms of APP, and A degradation products66. Secondary events include oxidative stress responses, inflammation and gliosis67. The diagnostic potential of these biomark ers is less well studied. However, some biomarkers such as BACe1 activity 68 and APP isoforms69 may also give important information on desired biochemical effects of certain drug candidates, such as BACe1 inhibitors. Monitoring the biochemical effect of new drugs. Because there is slow and variable progression of symptoms in Alzheimers disease, very large cohorts of patients and a treatment duration of several years will be needed to identify a change in the rate of cognitive decline in clini cal trials of diseasemodifying drug candidates. Small, shortterm trials that provide biochemical evidence of an effect of the drug on the central pathogenic processes would therefore be of great value to make go/nogo decision before embarking on Phase II or III clinical trials. Clinical treatment trials with acetylcholine esterase (AChe) inhibitors may serve as a proof of concept for the potential of CSF biomarkers to identify and monitor the biochemical effect of a drug in Alzheimers disease. Such studies found a marked increase in CSF AChe activity during treatment, which was dose dependent and linked to the mechanism of action of the drugs and the clinical outcome70. The mechanism for the increase in CSF AChe is unknown, but may involve an increased gene expres sion and release of AChe to the CSF, which is mediated by a muscarinic acetylcholine receptor feedback loop71. The intraindividual variability of CSF tau proteins and A42 is very low over time, with coefficients of variation of 46% during 6 months and 79% during 24 months of followup72,73. These results indicate that even minor changes in biomarker levels can be monitored. Studies in transgenic mice and in guinea pigs show reduced corti cal, CSF and plasma A levels during secretase inhibi tor treatment74,75. The decrease in CSF A also correlated with the decrease in cortical A75. In a Phase II trial of the secretase inhibitor ly450139, acute treatment resulted in a dosedependent decrease in plasma A levels, whereas after chronic treatment there was only a tendency
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Figure 3 | The four categories of biomarker: target, mechanism, pathophysiological and diagnostic. Biomarkers can be categorized into four groupsDrug Discovery on the Nature Reviews | basis of their contribution to business, regulatory and clinical decision-making. Clinical decision-making can be further divided into clinical research and patient care diagnostic subcategories. The objective is to use biomarkers as early as possible in the drug development process. The initial step is to confirm that a test compound hits the target and to quantify the extent to which it does so. Next is to test three concepts in logical sequence. First, that hitting this target alters the pathophysiological mechanism. Second, that altering this mechanism affects the pathophysiology. Third, that affecting pathophysiology predictably improves the clinical status of the patients. Biomarkers qualified to confirm the presence of the target and or extent to which the drug candidate hits the target may be validated later as diagnostic tests for early detection or diagnosis of Alzheimers disease (when that target is expressed differentially between healthy and diseased states). Biomarkers qualified for confirming and quantifying mechanistic effects may be validated later as diagnostic tests to inform choice of therapeutic regimen, either in choice of drug or initial dosing regimen. Biomarkers qualified for longitudinal quantification of patient response in terms of clinically relevant pathophysiology, may be validated later as diagnostic tests for monitoring and individualization of a therapeutic regimen. Biomarkers qualified for either monitoring or individualization of therapy on clinically relevant pathophysiology may also serve as surrogate end points to support regulatory decision-making. In addition, they can be used to ensure appropriateness of use, and as quantifiers of clinical outcomes to support reimbursement decisions.
Established CSF biomarkers. Four CSF biomarkers have been evaluated in a large number of independent studies: A40, A42, total tau and phosphorylated tau59. A 40, A 42 and phosphorylated tau reflect the core elements of the disease process in Alzheimers disease; that is, levels of brain amyloid60,61 and cortical neuro fibrillary pathology 62. Conversely, total tau is a nonspe cific marker for axonal damage that mirrors the activity
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Table 2 | Core CsF candidate biomarkers for alzheimers disease
Analyte (method)
A42 (ELISA; Luminex; Meso Scale Discovery)
Analyte and assay characteristics

Confounding factors evaluated in several publications57,121; assay characteristics, including within-day and between-day CVs, well known57,121,122 Confounding factors evaluated in several publications66; assay characteristics, including within-day and between-day CVs, well known123127 Assay characteristics and CVs published69,130
intra-individual variation
Longitudinal CV for 6 months of 5%72 and CV for 24 months of 7%73 Stable A40 levels during 12 months128 and 24 months129 of assessment
change in Alzheimers disease

