Patent Publication Number: US-2006004086-A1

Title: Method of reducing Abeta42 and treating diseases

Description:
CROSS REFERENCE TO RELATED APPLICATIONS  
      This application is a continuation-in-part of U.S. application Ser. No. 10/012,606, filed Dec. 7, 2001, now U.S. Pat. No. 6,911,466, which is a continuation-in-part and claims priority of PCT Application PCT/US01/11956, filed Apr. 12, 2001, which claims the benefit of U.S. Provisional Application No. 60/196,617, filed Apr. 13, 2000, all of which are herein incorporated by reference in their entireties. 
    
    
     STATEMENT AS TO FEDERALLY SPONSORED RESEARCH  
      Funding for the work described herein was provided, in part, by the federal government, which may have certain rights in the invention. 
    
    
     BACKGROUND  
      1. Technical Field  
      The invention relates to the use of Aβ 42  lowering agents to prevent, delay, or reverse the progression of Alzheimer&#39;s disease. The invention also relates to methods and materials involved in identifying Aβ 42  lowering agents that can be used to prevent, delay, or reverse Alzheimer&#39;s disease as well as methods and materials involved in identifying agents that (1) increase the risk of developing or (2) hasten the progression of Alzheimer&#39;s disease in a mammal.  
      2. Background Information  
      Alzheimer&#39;s disease (AD) is the most common form of age-related neurodegenerative illness. The defining pathological hallmarks of AD are the presence of neurofibrillary tangles and senile plaques in the brain. Amyloid β polypeptides (Aβ) are the major constituents of amyloid plaques and are derived from altered processing of amyloid precursor proteins (APPs). Aβ consists predominantly of two forms, Aβ 40  and Aβ 42 . Although Aβ 40  is the predominant form, recent evidence suggests that Aβ 42  is the pathogenic form. In addition to Aβ 40  and Aβ 42 , the processing of APP generates other Aβ forms such as Aβ 39 , Aβ 38 , Aβ 37 , and Aβ 34 .  
      Genetic predisposition is the largest cause of AD in the population, accounting for perhaps 50% or more cases of this disorder (Blacker et al. (1998)  Arch Neurol  55:294-6). In the past decade, epidemiological evidence suggests that non-steroidal anti-inflammatory drug (NSAID) treatment, estrogen replacement therapy, and antioxidant therapy may have beneficial effects in AD. Experimental support for these treatment methods, however, is indirect. In addition, there is no convincing evidence from randomized clinical trials that any medication tested to date slows the progression of AD. The rational development of compounds that influence key pathways or targets involved in the development of AD is critically important.  
     SUMMARY  
      The invention relates to the use of Aβ 42  lowering agents to prevent, delay, or reverse the progression of AD. The invention is based on the discovery that some but not all NSAIDs useful for treating AD are those that can selectively reduce the level of the pathogenic Aβ 42  form, do not affect the level of Aβ 40 , and increase levels of Aβ forms smaller than Aβ 40  such as Aβ 38 . More specifically, the invention provides methods and materials related to identifying Aβ 42  lowering agents, including NSAIDs, NSAID derivatives, and NSAID analogues, that (1) can reduce the level of Aβ 42  by reducing APP processing into Aβ 42  or by increasing Aβ 42  catabolism; (2) increase the level of Aβ 38  by increasing APP processing into Aβ 38 ; and (3) have increased selectivity for reduction of Aβ 42  relative to inhibition of COX-1, COX-2, or both COX-1 and COX-2. In addition, the invention provides methods and materials related to identifying agents that can increase the risk of developing AD, or hasten the progression of AD, in a mammal. The invention also provides compositions and kits that can be used to prevent, delay, or reverse the progression of AD.  
      In one embodiment, the invention provides a method of preventing, delaying, or reversing the progression of AD by administering an Aβ 42  lowering agent to a mammal under conditions in which levels of Aβ 42  are reduced, levels of Aβ 38  are increased, and levels of Aβ 40  are unchanged. The Aβ 42  lowering agent also can increase the levels of one or more of Aβ 34 , Aβ 36 , Aβ 37 , and Aβ 39 .  
      The Aβ 42  lowering agent can be an NSAID, an NSAID derivative, an NSAID analogue, or any compound that reduces levels of Aβ 42 , increases levels of Aβ 38 , and has no effects on levels of Aβ 40 , (i.e., levels of Aβ 40  are neither increased nor decreased). The Aβ 42  lowering agent can be an aryl propionic acid derivative, an aryl acetic acid derivative, or an amino carboxylic acid derivative. More specifically, the Aβ 42  lowering agent can be a structural derivative of an NSAID such as flufenmic acid, meclofenamic acid, fenoprofen, carprofen, ibuprofen, ketoprofen, and flurbiprofen. The Aβ 42  lowering agent also can be a structural derivative of 5-nitro-2-(3-phenylpropylamino) benzoic acid). Typically, the Aβ 42  lowering agent either (1) lacks COX-1, COX-2, or both COX-1 and COX-2 inhibiting activity, or (2) has a greater potency for lowering Aβ 42  levels than for inhibiting COX-1, COX-2, or both COX-1 and COX-2 activity. In one embodiment, the Aβ 42  lowering agent is R-flurbiprofen.  
      Aβ 42  lowering agents of the invention can be used to treat AD in a mammal such as a human. The mammal may not be diagnosed with AD, or may not have a genetic predisposition for AD.  
      In another embodiment, the invention provides a method for developing an Aβ 42  lowering agent. The method involves generating derivatives of the NSAIDs meclofenamic acid or flufenamic acid by altering the position of the carboxylic acid group on the phenyl ring or altering the position or type of substituents on the phenyl ring opposite the carboxylic acid group. Derivatives also can be generated by altering the bond connecting the two phenyl rings, altering the carboxylic acid group to propionic acid or another substituent, or performing any combination of these alterations. The derivative is then tested to determine its ability to decrease Aβ 42  levels while increasing Aβ 38  levels.  
      In another embodiment, the invention provides a method for developing an Aβ 42  lowering agent. The method involves generating derivatives of the NSAIDs fenoprofen, flurbiprofen, or carprofen. Derivatives can be generated by altering the position of the propionic acid group on the phenyl ring, or altering the position or type of substituents on the phenyl ring opposite the propionic acid group. Derivatives also can be generated by altering the bond connecting the two phenyl rings, altering the acetic acid group to carboxylic acid or another substituent, or performing any combination of these alterations. The derivative is then tested to determine its ability to decrease Aβ 42  levels while increasing Aβ 38  levels.  
      In another embodiment, the invention provides a method for developing an Aβ 42  lowering agent. The method involves generating derivatives of indomethacin by altering the carboxylic acid group to another substituent, altering the indole nitrogen to another substituent, or performing any combination of these alterations. The derivative is then tested to determine its ability to decrease Aβ 42  levels while increasing Aβ 38  levels.  
      In another embodiment, the invention provides a method for developing an Aβ 42  lowering agent. The method involves generating derivatives of sulindac sulfide by altering the methylthiol group, the propionic acid group, or the fluoride moiety to another substituent, or performing any combination of these alterations. The derivative is then tested to determine its ability to decrease Aβ 42  levels while increasing Aβ 38  levels.  
      In another embodiment, the invention provides a method for identifying an Aβ 42  lowering agent useful for preventing, delaying, or reversing the progression of Alzheimer&#39;s disease. The method involves treating a biological composition that has APP and an APP processing activity with a candidate Aβ 42  lowering agent under conditions in which APP processing occurs. An Aβ 42  lowering agent, useful for preventing, delaying, or reversing the progression of Alzheimer&#39;s disease, is one that, when present, decreases the level of Aβ 42  in the biological composition.  
      In another embodiment, the invention provides a method for identifying an Aβ 42  lowering agent useful for preventing, delaying, or reversing the progression of Alzheimer&#39;s disease. The method involves treating a biological composition that has Aβ 42  and an Aβ 42  catabolic activity with a candidate Aβ 42  lowering agent under conditions in which Aβ 42  catabolism occurs. An Aβ 42  lowering agent, useful for preventing, delaying, or reversing the progression of Alzheimer&#39;s disease, is one that, when present, decreases the level of Aβ 42  in a biological composition.  
      In another embodiment, the invention provides a method for identifying an Aβ 42  lowering agent that has a greater potency for lowering Aβ 42  levels than for inhibiting COX-1, COX-2, or both COX-1 and COX-2 activity. The method involves identifying Aβ 42  lowering agents by screening for those having the ability to lower the level of Aβ 42  in a biological composition. The IC50 of the Aβ 42  lowering agent for Aβ 42  lowering can be determined by performing dose response studies. The Aβ 42  lowering agent is examined for the ability to inhibit COX-1, COX-2, or both COX-1 and COX-2 using in vitro COX-1 and COX-2 inactivation assays. The IC50 for Aβ 42  lowering is compared to the IC50 for COX-1, COX-2, or both COX-1 and COX-2 inhibition. An Aβ 42  lowering agent that has an greater potency for lowering Aβ 42  levels than for inhibiting COX-1, COX-2, or both COX-1 and COX-2 activity is one that has an IC50 for Aβ 42  lowering greater than ten-fold the IC50 for COX-1, COX-2, or both COX-1 and COX-2 inhibition. The greater potency for lowering Aβ 42  levels than for inhibiting COX-1, COX-2, or both COX-1 and COX-2 activity can be confirmed by demonstrating that administration of the Aβ 42  lowering agent to an animal reduces Aβ 42  levels at doses that do not inhibit or only minimally inhibit COX-1, COX-2, or both COX-1 and COX-2 activity such that significant COX-related side-effects do not occur.  
      In another embodiment, the invention provides a method for identifying an agent that increases the risk of developing, or hastens progression of, AD in a patient. The method involves exposing a biological composition that has APP and an APP processing activity to a candidate agent under conditions in which APP processing occurs. The level of Aβ 42  in the biological composition exposed to the candidate agent is compared to the level of Aβ 42  in a biological composition not exposed to the candidate agent. The candidate agent is one that can increase the risk of developing, or hasten the progression of, AD if an increase in the level of Aβ 42  in the biological composition exposed to the agent is observed when compared with the level of Aβ 42  in the biological composition not exposed to the agent.  
      In another embodiment, the invention provides a method for identifying an agent that increases the risk of developing, or hastens progression of, AD in a patient. The method involves exposing a biological composition that has Aβ 42  and an Aβ 42  catabolic activity to a candidate agent under conditions in which Aβ 42  catabolism occurs. The level of Aβ 42  in the biological composition exposed to the candidate agent is compared to the level of Aβ 42  in a biological composition not exposed to the candidate agent. The candidate agent is one that can increase the risk of developing, or hasten the progression of, AD if an increase in the level of Aβ 42  in the biological composition exposed to the agent is observed when compared with the level of Aβ 42  in the biological composition not exposed to the agent.  
      In another embodiment, the invention provides a composition consisting of an Aβ 42  lowering agent and an antioxidant. The antioxidant can be, without limitation, vitamin E, vitamin C, curcumin, and Gingko biloba.  
      In another embodiment, the invention provides a composition consisting of an Aβ 42  lowering agent and a non-selective secretase inhibitor.  
      In another embodiment, the invention provides a composition consisting of an Aβ 42  lowering agent and an acetylcholinesterase inhibitor.  
      In another embodiment, the invention provides kits containing (1) an Aβ 42  lowering agent and an antioxidant; (2) an Aβ 42  lowering agent and a non-selective secretase inhibitor; or (3) an Aβ 42  lowering agent and an acetylcholinesterase inhibitor. Kits can include instructions that indicate dose regimens for the Aβ 42  lowering agent, the antioxidant, the secretase inhibitor, and/or the acetylcholinesterase inhibitor.  
      In another embodiment, the invention provides for the use of an Aβ 42  lowering agent in the manufacture of a medicament for the treatment of AD. When administered to a patient, the medicament containing the Aβ 42  lowering agent is effective for reducing Aβ 42  levels without affecting Aβ 40  levels. The medicament also can increase Aβ 38  levels, and may also increase Aβ 34 , Aβ 36 , Aβ 37 , or Aβ 39  levels. The Aβ 42  lowering agent in the medicament can be an aryl propionic acid derivative, an aryl acetic acid derivative, or an amino carboxylic acid derivative. More specifically, the Aβ 42  lowering agent in the medicament can be a structural derivative of an NSAID selected from the group consisting of flufenmic acid, meclofenamic acid, fenoprofen, carprofen, ibuprofen, ketoprofen, and flurbiprofen. The Aβ 42  lowering agent also can be a structural derivative of 5-nitro-2-(3-phenylpropylamino)benzoic acid). The Aβ 42  lowering agent in the medicament can lack COX-1, COX-2, or both COX-1 and COX-2 inhibiting activity. The Aβ 42  lowering agent in the medicament can have a greater potency, in vivo, for lowering Aβ 42  levels than for inhibiting COX-1, COX-2, or both COX-1 and COX-2 activity. The medicament can be used to treat AD in a mammal such as a human. The medicament can be used in a mammal that has not been diagnosed with AD, or in a mammal that does not have a genetic predisposition for AD.  
      Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention pertains. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, suitable methods and materials are described below. All publications, patent applications, patents, and other references mentioned herein are incorporated by reference in their entirety. In case of conflict, the present specification, including definitions, will control. In addition, the materials, methods, and examples are illustrative only and not intended to be limiting.  
      Other features and advantages of the invention will be apparent from the following detailed description, and from the claims. 
    
