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Effects of Xanomeline, a Selective Muscarinic Receptor Agonist, on Cognitive Function and Behavioral Symptoms in Alzheimer Disease

Neil C. Bodick, MD, PhD; Walter W. Offen, PhD; Allan I. Levey, MD, PhD; Neal R. Cutler, MD; Serge G. Gauthier, MD; Andrew Satlin, MD; Harlan E. Shannon, PhD; Gary D. Tollefson, MD, PhD; Kurt Rasmussen, PhD; Frank P. Bymaster, MS; Daniel J. Hurley, MD; William Z. Potter, MD, PhD; Steven M. Paul, MD
Arch Neurol. 1997;54(4):465-473. doi:10.1001/archneur.1997.00550160091022.
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Objective:  To evaluate the therapeutic effects of selective cholinergic replacement with xanomeline tartrate, an ml and m4 selective muscarinic receptor (mAChR) agonist in patients with probable Alzheimer disease (AD).

Design:  A 6-month, randomized, double-blind, placebocontrolled, parallel-group trial followed by a 1-month, single-blind, placebo washout.

Setting:  Outpatients at 17 centers in the United States and Canada.

Participants:  A total of 343 men and women at least 60 years of age with mild to moderate AD.

Interventions:  Patients received 75, 150, or 225 mg (low, medium, and high doses) of xanomeline per day or placebo for 6 months.

Outcome Measures:  Scores on the cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-Cog), the Clinician's Interview-Based Impression of Change (CIBIC+), the Alzheimer's Disease Symptomatology Scale (ADSS), and the Nurses' Observational Scale for Geriatric Patients (NOSGER).

Results:  A significant treatment effect existed for ADAS-Cog (high dose vs placebo; P≤.05), and CIBIC+ (high dose vs placebo; P≤.02). Treatment Emergent Signs and Symptoms analysis of the ADSS, which assesses behavioral symptoms in patients with AD, disclosed significant (P≤.002) dose-dependent reductions in vocal Out-bursts, bursts, suspiciousness, delusions, agitation, and hallucinations. On end-point analysis, NOSGER, which assesses memory, instrumental activities of daily living, self-care, mood, social behavior, and disturbing behavior in the elderly, also showed a significant dose-response relationship (P≤.02). In the high-dose arm, 52% of patients discontinued treatment because of adverse events; dose-dependent adverse events were predominantly gastrointestinal in nature. Syncope, defined as loss of consciousness and muscle tone, occurred in 12.6% of patients in the high-dose group.

Conclusions:  The observed improvements in ADAS-Cog and CIBIC+ following treatment with xanomeline provide the first evidence, from a large-scale, placebo-controlled clinical trial, that a direct-acting muscarinic receptor agonist can improve cognitive function in patients with AD. Furthermore, the dramatic and favorable effects on disturbing behaviors in AD suggest a novel approach for treatment of noncognitive symptoms.


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