Reduction in levels by 50% in Alzheimers disease and in Alzheimers disease with MCI59 Reduction in ratio in Alzheimers disease is more marked than for A42 alone
evaluation notes
Consistent results, for reviews see
REFS 11,66
comments
APP/A metabolism
CSF A42 is the central CSF biomarker for A metabolism
A42/A40 ratio (ELISA)
Data based on a limited number of studies, for review see

REF. 66
CSF A42/A40 ratio may give a more accurate measure of amyloidogenic A metabolism than A42 alone APP isoforms are not diagnostically useful, but may be valuable in clinical trials on, for example, BACE1 inhibitors The diagnostic value of BACE1 activity has to be further evaluated, but may be useful in clinical trials on, for example, BACE1 inhibitors A oligomers are highly promising biomarker candidates; however, very low CSF concentrations make method development difficult Method may be valuable to gauge A production and clearance in clinical trials; method development necessary to measure specific A isoforms, that is, A42 and A40 turnover CSF T-tau is the central CSF biomarker to monitor cortical axonal degeneration in clinical treatment trials
APP isoforms: sAPP, sAPP (ELISA; Meso Scale Discovery)
Not known
No change found in Alzheimers disease69,130
Data based on a limited number of studies
BACE1 (enzyme activity assay)
Assay characteristics, including within-day and between-day CVs, known69,131
Not known
Increase in BACE1 protein levels and activity in Alzheimers disease and in MCI68,69,132,133
Data based on publications using different methods
A oligomers (Bio-Barcode assay with PCR amplification134)
Not known
Not known
Increased CSF levels found in one pilot study134
Early method development
Total A turnover*
Not known
Not known
Not known
Method publication based on healthy volunteers
Total tau (T-tau)

T-tau (ELISA; Luminex) Confounding factors evaluated in several publications122,135,136; assay characteristics, including within-day and between-day CVs, well known57,122,135 Longitudinal CV for 6 months of 6%72 and CV for 24 months of 9%73 Marked increase in levels in Alzheimers disease and in Alzheimers disease with MCI11,59 Consistent results from numerous publications, for reviews see
REFS 11,59
Phosphorylated tau (P-tau)