    
     DESCRIPTION OF DRAWINGS  
       FIG. 1  is a bar graph summarizing Aβ 42 /Aβ 40  ratios and total Aβ levels determined for CHO cells expressing APP751 and PS-1 mutant M146L that had been treated with DMSO or with various concentrations of sulindac sulfide.  
       FIG. 2  is a bar graph summarizing Aβ 42 /Aβ 40  ratios and total Aβ levels determined for human neuroglioma cells (HS683) expressing APP695 that had been treated with DMSO or with various concentrations of sulindac sulfide.  
       FIG. 3  is a bar graph summarizing Aβ 42 /Aβ 40  ratios and total Aβ levels determined for CHO cells expressing APP751 and PS-1 mutant M146L that had been treated with ethanol or with various concentrations of ibuprofen.  
       FIG. 4  is a bar graph summarizing Aβ 42 /Aβ 40  ratios and total Aβ levels determined for CHO cells expressing APP751 and PS-1 mutant M146L that had been treated with DMSO or with various concentrations of indomethacin.  
       FIG. 5  is a bar graph summarizing Aβ 42 /Aβ 40  ratios and total Aβ levels determined for CHO cells expressing APP751 that had been treated with DMSO or with various concentrations of naproxen.  
       FIG. 6  is a bar graph comparing Aβ 42 /Aβ 40  ratios and total Aβ levels in CHO cells expressing APP751 that had been treated with ethyl acetate or various concentrations of celecoxib.  
       FIG. 7  is a bar graph summarizing Aβ 42 /Aβ 40  ratios and total Aβ levels determined for primary fibroblasts (from COX-1/COX-2 double-knockout mice) expressing APP 695 that had been treated with DMSO or various concentrations of sulindac sulfide.  
       FIG. 8  is two representative mass spectra of Aβ species secreted by CHO cells expressing APP751 after treatment with DMSO or 100 μM sulindac sulfide.  
       FIG. 9  is a bar graph illustrating ratios of Aβ 1-42 , Aβ 1-39 , Aβ 1-38 , and Aβ 1-37  to Aβ 1-40  in cells treated with DMSO or sulindac sulfide.  
       FIG. 10  is a scattergram of Aβ 40  and Aβ 42  levels in the brains of Tg2576 mice after short-term NSAID treatment.  
       FIG. 11  is a summary of the structures of indomethacin and meclofenamic acid, possible side chain modifications, and the effects of these modifications on COX-1 and COX-2 activities.  
       FIG. 12  is a compilation of the structures of newly synthesized biphenyl amines.  
       FIG. 13  is a time course of Aβ 42  reduction in CHO APP695NL,I,his cell cultures treated with meclofenamic acid.  
       FIG. 14  is a bar graph illustrating the effect of NSAIDs on Aβ42 production in H4 APP 695 wild type cells. Cells treated with the vehicle (DMSO) alone were used as controls.  
       FIG. 15  is a bar graph comparing the effect of the S and R enantiomers of flurbiprofen and the effect of a mixture of R+S enantiomers on brain Aβ 42  levels in Tg2576 mice. Data are expressed as a % of the control. Both the mixture of R+S enantiomers and R-flurbiprofen alone lower Aβ 42  levels in 3-month old Tg2576 mouse brains (p&lt;0.01). 
    