P-tau 181 (ELISA; Luminex) Confounding factors evaluated in several publications122,135,136; assay characteristics, including within-day and between-day CVs, well known57,122,135 Confounding factors and assay characteristics published137 Longitudinal CV for 6 months of 4%72 and CV for 24 months of 7%73 Marked increase in levels in Alzheimers disease and in Alzheimers disease with MCI11,59 Marked increase in levels in Alzheimers disease and in Alzheimers disease with MCI11,137,138 Consistent results from numerous publications, for reviews see
REFS 11,59
CSF P-tau is the central CSF biomarker to monitor tau phosporylation state in clinical treatment trials CSF P-tau is the central CSF biomarker to monitor tau phosporylation state in clinical treatment trials
P-tau 231 (ELISA)
Increased P-tau 231 levels during 12 months128 and 24 months129 of assessment
Consistent results from numerous publications, for review see REF. 11
A, amyloid-; APP, amyloid precursor protein; BACE1, -site amyloid precursor protein-cleaving enzyme 1; CSF, cerebrospinal fluid; CV, coefficients of variation; MCI, mild cognitive impairment; sAPP, soluble APP. *Infusion of isotope-labelled leucine combined with continuous CSF sampling and immunoprecipitation, tryptic digestion and mass spectrometry measurement of A.
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for a reduction in CSF A42 (REF. 76). Treatment of mon keys with a BACe1 inhibitor resulted in lower CSF A42, A40 and soluble APP levels77. Furthermore, a clinical trial on PBT2, which is suggested to affect metalinduced A aggregation78, showed a dosedependent reduction in CSF A42 levels79. The mechanism underlying the reduc tion in A42 during treatment is unclear. Data from a small clinical study on the amyloidtargeting drug phenserine also suggest that CSF A may be of value for evaluating treatment effects31. Based on longitudinal studies of conditions that involve acute neuronal injury 80,81 and data from the interrupted Phase IIa An1792 trial82, total tau should decrease towards normal levels if a treatment is success ful in inhibiting the neurodegenerative process. The same may be expected for phosphorylated tau 181, which is supported by one pilot study of memantine83. It is currently unknown whether changes in levels of biomarkers, especially for CSF A42, during treatment will be different for Alzheimers disease cases who have low levels of CSF A42 due to deposition in plaques at begin ning of treatment. The degree and direction of change may also depend on the timepoint of sampling after ini tiation of treatment. In summary, these findings support the proposal that CSF biomarkers could be valuable tools to monitor biochemical drug effects in clinical trials. strategies for recruitment to the trial (that is, choosing only those most likely to gain benefit or least likely to suffer an adverse event) can shorten trials and improve the response rate. A successful example of this approach is HeR2/neu (also known as eRBB2) testing in breast can cer for trastuzumab (Herceptin; Genentech) treatment84. Furthermore, biomarkers can be used for withinpatient dose titration during clinical trials, thereby effectively individualizing the therapeutic index. For example, a patient without amyloid plaques in the brain is less likely to respond to a drug that targets A, whereas patients screened into the study with a positive plaque biomarker at baseline may not respond to the low starting dose, therefore warranting escalation to the next dose. Identifying biomarkers at Phase 0. Currently, the efficacy of drugs for Alzheimers disease is assessed in patients clinically diagnosed with symptomatic Alzheimers disease. Although refinements in neuropsy chological testing are facilitating earlier (presumptive) diagnoses, it is hoped that in the future Alzheimers disease can be diagnosed definitively before symptoms become apparent. It is at this stage that the drug has a better chance of efficacy, before the pathological changes in the brain are too advanced for therapeutic interven tion. This is particularly important because of the long duration of pathophysiology changes before Alzheimers disease manifests in cognitive loss, and the shortcomings in clinical diagnosis85. For this purpose, biomarkers of early stages of Alzheimers disease are needed86. There is currently no regulatory framework for which to approve drugs that could treat Alzheimers disease in its presymptomatic stages, so in anticipation of efficacy trials eventually being performed in earlystage disease, and in hope of drugs being approved for asymptomatic Alzheimers disease, Phase 0 trials of potential biomarkers should be started immediately so that the data are avail able to inform design of the Phase IIII trials in early disease87,88. Such a biomarker of earlystage pathophysi olgy would also enable treatment effects to be distin guished from symptomatic improvements, so that the drug can be labelled and prescribed appropriately (and priced accordingly). Such labelling could include dis ease modification claims that were based on the drugs modification of the pathophysiological mechanism89. Conversely, if it is demonstrated that a drug inhibits the target without affecting downstream biomarkers, the drug class and target need reconsideration (TABLE 3). molecular imaging biomarkers are particularly valuable because they provide noninvasive anatomical specifi city for A plaques, tau and neurofibrillary tangles in animals and in humans. Clinical use of Alzheimers disease biomarkers. The most valuable role for biomarkers has been identified by the uS Food and Drug Administration (FDA), and the national Cancer Institute90 as a clinical diagnostic (rather than a surrogate end point). A convergence is occurring between the requirements of biomarkers for quantification of drug effects in research and develop ment, which are analysed as population means with
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industry perspective on biomarkers Monitoring the biochemical effect of new drugs. Biomarkers that are qualified for use in clinical trials to facilitate business and regulatory decisionmaking should also be available as diagnostic agents to enable appropriate prescribing. Therefore, each biomarker will have utility at one stage or another stage of medical product develop ment; that is, from discovery to adoption in clinical prac tice (FIG. 4). moreover, the biomarkers could be used in our proposed diagnostic flow that incorporates risk assess ment screening, diagnosis and prognosis, and monitoring treatment effect (FIG. 3). This diagnostic flow begins with tests that have high sensitivity but low specificity (and low cost) to those that have increasing specificity and potential for longitudinal quantification of treatment benefit.
What an Alzheimers disease biomarker could achieve in drug development. The determination of complete pharmacokinetic and pharmacodynamic relationships in relevant preclinical models shortens and aids objectivity in the selection of drug candidates and doses for clinical development. Given the costs associated with clinical development, the long duration of clinical trials relative to patent life and the difficulty in recruiting participants for clinical trials which is partly due to the multi plicity of drugs being developed and other factors such as patient awareness no drug candidate should enter the clinic without a speciesindependent biomarker as the central element of translational medicine (FIG. 4). In addition to measuring pharmacological and toxico logical effects during clinical trials, as well as efficacy and safety issues that arise postapproval, biomarkers facili tate stratification of the patients and dose optimization based on phenotype or genotype. moreover, enrichment
Phase 0 trial
An exploratory first-in-human trial with single subtherapeutic drug doses and small numbers of subjects to provide first data on drug pharmacokinetics and pharmacodynamics.
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Quantifying treatment effect enables individualization of regimen Diagnostics and clinical decision support inform likelihood of response to treatment Differential diagnostics confirm Alzheimers disease-specific pathophysiology Diagnostic screening plans tailored to risk profile channel patients to more specifc diagnostics Genomics and family history inform screening plans and primary prevention strategies
Posttreatment
Early, individualized treatment with diseasemodifying drugs at optimal therapeutic index
Treatment-specific prognosis Nonspecific, early symptoms
Alzheimers diseasespecific diagnosis
Early detection Sensitive, not specific
Asymptomatic
Screen for risk Sensitive, not specific
Asymptomatic
Figure 4 | Translation of biomarkers. The translation of biomarkers from being research tools that can be used in clinical trials, to being aids in regulatory decision-making and to being commercial diagnostics that can aid clinical decision-making facilitates the efficient selection of different patient populations. When used as research tools, biomarkers can identify a large population of individuals (that is, the base of the pyramid) who may Reviews from low-cost Nature benefit | Drug Discovery and safe primary prevention strategies. Diagnostic biomarkers can be used in smaller populations with early forms of the disease which, when proven by a definitive diagnosis, warrants a more expensive and riskier therapeutic intervention that is tailored to their individual pathophysiology and monitored for efficacy (that is, the pinnacle of the pyramid). This role of biomarkers for diagnostics in individualization of therapy is also enabled by information technology, known as clinical decision support. Different biomarkers such as genomics and molecular imaging will each be useful in a diagnostic flow. This begins with risk assessment (enabling primary prevention) to screening (for early detection and early intervention), to diagnosis and prognosis (for staging and best choice of therapy) and finally to monitoring treatment effect (for true individualization of treatment). This flow starts from tests with high sensitivity but low specificity and low cost to those with increasing specificity and value with potential for longitudinal quantification. Patients will enter at different points in this diagnostic flow (from the bottom to the top of the pyramid) according to the manner in which they present; the two main options being with or without symptoms.
standard errors, and the requirements of diagnostics in clinical practice, which are assessed on a perpatient basis. The common element in this convergence is longitudinal quantification; both analyses require pre treatment and posttreatment effects of the drug to be measured. As diagnostics, biomarkers are of inter est to payers and purchasers of health care for parallel applications. As an example, clinical evidence from the national oncologic PeT Registry resulted in expanded coverage by medicare for FDGPeT/CT. In addition to diagnosis and staging, a new subsequent category was covered, which includes the monitoring of thera peutic benefit. Furthermore, earlier detection of disease facilitates earlier intervention, which, when followed by effective, individualized treatment, will yield better patient outcomes and reduced institutionalization. This is not unique to Alzheimers disease, but is particularly important because of the development of significant pathophysiology before the appearance of symptoms in Alzheimers disease, the inaccessibility of the lesions in the brain, and the need to distinguish between causes of dementia and then discern symptomatic improve ment from disease modification. once a biomarker is proved to be qualified for use (a phrase to be defined by regulatory guidance), withinpatient dose titration
nATuRe ReVIeWS | Drug Discovery
can be incorporated into design of clinical trials and the resultant biomarker data could provide the information necessary for prescribing information to optimize out comes for individuals by dose adjustments in clinical practice (TABLE 3). The biomarkers that are most likely to be utilized for the individualization of therapy are those that are useful in the longitudinal quantification of drug effects during research and development. Who should pay for biomarker development? The costs and risks involved in qualifying biomarkers to satisfy the regulatory authorities, whether as surrogate end points or as a standard biomarker, may be prohibitive for a single company to invest in, but the alternatives of collabora tion or publicprivate partnerships are complex. These costs, risks and complexities could be addressed by the issuance by the FDA, the european medicines Agency (emA) and other regulatory bodies, of harmonized guidelines for biomarker qualification that were more practical than unattainably pure statistical criteria that require capture of both efficacy and safety effects. Such guidelines would clearly outline the linkage between the degree of qualification required and the utility of the biomarker (that is, the biomarker would be qualified for use).
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Table 3 | recommended biomarkers in clinical research and development
Biomarker entry criteria (early diagnosis)*
++ ++ ++ + ++ /+ ++ ++
stratification (prognosis)*
+ + + + /+ /+ ++
Monitoring effect (individualization of treatment)*