    
     DETAILED DESCRIPTION  
      The invention relates to the use of Aβ 42  lowering agents to prevent, delay, or reverse the progression of AD. The invention is based on the discovery that some but not all NSAIDs useful for treating AD are those that can reduce the level of the pathogenic Aβ 42  form and increase the levels of Aβ forms smaller than Aβ 40  such as Aβ 38 . Therefore, the invention provides methods and materials related to identifying Aβ 42  lowering agents, including NSAIDs, NSAID derivatives, and NSAID analogues that (1) can reduce the level of Aβ 42  by reducing APP processing into Aβ 42  or by increasing Aβ 42  catabolism; (2) increase the level of Aβ 38  by increasing APP processing into Aβ 38 ; and (3) have increased selectivity for reduction of Aβ 42  relative to inhibition of COX-1, COX-2, or both COX-1 and COX-2. In addition, the invention provides methods and materials related to identifying agents that can increase the risk of, or hasten the progression of, AD in a mammal, by increasing the processing of APP into Aβ 42 , or decreasing the catabolism of Aβ 42 . The invention also provides compositions and kits that can be used to prevent, delay, or reverse the progression of AD.  
      1. Aβ 42  Lowering Agents  
      Aβ 42  lowering agents include, without limitation, NSAIDs, NSAID derivatives, and NSAID analogues. NSAIDs can be FDA-approved NSAIDs. NSAID derivatives are compounds generated by modifying functional groups of known NSAIDs. Once modified, derivatives may or may not have the anti-inflammatory properties of the parent NSAIDs. Structural analogues of NSAIDs are compounds that are structurally similar to NSAIDs. Analogues also may not have the anti-inflammatory properties of the corresponding structurally similar NSAIDs to which they resemble. Analogues can also be specific enantiomers of an NSAID drug that is racemic.  
      NSAIDs are non-steroidal anti-inflammatory drugs that are distinct from steroidal drugs with anti-inflammatory properties such as corticosteroids. NSAIDs, many of which are organic acids, typically have analgesic (pain-killing), anti-inflammatory, and antipyretic (fever-reducing) properties. Some examples of NSAIDs include salicylic acid (Aspirin), ibuprofen (Motrin, Advil), naproxen (Naprosyn), sulindac (Clinoril), diclofenac (Voltaren), piroxicam (Feldene), ketoprofen (Orudis), diflunisal (Dolobid), nabumetone (Relafen), etodolac (Lodine), oxaprozin (Daypro), Meclofenamic acid (Meclofen) and indomethacin (Indocin). NSAIDs can be grouped into classes, for example, amino aryl carboxylic acid derivatives (e.g., flufenamic acid, meclofenamic acid); aryl acetic acid derivatives (e.g., indomethacin, sulindac); and aryl propionic acid derivatives (fenoprofen, ibuprofen, carprofen and flurbiprofen).  
      Although NSAIDs have multiple cellular effects (see Cronstein et al. (1995)  Annu Rev Pharmacol Toxicol  35:449-62; and Amin et al. (1999)  Cell Mol Life Sci  56:305-12), many act through direct inhibition of COX enzymes. COX enzymes oxidize arachidonic acids from membrane bound phospholipids to prostaglandins (see Smith et al. (2000)  Ann Rev Biochem  69:145-82). Inhibition of COX enzymes and therefore prostaglandin synthesis is believed to underlie the analgesic and anti-inflammatory properties of aspirin and NSAIDs (see Dubois et al. (1998)  FASEB J  12:1063-73). There are two isoforms of COX: COX-1 and COX-2. Although COX-1 and COX-2 catalyze the same reaction, they are derived from two different genes. COX-1 is traditionally viewed as a constitutive or housekeeping enzyme while COX-2 is viewed as an inducible enzyme that is expressed during inflammatory circumstances. COX products, primarily prostaglandin E2, modulate classical signs of inflammation. Another COX product is thromboxane A2 that promotes platelet aggregation and vasoconstriction. Although COX is expressed in neurons, its function in the central nervous system is unclear.  
      Another target of NSAIDs is the peroxisome proliferator-activator receptor (PPAR) family of nuclear hormone receptors. The PPAR family consists of at least three subtypes: PPARα, PPARδ, and PPARγ (see Corton et al. (2000)  Annu Rev Pharmacol Toxicol  40:491-518). These receptors are thought to function as ligand-dependent activators of transcription. All three PPAR members are modulated by NSAIDs, although in different ways. For example, NSAIDs activate the activities of PPARδ and PPARγ but inhibit PPARγ activity (see He et al. (1999)  Cell  99:335-45). It is known that PPARγ expression is increased in brains of AD individuals (Kitamura et al. (1999)  Biochem Biophys Res Commun  254:582-6), and that PPARγ agonists block Aβ-stimulated secretion of proinflammatory products of microglia, including IL-1 and TNF-α (see Combs et al. (2000)  J Neurosci  20:558-67). It has been suggested that the beneficial effects of NSAIDs in AD may be mediated via their activity on PPARγ rather than or in addition to COX inhibition (Combs et al. (2000)  J Neurosci  20:558-67). It is not known, however, what downstream genes are activated by PPARs, or whether they are involved in Aβ production.  
      The term “Aβ 42  lowering agent” as used herein refers to an NSAID, an NSAID derivative, an NSAID analogue, or any compound that can reduce the level of Aβ 42  secreted from human cells. In addition, the Aβ 42  lowering agents according to the present invention also have one or both of the following two properties: (1) they do not substantially affect the level of Aβ 40  secretion from human cells; (2) they increase the level of Aβ 38  secreted from human cells. Such effects of Aβ 42  lowering agents can be determined in an assay provided in Examples 8 and 12 below. Examples of Aβ 42  lowering agents according to the present invention include, e.g., the NSAIDs, NSAID derivatives, and NSAID analogues disclosed in Examples 8, 9, 10, 15, 17 and 37, and particularly those in Tables 1 and 3 that meet the above definition for Aβ 42  lowering agents. Other specific examples of Aβ 42  lowering agents include the NSAID derivatives provided in  FIGS. 11 and 12  that meet the above definition for Aβ 42  lowering agents. Generally examples of Aβ 42  lowering agents can be sulindac sulfide, flufenmic acid, mefenamic acid, fenoprofen, ibuprofen, indomethacin, and flurbiprofen, and derivatives or analogues of such NSAIDs that are aryl propionic acid, aryl acetic acid, or amino carboxylic acid. Methods of providing or identifying NSAIDs, NSAID derivatives and analogues that are Aβ 42  lowering agents are described in detail below.  
      In preferred embodiments, the Aβ 42  lowering agents according to the present invention can selectively reduce Aβ 42  production or secretion from human cells, and have all of the following three properties: (1) the ability to reduce the level of Aβ 42  either through reducing APP processing or increasing Aβ 42  catabolism, (2) substantially no effect on the level of Aβ 40 , and (3) and the ability to increase the level of Aβ 38 . In other words, in these preferred embodiments, the Aβ 42  lowering agents can reduce the ratio between the level of Aβ 42  and Aβ 40  (Aβ 42 /Aβ 40 ) or between the level of Aβ 42  and the total level of Aβ peptides secreted human cells, and increase the ratio between the level of Aβ 38  and Aβ 40  (Aβ 42 /Aβ 40 ) or between the level of Aβ 38  and the total level of Aβ peptides secreted human cells. The levels can be measured as levels of secretion of the individual or total Aβ peptides from human cells. The three properties are referred to collectively as the Alzheimer&#39;s-Aβ 42 -NSAID (Aβ 42 -NSAID) footprint. In addition to having the Aβ 42 -NSAID footprint, an Aβ 42  lowering agent of the invention preferably can increase the level of secretion of Aβ forms smaller than Aβ 40  such as Aβ 34 , Aβ 36 , Aβ 37 , and Aβ 39  from human cells.  
      As used herein, the terms “increase,” “decrease” and “reduce” refer to a change in any amount that is reproducible and significant. When characterizing an Aβ 42  lowering agent as one that “increases”, “decreases” or “reduces” an Aβ peptide, it is meant that the Aβ 42  lowering agent is such that in an assay in Example 8 or 12, the concentration of the Aβ 42  lowering agent required to achieve a 50% reduction or increase of the level of the secreted Aβ peptide is no greater than about 250 μM. The increase or decrease is comparative to a control in the absence of an Aβ 42  lowering agent as is clear from Example 8 or 12. A reproducible and significant change is differentiated from irreproducible or insignificant experimental variations in measurements by standard statistical analysis methods including analysis that involves comparison with changes observed for control agents known to have no effects on the levels of the Aβ forms of interest.  
      In some preferred embodiments, the Aβ 42  lowering agent lack COX-1, COX-2, or both COX-1 and COX-2 inhibiting activity. That is, at a concentration of about 250 μM, an Aβ 42  lowering agent does not have any detectable inhibitory activity against COX-1 or COX-2 enzyme, or exhibits less than 20% inhibition of COX-1 or COX-2 enzyme activity as determined using the method described in Kalgutkar et al.  Proc. Nat&#39;l. Acad. Sci. USA,  97:925-930 (2000). Specifically, in a time-dependent and competitive inhibition assays, recombinant human COX-2 (66 nM) or ovine COX-1 (44 nM) in 100 mM Tris-HCl buffer (pH 8.0) containing 500 μM phenol is incubated with a test compound in DMSO (0-66 μM) at 25° C. for 20 min and then analyzed for remaining COX activity by treatment with [1- 14 C]arachidonic acid (50 μM, 57 mCi/mmol) for 30 sec at 37° C. Competitive inhibition by the test compounds is studied by adding COX-1 (2 nM) or COX-2 (2 nM) to an incubation mixture containing [1- 14 C]arachidonate (2 μM) and inhibitor (0-20 μM). Isolation and quantification of radio-labeled prostanoid products is done by a known method. All IC 50  values should average determinations from two independent experiments.  
      2. Identification of Aβ 42  Lowering Agents Useful for Treating AD  
      Aβ 42  lowering agents can be identified from collections of NSAIDs, NSAID derivatives, NSAID analogues, or other compounds using the Aβ 42 -NSAID footprint. Such compounds can be obtained from any commercial source. For example, NSAIDs, NSAID derivatives, and NSAID analogues can be obtained from Sigma, Biomol, Cayman Chemical, ICN, or from the web through the Chemnavigator website. Novel NSAIDs, novel NSAID derivatives, and novel NSAID analogues can be chemically synthesized using methods described in many published protocols. NSAIDs, NSAID derivatives, and NSAID analogues can be synthesized with altered potency for their known targets such as COX-1 and COX-2. For example Kalgutkar et al.,  Proc. Nat&#39;l. Acad. Sci. USA,  97:925-930 (2000) have made derivatives of indomethacin and meclofenamic acid and Bayly et al,  Biorg. Med. Chem. Letters  9:307-312 (1999) have made derivatives of Flurbiprofen. Indeed, because of the great effort to engineer NSAIDs so that they preferentially inhibit COX-2 rather than non-selectively inhibit COX-1 and COX-2, there have been numerous published articles and patents documenting synthesis derivatives of known NSAIDs. See Dewitt,  Mol. Pharm.,  55:625-631 (1999).  
      It is recognized that some NSAID derivatives or NSAID analogues generated can have (1) increased potency for lowering Aβ 42  levels and (2) decreased potency for COX inhibition. Although derivatives and analogues may no longer be considered NSAIDs since they may lack anti-inflammatory properties, Aβ 42  lowering agents can include such NSAID derivatives and NSAID analogues.  
      Aβ 42  lowering agents that have the Aβ 42 —NSAID footprint can be identified using cell free assays, in vitro cell-based assays, and in vivo animal studies. Aβ 42  lowering agents can be dissolved in any suitable vehicle for in vitro cell culture studies or in vivo animal or human studies. A vehicle is an inert solvent in which a compound can be dissolved for administration. It is recognized that for any given Aβ 42  lowering agent, a vehicle suitable for in vitro cell culture studies or in vivo animal studies may not be the same as the vehicle used for human treatment. Some examples of suitable vehicles for cell culture or animal studies include water, dimethyl sulfoxide, ethanol, and ethyl acetate.  
      To identify Aβ 42  lowering agents that reduce APP processing, a biological composition having an APP processing activity (i.e. an activity that processes APP into various Aβ forms, one of which is Aβ 42 ), is incubated with APP under conditions in which APP processing occurs. To identify Aβ 42  lowering agents that increase Aβ 42  catabolism, a biological composition having Aβ 42  catabolic activity is incubated with Aβ 42  under conditions in which Aβ 42  catabolism occurs. Depending on the nature of the biological composition, the APP or Aβ 42  substrate can be added to the biological composition, or, each or both can be a component of the biological composition. APP processing or Aβ 42  catabolism is allowed to take place in the presence or absence of the candidate Aβ 42  lowering agent. The level of Aβ 42  generated from APP processing or the level of Aβ 42  remaining after the catabolic reaction, in the presence and absence of the candidate Aβ 42  lowering agent, is determined and compared. Aβ 42  lowering agents useful for treating AD are those that reduce the level of Aβ 42  either by reducing APP processing into Aβ 42  or by enhancing Aβ 42  catabolism and increasing Aβ 38  production.  
      The biological composition having an APP processing and/or catabolic activity can be a cell-free biological sample. For example, a cell-free biological sample can be a purified or partially purified enzyme preparation; it also can be a cell lysate generated from cells able to process APP into Aβ 42  or from cells able to catabolize Aβ 42 . Cell lysates can be prepared using known methods such as, for example, sonication or detergent-based lysis. In the case of an enzyme preparation or cell lysate, APP can be added to the biological composition having the APP processing activity, or Aβ 42  can be added to the biological composition having Aβ 42  catabolic activity.  
      In addition, the biological composition can be any mammalian cell that has an APP processing activity as well as a nucleic acid vector encoding APP. Alternatively, the biological composition can be any mammalian cell that has Aβ catabolic activity as well as a nucleic acid vector or a viral nucleic acid-based vector containing a gene that encodes Aβ 42 . The vector typically is an autonomously replicating molecule, a molecule that does not replicate but is transiently transfected into the mammalian cell, or a vector that is integrated into the genome of the cell. Typically, the mammalian cell is any cell that can be used for heterologous expression of the vector-encoded APP or Aβ 42  in tissue culture. For example, the mammalian cell can be a Chinese hamster ovary (CHO) cell, a fibroblast cell, or a human neuroglioma cell. The mammalian cell also can be one that naturally produces APP and processes it into Aβ 42 , or one that naturally produces and catabolizes Aβ 42 .  
      Further, the biological composition can be an animal such as a transgenic mouse that is engineered to over-express a form of APP that then is processed into Aβ 42 . Alternatively, the animal can be a transgenic mouse that is engineered to over-express Aβ 42 . Animals can be, for example, rodents such as mice, rats, hamsters, and gerbils. Animals also can be rabbits, dogs, cats, pigs, and non-human primates, for example, monkeys.  