/+ ++ ++ ++ /+ + /+ /+ ++
qualification of a biomarker as a surrogate end point might be achieved after marketing. Guidance on co development of therapeutics and diagnostics would also be helpful.
APOE genotype A42, A40 (plasma) A42, A40 (CSF) Tau (CSF) P-tau (CSF) BACE1 (CSF) MR volumetrics MR functional MR spectroscopy FDG-PET Amyloid-PET
not useful; /+ useful in limited circumstances, for example plasma amyloid- (A) for passive immunization; + generally useful; ++ always useful, as discerned from recent meetings of the Alzheimers Association Research Roundtable. APOE, apolipoprotein E; BACE1, -site amyloid precursor protein-cleaving enzyme 1; CSF, cerebrospinal fluid; FDG, 18F-2-fluoro-2-deoxy-dglucose; MR, magnetic resonance; P-tau, phosphorylated tau; PET, positron emission tomography. *Text in parentheses indicates potential application in clinical practice. Measurements in plasma may be confounded due to other proteins present in plasma, and so may not accurately reflect the pathology.
What creates disincentives? The qualification of a biomarker for disease modification requires that the biomarker is shown to capture the treatment benefit of a drug in development, that is, the drug candidate is a positive control. once this correlation between treat ment benefit and biomarker has been achieved for two drugs with the same mechanism of action it might be construed as a surrogate end point for drugs with that mechanism of action. A biomarker that correlated with clinical benefit across drugs with differing mechanisms of action might be construed as a surrogate end point irrespective of mechanism of action. Although companies may collaborate on Phase 0 trials, such as the ADnI (see Further information), trials that aim to measure treatment effect are inher ently linked to specific compounds. The first company to succeed may enter the market earliest but will have taken all the risks, thereby effectively underwriting the qualification of that biomarker for competitors to use in reducing development costs, reducing regulatory risk, and increasing speed to market. When a second com pany successfully deploys that same biomarker, it might elevate it to surrogate end point status, but with the ben efits again accruing to competitors and, ultimately, to the regulators and to patients. An exclusivity provision analogous to that developed for paediatric trials (Guidance for Industry Qualifying for Pediatric Exclusivity Under Section 505A of the Federal Food, Drug, and Cosmetic Act) might compensate for these disincentives; however, more immediately, regula tory guidance on the qualification of biomarkers would be helpful, perhaps rendered less complex by making it specific to particular research platforms (for example, imaging as distinct from in vitro tests). meanwhile, the
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regulatory perspective on biomarkers For regulatory purposes, the efficacy and safety of treat ments are typically determined in at least two separate randomized, doubleblind, placebocontrolled trials that are each of at least 6 months duration. As a further requirement, efficacy must be established in a cognitive domain and a functional (for example, activities of daily living) or global domain (for example, clinical global impression of improvement). Significant differences must be demonstrated in both end points. These co primary outcome measures are required for symptomatic and diseasemodifying approaches in pivotal Phase III studies. However, because of the pattern of symptom progression in Alzheimers disease and depending on the proposed mechanism of action of the drug, attempts to establish that a drug leads to a diseasemodifying effect are likely to require a much longer study duration and alternative trial designs91 compared with trials that measure symptomatic improvements. As a consequence, the use of biomarkers for disease modifying approaches and the search for adequate surrogate end points is encouraged by all stakeholders involved in drug development in europe (for example, the Qualification of novel methodologies for drug development Guidance to applicants by the emA, and the Improved Predictivity of Efficacy Evaluation Brain Disorders by the Innovative medicines Initiative) and the united States92 (for example, the Critical Path Initiative). However, it is necessary to consider specific regulatory requirements when biomarkers are used as outcome measures to assess therapeutic agents particularly those that lead to disease modification for Alzheimers disease.
Biomarkers as surrogate end points. Although the use of biomarkers in earlier phases of drug development is well established, their value in pivotal efficacy studies for Alzheimers disease is still limited. A biomarker is a surro gate end point when it can be considered as a substitution for a clinically relevant end point that is a direct measure of how a patient feels, functions or survives, and can be expected to predict the effect of and allow measurement of the specific therapy 93,94 (BOX 2) . However, even a per fect correlation between the level of marker with stage of disease in the untreated state is not sufficient to accept a biomarker as a surrogate for a clinical end point95,96. none of the imaging or biochemical markers has been suffi ciently qualified as a surrogate end point in Alzheimers disease. There should be a link between a treatment induced change in the biomarker and the desired clinical outcome measure, as well as a link between the treatment induced change in the biomarker and change of disease process95,96. Additionally, based on the assumed mecha nism of action of a given compound, there should be high plausibility (for example, based on preclinical models) that the disease process will be modified.
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Box 2 | Qualification of a surrogate end point
Listed below are some aspects that need to be addressed when qualifying a biomarker as a surrogate end point: Plausible connection between basic science and clinical trials Is there a strong, independent, consistent association between surrogate end point and clinical outcome (necessary, not sufficient)? Evidence from randomized clinical trials that improvements in the surrogate end point leads consistently to improvement of the target outcome Large, precise, and lasting treatment effects Are the likely benefits worth the potential harms and costs?
So, although the use of biomarkers as primary out come measures (that is, surrogate end points) in pivotal efficacy trials is unlikely at this time, they can currently be used to allow decisionmaking on other aspects of drug development. For instance, they can be used in Phase II studies (for example, proof of concept, dose finding) as primary prespecified outcome measures or to better define patient populations at risk (for example, enrich ing populations likely to respond to therapy) for efficacy trials (BOX 3). The use of biomarkers in these ways may allow Phase II studies to be shorter or smaller in size, and if potential biomarkers can be qualified as surrogate end points, definitive effectiveness trials may also be con siderably shorter and/or smaller than studies that use traditional clinical outcomes as primary end points. Problems and concerns with using biomarkers as surrogate end points. As noted above, the reliance on the drugs pharmacological effect to modulate levels of a biomarker that has not been qualified for use as a surrogate end point has interpretative problems. For example, it is assumed that a treatment that is efficacious in Alzheimers dis ease will slow the progression of medial temporal lobe atrophy as measured by mRI. However, in the trial with the vaccine An1792 the extent of brain atrophy seemed to increase in patients that had increased antibodies to A and that showed clinical improvement97. This was an entirely unexpected outcome, and provides evidence that the effects of a treatment (even a potentially beneficial treatment) on a biomarker can be unpredictable.
Box 3 | regulatory view: potential use of biomarkers in clinical trials
Cerebrospinal fluid markers (for example, increased phosphophorylated tau and decreased amyloid-1-42 levels) are helpful as trait markers of Alzheimers disease that have high sensitivity and specificity. However, they have yet to show value as markers of disease state. Brain imaging (for example, magnetic resonance imaging (MRI) of the medial temporal lobe) can be helpful as trait markers for enrichment of populations at risk of developing Alzheimers disease, and serial MRI can be helpful as a marker of disease state. Brain imaging can also be used as an end point in dose-finding or proof-of-concept studies, and as a secondary end point in pivotal studies. Other brain imaging techniques such as positron emission tomography (PET) of amyloid- or regional glucose (18F-2-fluoro-2-deoxy-d-glucose; FDG) metabolism can also be helpful as a trait marker. FDG-PET is potentially useful as a marker of disease state in proof-of-concept studies and as a secondary end point in pivotal studies.
of more concern though are potential cases in which the desired effect on a nonvalidated biomarker is achieved. If the clinical effects of a medicinal prod uct are unknown, then concluding that the drug has a beneficial effect for the patients would be based on the assumption that the desired effect seen on the biomar ker will translate into the desired beneficial clinical effect. If this assumption is wrong, a drug that has no beneficial effect (or even, perhaps, a deleterious effect) might be approved. It is for this reason that approval of a treatment for Alzheimers disease based on an effect on a biomarker alone (that is, a surrogate end point) is unlikely at this time. However, as outlined in other sec tions, there is progress with some biomarkers towards validation for this purpose. As a general principle, if it is possible to ascertain effects of a drug on clinical out comes in trials of reasonable size and duration, it is likely that approval of the drug will not be granted if the study has examined biomarkers as primary outcomes. That is, a clinical outcome is preferable to a biomarker. The use of biomarkers as surrogate end points is likely to be considered in settings in which clinical outcomes can not be practically assessed; for example, in studies that examine prevention of Alzheimers disease in which the clinical outcomes (such as the time of onset of clinical Alzheimers disease) may not occur for many years after treatment initiation. neurochemical markers from CSF that have high sensitivity and specificity for Alzheimers disease may be considered helpful for diagnostic purposes, whereas addition of a neuroimaging tool such as mRI or amyloid PeT may also offer the possibility to assess the effects of a particular treatment in these populations. multicentre and worldwide activities such as those carried out by the ADnI which use several prespecified neurochemi cal and neuroimaging biomarkers, and standardization across sites and platforms98,99 should help in further qualification of at least some of these biomarkers. Creating innovation in biomarker development. Regulatory bodies such as the FDA and the emA have identified development of biomarkers as a high prior ity in general and particularly in dementia. To foster innovation in this field, consortia like the Biomarker Consortium, the Critical Path Initiative and the Innovative medicines Initiative, which involve collabo ration of the different stakeholders, are highly welcomed and proactively supported. We think that such public private partnerships (BOX 4) encourage detection and development of new biomarkers and improve consensus on the requirements of their validation process. This will be supported by the ongoing dialogue on harmo nization of regulatory practices between the emA and the FDA, and both organizations will consider the expe rience with biomarkers in other fields for example, oncology or cardiovascular medicine for Alzheimers disease. Therefore regulators encourage the different stakeholders to involve regulatory bodies as early on as possible in biomarker development to accomplish better coordination of regulatory requirements and ongoing research in the different stages of drug development.
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Box 4 | Publicprivate partnerships
Like any scientific endeavour that involves multiple disciplines, biomarker development requires a high degree of collaboration between stakeholders so that basic research can be translated into clinical decisions. Although incremental progress is possible within individual organizations, this will be limited by resources and the intellectual capital possessed by these organizations. Furthermore, while an organization may be capable of investing significant resources towards the development of a particular biomarker in a given pathology or area of research, it is not likely to obtain a return on its investment if there is no complementary diagnostic product for Alzheimers disease on the market. Biomarker development that is independent of marketable products is not a feasible or sustainable business model. Therefore, significant advances in this field are more likely to be achieved through joint investments and pooling of resources and expertise, with the payback being sharing outcomes and results, such as clinical trial data, that will stimulate competition in the marketplace and product development. There are many examples of strategic alliances that span multiple industries that were established with different goals103. The Biomarker Consortium is an example in which government agencies, academic institutions, industry, patient advocacy and professional organizations have assembled to bridge gaps in biomarker development. Public-health gaps in several disease areas are addressed including oncology, neuroscience, metabolic disorders, and immunity and inflammation. The Alzheimers disease Neuroimaging Initiative (ADNI) is a publicprivate partnership that tracks normal individuals, patients with mild cognitive impairment and patients with Alzheimers disease over a 5-year period. The ADNI aims to use the latest technologies and platforms to map out morphological changes in the human brain and to correlate them to disease progression. Analogous programmes have been initiated in Europe (the ADNI of the European Alzheimers disease Commission), Japan, and Germany (the Competence Network on Dementia). Ultimately, it is hoped that these studies will inform medical product development and bring safer, more effective and cheaper therapies to patients.