      To perform an in vitro cell-free assay, a cell-free biological sample having an activity that can process APP into Aβ 42  is incubated with the substrate APP under conditions in which APP is processed into various Aβ forms including Aβ 42  (see Mclendon et al. (2000)  FASEB  14:2383-2386). Alternatively, a cell-free biological sample having an activity that can catabolize Aβ 42  is incubated with the substrate Aβ 42  under conditions in which Aβ 42  is catabolized. To determine whether a candidate Aβ 42  lowering agent has an effect on the processing of APP into Aβ 42  or the catabolism of Aβ 42 , two reactions are compared. In one reaction, the candidate Aβ 42  lowering agent is included in the processing or catabolic reaction, while in a second reaction, the candidate Aβ 42  lowering agent is not included in the processing or catabolic reaction. Levels of the different Aβ forms produced in the reaction containing the candidate Aβ 42  lowering agent are compared with levels of the different AP forms produced in the reaction that does not contain the candidate Aβ 42  lowering agent.  
      The different Aβ forms can be detected using any standard antibody based assays such as, for example, immunoprecipitation, western hybridization, and sandwich enzyme-linked immunosorbent assays (ELISA). Different Aβ forms also can be detected by mass spectrometry; see, for example, Wang et al. (1996)  J Biol Chem  271:31894-902. Levels of Aβ species can be quantified using known methods. For example, internal standards can be used as well as calibration curves generated by performing the assay with known amounts of standards.  
      In vitro cell-based assays can be used determine whether a candidate Aβ 42  lowering agent has an effect on the processing of APP into Aβ 42  or an effect on catabolism of Aβ 42 . Typically, cell cultures are treated with a candidate Aβ 42  lowering agent. Then the level of Aβ 42  in cultures treated with a candidate Aβ 42  lowering agent is compared with the level of Aβ 42  in untreated cultures. For example, mammalian cells expressing APP are incubated under conditions that allow for APP expression and processing as well as Aβ 42  secretion into the cell supernatant. The level of Aβ 42  in this culture is compared with the level of Aβ 42  in a similarly incubated culture that has been treated with the candidate Aβ 42  lowering agent. Alternatively, mammalian cells expressing Aβ 42  are incubated under conditions that allow for Aβ 42  catabolism. The level of Aβ 42  in this culture is compared with the level of Aβ 42  in a similar culture that has been treated with the candidate Aβ 42  lowering agent.  
      In vivo animal studies also can be used to identify Aβ 42  lowering agents useful for treating AD. Typically, animals are treated with a candidate Aβ 42  lowering agent and the levels of Aβ 42  in plasma, CSF, and/or brain are compared between treated animals and those untreated. The candidate Aβ 42  lowering agent can be administered to animals in various ways. For example, the candidate Aβ 42  lowering agent can be dissolved in a suitable vehicle and administered directly using a medicine dropper or by injection. The candidate Aβ 42  lowering agent also can be administered as a component of drinking water or feed. Levels of Aβ in plasma, cerebral spinal fluid (CSF), and brain are determined using known methods. For example, levels of Aβ 42  can be determined using sandwich ELISA or mass spectrometry in combination with internal standards or a calibration curve. Plasma and CSF can be obtained from an animal using standard methods. For example, plasma can be obtained from blood by centrifugation, CSF can be isolated using standard methods, and brain tissue can be obtained from sacrificed animals.  
      When present in an in vitro or in vivo APP processing or Aβ 42  catabolic reaction, Aβ 42  lowering agents reduce the level of Aβ 42  generated by APP processing or remaining following Aβ catabolism. For example, in an in vitro cell-free assay, the level of Aβ 42  is reduced due to either a reduction of APP processing or an increase in Aβ 42  catabolism in the presence the Aβ 42  lowering agent. In an in vitro cell culture study, a reduction in the level of Aβ 42  secreted into the supernatant results from the effect of the Aβ 42  lowering agent on either a reduction in processing of APP into Aβ 42  or an increased catabolism of Aβ 42 . Similarly, in animal studies, a reduction in the level of Aβ 42  that can be detected in plasma, CSF, or brain is attributed to the effect of the Aβ 42  lowering agent on either a reduction in the processing of APP into Aβ 42  or an increase in the catabolism of Aβ 42 .  
      The level of Aβ 42  can be reduced by a detectable amount. For example, treatment with an Aβ 42  lowering agent leads to a 0.5, 1, 3, 5, 7, 15, 20, 40, 50, or more than 50% reduction in the level of Aβ 42  generated by APP processing or remaining following Aβ 42  catabolism when compared with that in the absence of the Aβ 42  lowering agent. Preferably, treatment with the Aβ 42  lowering agent leads to at least a 20% reduction in the level of Aβ 42  generated when compared to that in the absence of Aβ 42  lowering agent. More preferably, treatment with an Aβ 42  lowering agent leads to at least a 40% reduction the level of Aβ 42  when compared to that in the absence of an Aβ 42  lowering agent.  
      Typically, the Aβ 42  lowering agent-associated reduction of Aβ 42  levels is accompanied by an increase in the level of Aβ 38 . In contrast, (1) the level of Aβ 40  generated by APP processing or Aβ 42  catabolism in cell-free assays, (2) the level of Aβ 40  secretion into culture supernatants in cell-based assays, or (3) the level of Aβ 40  detected in blood plasma, CSF, or brains of animals treated with Aβ 42  lowering agent, is substantially unchanged or not affected.  
      Aβ 42  lowering agents of the invention may lack COX inhibitory activity or have reduced COX-1, COX-2, or both COX-1 and COX-2 activity. COX inhibitory activity can be determined using known methods. For example, COX inhibitory activity can be determined using the method described in Kalgutkar et al. (2000) PNAS 97:925-930.  
      A method to identify NSAID derivatives and NSAID analogues that possess Aβ 42  lowering ability and have altered COX activity is described. NSAID derivatives and NSAID analogues of aminocarboxylic acids, arylacetic acids and arylpoprionic acids can be tested for their ability to lower Aβ 42  and increase Aβ 38  in cultured cells and in animals (as described herein). They also can be tested simultaneously for their ability to inhibit COX-1 and COX-2 using in vitro assays as described by Kalgutkar et al. (2000)  PNAS  97:925-930.  
      Derivatives of the NSAIDs sulindac, meclofenamic acid, flufenamic acid, indomethacin, carprofen, fenoprofen, and flurbiprofen that can be tested include the following:  
      (1) meclofenamic acid and flufenamic acid derivatives in which (a) the position of the carboxylic acid substituent on the phenyl ring is altered to a different position on the same phenyl ring, (b) the position(s) of the substituent(s) on the phenyl ring opposite the carboxylic acid substituent are altered to different position(s) on the same phenyl ring, (c) the substituent(s) on the phenyl ring opposite the carboxylic acid substituent are altered, e.g., to halogen, C 1-3  alkyl, C 1-3  haloalkyl, hydroxyl, nitro, etc., and optionally the same phenyl ring is substituted with one or more additional substituents such as halogen, C 1-3  alkyl, C 1-3  haloalkyl, hydroxyl, etc., (d) the bond connecting the two phenyl rings is altered, e.g., by changing —NH— to —CH 2 ) 0-3 —NH—(CH 2 ) 0-3 , (e) the carboxylic acid substituent is altered to, e.g., ester, sulfonate, amide, sulfonamide, or another carboxylic acid or carboxylic acid derivative, such as acetic acid or propionic acid or other derivatives, e.g., —CH(CH 2 CH 3 )C(═O)OH, —C(CH 3 )(CH 2 CH 3 )C(═O)OH, —CH═C(CH 3 )C(═O)OH, —C(CH 2 CH 3 ) 2 C(═O)OH, —CH 2 OH, —C(═O)H, —CH(OH)OCH 3 , —CH(CH 3 )tetrazole, —CH 2 C(═O)OH, —C(CH 3 ) 2 C(═O)OH, and —NHC(═O)CH 3 , or (e) any combination of these alterations;  
                 