Discussion and perspectives There is a consensus between academic institutions, industry and regulatory authorities that there are three potential uses of biomarkers in clinical trials. one use is as diagnostic tools to enrich the sample of patients with Alzheimers disease and to exclude other causes of dementia for which symptoms resemble Alzheimers dis ease. However, this could restrict the clinical indication of the investigational compound in the general popula tion. Furthermore, as drug candidates with a disease modifying effect can be expected to be most effective in the earlier stages of the disease, biomarkers would be essential for early disease detection. A second use of biomarkers is to identify and monitor the biochemical effect of a drug to facilitate drug develop ment. This would increase the predictive power of non imaging biomarkers when translating drug effects from mouse models of Alzheimers disease to the clinical set ting. of the more than 40 molecules that reduce plaque burden in these animal models1 several lack preventive or clinical effect in treating patients with Alzheimers dis ease. In addition, small, shortterm clinical trials using
biomarkers can verify a biochemical effect of disease modifying drug candidates, before the expensive and timeconsuming step is taken to larger Phase II or III clinical trials. Indeed, biomarkers have already been implemented in Phase I and II studies in patients with Alzheimers disease, and are noncontroversial for regula tors. But before a biomarker can be used as surrogate end points in Phase III studies, a link between the treatment induced change in the biomarker and the desired clinical outcome has to be established. largescale worldwide multicentre initiatives, such as the ADnI100,101, will support validation and qualification efforts in this respect. A third application of biomarkers in clinical trials is to enable early and specific detection of side effects of the drug. As an example, in A immunotherapy trials there is a risk of encephalitis10 and vasogenic oedema102, which may be difficult to identify clinically, but are easily detected by mRI and CSF analyses. Furthermore, if longi tudinal mRI and CSF measures are part of a clinical trial, this can provide definitive information that a drug candi date is not associated with this type of adverse events. Although several mRI, PeT and CSFbased biomar kers have proved useful as diagnostic markers in clinical trials, there are only some reports suggesting that biomar kers may identify and monitor the effect of the drug on the neurodegenerative process70,79,82, and there are no qualified surrogates for the clinical end point. It is hoped that the involvement of regulatory authorities as early on as pos sible in the biomarker discovery process will accomplish better coordination of regulatory requirements for the qualification of biomarkers, and that biomarker consor tia, with strong collaboration of the different stakehold ers, will foster the ongoing dialogue on harmonization of regulatory practices between the emA and the FDA. Another challenge is the lack of drugs with an established diseasemodifying effect that can be used to validate that a certain biomarker will correlate with the biochemical effect of the drug and therefore predict the clinical outcome. At the same time, evidence that a drug candidate affects the central disease process and the characteristic neuropathology will be required to label the drug as diseasemodifying. This dual depend ency introduces a catch22like situation in Alzheimers disease drug development and biomarker research. nevertheless, there are numerous ongoing clinical tri als on diseasemodifying drug candidates that include biomarkers as end points. These trials will successively provide accumulating evidence on whether biomarkers will be useful as proofofconcept tools for the intended mechanism of action of a compound, as surrogate end points to predict the clinical outcome, and as the basis for a diseasemodifying claim of the drug.
1. 2. 3.
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Acknowledgements
The authors would like to thank K. Duggan for technical assistance. H.H. acknowledges support by the Science Foundation Ireland Investigator Neuroimaging Grant Programme (08/IN.1/ B1846).
Competing interests statement
The authors declare competing financial interests: see web version for details.
DaTabases
Entrez Gene: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=gene APOE | APP | CLU | CR1 | MAPT | PICALM | PSEN1 | PSEN2 OMIM: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM Alzheimers disease UniProtKB: http://www.uniprot.org BACE1
FUrTHer iNFormaTioN
ADNI: http://www.adni-info.org ADNI clinical trial: http://www.alzheimers.org/clinicaltrials/ fullrec.asp?PrimaryKey=208 Alzheimers Association Research Roundtable: http://www.alz.org/professionals_and_researchers_ research_roundtable.asp Guidance for Industry Qualifying for Pediatric Exclusivity Under Section 505A of the Federal Food, Drug, and Cosmetic Act: http://www.fda.gov/downloads/Drugs/Development ApprovalProcess/DevelopmentResources/UCM049924.pdf Improved Predictivity of Efficacy Evaluation Brain Disorders: http://www.imi-europe.org/Lists/ IMIPublicationDocuments/3_%20Improved%20 Predictivity%20of%20Efficacy%20Evaluation%20-%20 Brain%20Disorders.pdf Qualification of novel methodologies for drug development Guidance to applicants: http://www.ema.europa.eu/pdfs/ human/biomarkers/7289408en.pdf The Biomarkers Consortium: http://www.biomarkersconsortium.org The Critical Path Initiative: http://www.fda.gov/ScienceResearch/SpecialTopics/ CriticalPathInitiative/ucm204289.htm
sUPPLemeNTarY iNFormaTioN
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Biomarkers for Alzheimers disease: academic, industry and regulatory perspectives

560 | july 2010 | Volume 9

Primary end point

Surrogate end point

Secondary end point

Disease modifying Symptomatic Placebo Time

Disease modifying Symptomatic Placebo Time

Manual volumetry of hippocampus

Automated whole brain volumetry

Positron emission tomography (PET)

Glucose (FDG) consumption

Effects of cholinergic treatment on cortical metabolism in Alzheimers disease117,118

Amyloid (11C- PIB)

AN1792 vaccination trial

2010 Macmillan Publishers Limited. All rights reserved

Analyte and assay characteristics

change in Alzheimers disease

A42/A40 ratio (ELISA)

Data based on a limited number of studies, for review see

APP isoforms: sAPP, sAPP (ELISA; Meso Scale Discovery)

No change found in Alzheimers disease69,130

Data based on a limited number of studies

BACE1 (enzyme activity assay)

Assay characteristics, including within-day and between-day CVs, known69,131

Data based on publications using different methods

A oligomers (Bio-Barcode assay with PCR amplification134)

Increased CSF levels found in one pilot study134

Early method development

Method publication based on healthy volunteers

Total tau (T-tau)

Phosphorylated tau (P-tau)

P-tau 231 (ELISA)

Increased P-tau 231 levels during 12 months128 and 24 months129 of assessment

Consistent results from numerous publications, for review see REF. 11

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Early, individualized treatment with diseasemodifying drugs at optimal therapeutic index

Treatment-specific prognosis Nonspecific, early symptoms

Alzheimers diseasespecific diagnosis

Early detection Sensitive, not specific

Screen for risk Sensitive, not specific

2010 Macmillan Publishers Limited. All rights reserved

Monitoring effect (individualization of treatment)*

2010 Macmillan Publishers Limited. All rights reserved

10. 11. 12.

17. 18. 19. 20. 21. 22. 23.

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Competing interests statement

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