 
      Several exemplary derivatives and analogues of Meclofenamic acid or Flufenamic acid suitable as Aβ 42  lowering agents according to the present invention are:  
                 
                 
 
 Additional compounds in this class are shown in  FIG. 12 . 
 
      (2) flurbiprofen derivatives in which (a) the position of the propionic acid substituent on the phenyl ring is altered to a different position in the same phenyl ring, (b) the position of fluoride on the phenyl ring is altered to a different position, and optionally the same phenyl ring is substituted with one or more additional substituents such as halogen, C 1-3  alkyl, C 1-3  haloalkyl, hydroxyl, etc., (c) the fluoride on the phenyl ring proximal to the propionic acid substituent is altered, e.g., to one or more substituents such as Cl, Br, I, C 1-3  alkyl, C 1-3  haloalkyl, hydroxyl, etc., and optionally the same phenyl ring is substituted with one or more additional substituents such as halogen, C 1-3  alkyl, C 1-3  haloalkyl, hydroxyl, etc., (c) the phenyl ring distal to the propionic acid substituent is substituted with, e.g., one or more subsitituents such as halogen, C 1-3  alkyl, C 1-3  haloalkyl, hydroxyl, or combinations thereof, (d) the bond connecting the two phenyl rings is altered, e.g., to a —CH 2 ) 1-3 , —NH—, etc., (e) the propionic acid substituent is altered to e.g., ester, sulfone, amide, sulfonamide, or another carboxylic acid derivative, such as acetic acid (—CH 2 C(═O)OH), —C(═O)OH, —CH(CH 2 CH 3 )C(═O)OH, —C(CH 3 )(CH 2 CH 3 )C(═O)OH, —CH═C(CH 3 )C(═O)OH, —C(CH 2 CH 3 ) 2 C(═O)OH —CH 2 OH, —C(═O)H, —CH(OH)OCH 3 , —CH(CH 3 )tetrazole, —CH 2 C(═O)OH, —C(CH 3 ) 2 C(═O)OH, and —NHC(═O)CH 3 , or (f) any combination of these alterations.  
                 
 
      Examples of such derivatives include those disclosed in e.g., U.S. Pat. Nos. 1,091,403, 1,116,432, 1,359,987, 1,382,996, 1,396,726, 4,367,238, 4,699,925, 5,994,379; Japan Patent No. 08099924A2, the compounds and synthesis thereof in these patents being incorporated by references.  
      Several exemplary derivatives and analogues of flurbiprofen suitable as Aβ 42  lowering agents according to the present invention are:  
                 
 
      (2) fenoprofen derivatives in which (a) the position of the propionic acid substituent on the phenyl ring is altered to a different position on the same phenyl ring, (b) the phenyl ring opposite the propionic acid substituent is substituted with, e.g., one or more substituents such as halo, C 1-3  alkyl, C 1-3  alkoxy, C 1-3  haloalkyl, C 1-3  haloalkoxy, hydroxyl, (c) the phenyl ring proximate to the propionic acid group is additionally substituted with one to four substituents such as halo, C 1-3  alkyl, C 1-3  alkoxy, C 1-3  haloalkyl, C 1-3  haloalkoxy, hydroxyl, etc., (d) the propionic acid substituent is altered to e.g., ester, sulfonate, amide, sulfonamide, or another carboxylic acid or derivative thereof, e.g., acetic acid (—CH 2 C(═O)OH), —C(═O)OH, —CH(CH 2 CH 3 )C(═O)OH, —C(CH 3 )(CH 2 CH 3 )C(═O)OH, —CH═C(CH 3 )C(═O)OH, —C(CH 2 CH 3 ) 2 C(═O)OH —CH 2 OH, —C(═O)H, —CH(OH)OCH 3 , —CH(CH 3 )tetrazole, —CH 2 C(═O)OH, —C(CH 3 ) 2 C(═O)OH, and —NHC(═O)CH 3 , or (e) any combination of these alterations.  
                 
 
 fenoprofen. 
 
      Several exemplary derivatives and analogues of fenoprofen suitable as Aβ 42  lowering agents according to the present invention are:  
                 
                 
 
      (3) indomethacin derivatives in which (a) the carboxylic acid group on indomethacin is altered to another substituent, e.g., ester, sulfonate, amide, sulfonamide, or another carboxylic acid or derivative thereof, e.g., such as —C(═O)OH, —CH(CH 2 CH 3 )C(═O)OH, —C(CH 3 )(CH 2 CH 3 )C(═O)OH, —CH═C(CH 3 )C(═O)OH, —C(CH 2 CH 3 ) 2 C(═O)OH —CH 2 OH, —C(═O)H, —CH(OH)OCH 3 , —CR(CH 3 )tetrazole, —CH 2 C(═O)OH, —C(CR 3 ) 2 C(═O)OH, and —NHC(═O)CH 3 , (b) the position of the Cl substituent is changed to another position on the same phenyl ring, (c) the Cl substituent is altered to a different substituent such as F, Br, hydroxyl, C 1-3  alkyl optionally substituted with 1-3 halo, and C 1-3  alkoxy optionally substituted with 1-3 halo, wherein the position can be at any one of the five positions on the same phenyl ring, and optionally the phenyl ring may be additionally substituted with one or more substituents such as halo, hydroxyl, C 1-3  alkyl, C 1-3  alkoxy, etc., (d) the 2-methyl on the indole core is altered to e.g., C 2-3  alkyl, (e) the methoxy group is changed to another position on the same phenyl ring, (f) the methoxy group is changed to a different subsitutuent, e.g., C 2-3  alkoxy optionally substituted with 1-3 halo, C 1-3  alkylthio optionally substituted with 1-3 halo, wherein the position can be at any one of the five positions on the phenyl ring, and optionally the phenyl ring may be additionally substituted with one or more substituents such as halo, hydroxyl, C 1-3  alkyl, C 1-3  alkoxy, etc., or (c) any combination of the two;  
                 
 
      Examples of such derivatives include those disclosed in e.g., U.S. Pat. Nos. 3,161,654, 3,647,858, 3,654,349 and 5,436,265, the compounds and synthesis thereof in these patents being incorporated by references.  
      Several other exemplary derivatives and analogues of indomethacin suitable as Aβ 42  lowering agents according to the present invention are:  
                 
 
      (4) sulindac sulfide in which (a) the methylthio derivative of sulindac sulfide is altered to other substituents, e.g., C 2-3  alkylthio optionally substituted with 1-3 halo, C 1-3  alkoxy optionally substituted with 1-3 halo, wherein the position can be at any one of the five positions on the phenyl ring, and optionally the phenyl ring may be additionally substituted with one or more substituents such as halo, hydroxyl, C 1-3  alkyl, C 1-3  alkoxy, etc., (b) the methylthio group can be altered to a different position on the same phenyl ring, (c) the propionic acid derivative is altered to another substituent, e.g., ester, sulfonate, amide, sulfonamide, or another carboxylic acid or derivative thereof, e.g., such as acetic acid (—CH 2 C(═O)OH), —C(═O)OH, —CH(CH 2 CH 3 )C(═O)OH, —C(CH 3 )(CH 2 CH 3 )C(═O)OH, —CH═C(CH 3 )C(═O)OH, —C(CH 2 CH 3 ) 2 C(═O)OH —CH 2 OH, —C(═O)H, —CH(OH)OCH 3 , —CH(CH 3 )tetrazole, —CH 2 C(═O)OH, —C(CH 3 ) 2 C(═O)OH, and —NHC(═O)CH 3 , (d) the position fluoride is altered to a different position at the same phenyl ring, (e) the fluoride is altered to a different substituent such as Cl, Br, hydroxyl, C 1-3  alkyl optionally substituted with 1-3 halo, and C 1-3  alkoxy optionally substituted with 1-3 halo, wherein the position can be at any one of the five positions on the same phenyl ring, and optionally the phenyl ring may be additionally substituted with one or more substituents such as halo, hydroxyl, C 1-3  alkyl, C 1-3  alkoxy, etc., or (d) any combination of the above.  
                 
 
      Examples of such derivatives include those disclosed in e.g., U.S. Pat. Nos. 3,161,654, 3,647,858, 3,654,349 and 5,436,265, the compounds and synthesis thereof in these patents being incorporated by references.  
      (5) ibuprofen derivatives in which (a) the position of the propionic acid substituent on the phenyl ring is altered to a different position in the same phenyl ring, (b) the position of the isobutyl group on the phenyl ring is altered to a different position, and optionally the same phenyl ring is substituted with one or more additional substituents such as halogen, C 1-3  alkyl, C 1-3  haloalkyl, hydroxyl, etc., (c) the propionic acid substituent is altered to e.g., ester, sulfone, amide, sulfonamide, or another carboxylic acid derivative, such as acetic acid (—CH 2 C(═O)OH), —C(═O)OH, —CH(CH 2 CH 3 )C(═O)OH, —C(CH 3 )(CH 2 CH 3 )C(═O)OH, —CH═C(CH 3 )C(═O)OH, —C(CH 2 CH 3 ) 2 C(═O)OH —CH 2 OH, —C(═O)H, —CH(OH)OCH 3 , —CH(CH 3 )tetrazole, —CH 2 C(═O)OH, —C(CH 3 ) 2 C(═O)OH, —NHC(═O)CH 3 , cycloalkyl-(CH 2 ) 0-3 COOH or ester thereof, (d) the isobutyl group on the phenyl ring is substituted by (altered to) another substituent such as ethyl, propyl, isopropyl, C 5-7  alkyl, C 1-6  haloalkyl, C 1-6  hydroxyalkyl, or (e) any combination of these alterations.  
                 
 
      Examples of such ibuprofen derivatives include those disclosed in e.g., U.S. Pat. No. 3,746,751, the compounds and synthesis thereof being incorporated herein by reference.  
      In addition structural analogues of NSAIDs that possess Aβ 42  lowering ability, identified by pharamacophore searches (Perola et al., (2000)  J. Med. Chem.  43: 401-408) or other computer based structural comparison programs of commercially available compounds can be tested for Aβ 42  lowering activity, ability to increase Aβ 38 , and COX inhibition as described herein.  
      Thus, the present invention provides methods of treating, or delaying the onset of, neurodegenerative disorders mediated by Aβ 42  including dementia, and particularly Alzheimer&#39;s disease or mild cognitive impairment, using one or more Aβ 42 -lowering agents provided according to the present invention. The methods generally include the steps of identifying a patient in need of the treatment or delay; and administering to the patient an Aβ 42 -reducing effective amount of an Aβ 42 -lowering agent which can reduce the level of Aβ 42  secretion from a human cell. In some embodiments, the Aβ 42 -lowering agent is characterized by the ability to reduce the level of Aβ 42  secretion without substantially affecting the level of Aβ 40  secretion. In specific embodiments, the Aβ 42 -lowering agent is characterized by the ability to reduce the level of Aβ 42  secretion, increase the level of Aβ 38  secretion without substantially affecting the level of Aβ 40  secretion in assays performed in Examples 8 and 12. For example, the Aβ 42 -lowering agent can be an NSAID, or a structural derivative or analogue thereof as described in detail above. Preferably, the Aβ 42 -lowering agent reduces the plasma concentration of Aβ 42  in the patient treated. Preferably, the Aβ 42 -lowering agent is a compound described above that causes at least 50% reduction in Aβ 42 /Aβ 40  ratio at about 10 μM, 25 μM, 50 μM, 100 μM, 200 μM, or 250 μM in the assay of Example 8. Also preferably, the Aβ 42 -lowering agent causes at least a two-fold increase in Aβ 38 /Aβ 40  ratio at about 10 μM, 25 μM, 50 μM, 75 μM in the assay of Example 12.  
      The patients to be treated may have been diagnosed of mild cognitive impairment (MCI), mild Alzheimer&#39;s disease or mild to moderate disease. The patients may also be those who are free of any symptoms or signs of mild cognitive impairment or Alzheimer&#39;s disease, but desire to prevent or delay the onset of such symptoms or signs. Thus, the treatment can be applied to the patients at any progression stage of Alzheimer&#39;s disease, including prevention before the onset of mild cognitive impairment, or onset of Alzheimer&#39;s disease such that the onset is delayed, and treatment upon the detection of certain symptoms or signs of MCI or Alzheimer&#39;s disease to delay the onset of other symptoms or signs, slow the worsening of the symptoms or signs, or reverse the progression of the disease by improving the symptoms or signs.  
      In certain embodiments, either before or after the treatment with the Aβ 42 -lowering agent or both, at least one of the following is monitored: (1) the plasma concentration of Aβ 42 , (2) the plasma concentration of Aβ 40 , (3) the plasma concentration of Aβ 34 , Aβ 36 , Aβ 37 , or Aβ 39 , (4) the plasma concentration of Aβ 38 , (5) the Aβ 42 /Aβ 40  concentration ratio, (6) the concentration ratio between one or more of Aβ 34 , Aβ 36 , Aβ 37 , Aβ 38 , and Aβ 39  over Aβ 40 , and (7) the total concentration of Aβ peptides.  
      The present invention also provides method for treating, or delaying the onset of, Alzheimer&#39;s disease, comprising (1) identifying a patient in need of the treatment or delay; (2) selecting an Aβ 42 -lowering agent which reduces the level of Aβ 42  secretion, increases the level of Aβ 38  secretion without substantially affecting the level of Aβ 40  secretion from a human cell; and (3) administering to the patient an Aβ 42 -reducing effective amount of said Aβ 42 -lowering agent.  
      In preferred embodiments, the Aβ 42 -lowering agent used in the various treatment methods of the present invention is an Aβ 42 -reducing effective amount of (2R)-2-(2-Fluoro-1,1′-biphenyl-4-yl)propanoic acid or a pharmaceutically acceptable salt or ester thereof.  
      3. Identification of Mammals in Need of Treatment with an Aβ 42  Lowering Agent  
      Clinical symptoms of AD include, for example, progressive disorientation, memory loss, and aphasia; eventually, disablement, muteness, and immobility occur. Pathological indicators of AD include, for example, the presence of neurofibrillary tangles, neuritic plaques, and amyloid angiopathy. Preventing the progression of AD can be interpreted to mean preventing the onset or further development of clinical symptoms and/or pathological indicators of AD. For example, an individual who does not have clinical symptoms or pathological indicators of AD can be prevented from developing clinical symptoms or pathological indicators. Further, an individual who has a mild form of AD can be prevented from developing a more severe form of AD. Delaying the progression of AD can be interpreted to mean delaying the time of onset of AD-related symptoms and/or pathological indicators or slowing the rate of progression of AD, determined by the rate of development of clinical symptoms and pathological indicators. Reversing the progression of AD can be interpreted to mean that the severity of an AD condition has been lessened, i.e., the AD condition of an individual has changed from severe to less severe as indicated by fewer clinical symptoms or pathological indicators.  
      An individual can choose to take an Aβ 42  lowering agent as a preventative measure to avoid developing AD. For example, an individual with a genetic predisposition to AD can take an Aβ 42  lowering agent to prevent or delay the development of AD. A genetic predisposition can be determined based on known methods. For example, an individual can be considered to have a genetic predisposition to AD if the individual has a family history of AD. Genetic predisposition to AD also can include point mutations in certain genes such as the APP gene, the presenilin-1 or presenilin-2 gene, or the apolipoprotein E gene. Such mutations can predispose individuals to early-onset familial AD (FAD), increased risk of developing AD, or decreased age at onset of AD. (See page 1332, Table 30-2 of Cotran et al. (1999)  Robbins Pathologic Basis of Disease , Sixth Edition, W.B. Saunders Company; and U.S. Pat. No. 5,455,169.) Furthermore, an individual who has clinical symptoms of, or has been diagnosed with, AD can take an Aβ 42  lowering agent to prevent or delay further progression of AD as well as to reverse the pathological condition of the disease.  
      An AD diagnosis can be made using any known method. Typically, AD is diagnosed using a combination of clinical and pathological assessments. For example, progression or severity of AD can be determined using Mini Mental State Examination (MMSE) as described by Mohs et al. (1996)  Int Psychogeriatr  8:195-203; Alzheimer&#39;s Disease Assessment Scale-cognitive component (ADAS-cog) as described by Galasko et al. (1997)  Alzheimer Dis Assoc Disord,  11 suppl 2:S33-9; the Alzheimer&#39;s Disease Cooperative Study Activities of Daily Living scale (ADCS-ADL) as described by McKhann et al. (1984) Neurology 34:939-944; and the NINCDS-ADRDA criteria as described by Folstein et al. (1975)  J Psychiatr Res  12:189-198. In addition, methods that allow for evaluating different regions of the brain and estimating plaque and tangle frequencies can be used. These methods are described by Braak et al. (1991)  Acta Neuropathol  82:239-259; Khachaturian (1985)  Arch Neuro  42:1097-1105; Mirra et al. (1991)  Neurology  41:479-486; and Mirra et al. (1993)  Arch Pathol Lab Med  117:132-144.  
      4. Treatment of Mammals with Aβ 42  Lowering Agents  
      Aβ 42  lowering agents can be administered in any standard form using any standard method. For example, Aβ 42  lowering agents can be in the form of tablets or capsules that are taken orally. Aβ 42  lowering agents also can be in a liquid form that can be taken orally or by injection. Aβ 42  lowering agents also can be in the form of suppositories. Further, Aβ 42  lowering agents can be in the form of creams, gels, and foams that can be applied to the skin, or in the form of an inhalant.  
      Aβ 42  lowering agents can be administered at any dose that is sufficient to reduce levels of Aβ 42  in the blood plasma, CSF, or brain. Lower doses can be taken over a period of years to prevent and/or delay the progression of AD. Higher doses can be taken to reverse the progression of AD. Depending on the effectiveness and toxicity of a particular Aβ 42  lowering agent, an Aβ 42  lowering agent can be used at a dose of 0.1-50 mg/kg/day.  
      5. Compositions and Kits  
      The invention also provides pharmaceutical compositions containing combinations of an Aβ 42  lowering agent and an antioxidant effective in preventing, delaying, or reversing the progression of Alzheimer&#39;s disease. An Aβ 42  lowering agent of the invention that has the ability to reduce Aβ 42  levels can be combined with any antioxidant. The antioxidant can be a vitamin, for example vitamin E, vitamin C or curcumin; the antioxidant also can be Gingko biloba. Other pharmaceutical compositions can include an Aβ 42  lowering agent and a non-selective secretase inhibitor or an acetylcholinesterase inhibitor.  
      The pharmaceutical composition can be in any form, for example tablets, capsules, liquids, creams, gels, or suppositories and can include a suitable pharmaceutical carrier. In addition, the invention provides kits containing pharmaceutical compositions of Aβ 42  lowering agents and antioxidants as well as instructions that indicate dose regimens for effective use.  
      The invention will be further described in the following examples, which do not limit the scope of the invention described in the claims.  
     EXAMPLES  
     Example 1  
     Cell Cultures, Drug Treatments, and Cell Toxicity Analysis  
      Cell cultures were maintained in standard cell culture media supplemented with 10% fetal bovine serum and 100 U/mL penicillin/streptomycin (Life Technologies Inc., Germany). Cell cultures consisted of the following: Chinese hamster ovary (CHO) cells that expressed human APP751 from a vector containing a gene encoding APP751; CHO cells that expressed both human APP751 and human mutant PS-1 (M146L) from vectors containing genes encoding APP751 and mutant PS-1 (M146L); CHO cells that expressed human mutant APP751 (V717F) from a vector containing a gene encoding mutant APP751 (V717F); human neuroglioma cells HS683 that expressed human wild type APP695 from a vector containing a gene encoding wild type APP695; HEK 293 cells that expressed human wild type APP695 from a vector containing a gene encoding wild type APP695; and embryonic fibroblasts (that had immortalized spontaneously) from COX-1 and COX-2 double-knockout mice.  
      The NSAIDs, sulindac sulfide (50 mM, Biomol, PA, USA), sulindac sulfone (50 mM, Biomol, PA, USA), naproxen (100 mM, Cayman Chemical, MI, USA), and aspirin (2.5 M, ICN Biomedicals, CA, USA) were dissolved in the vehicle DMSO. Indomethacin (50 mM, Biomol, PA, USA) and (S)-ibuprofen (250 mM, Biomol, PA, USA) were dissolved in ethanol. Celecoxib and rofecoxib capsules were obtained from and dissolved in ethyl acetate. For analyses of Aβ secretion, APP processing, and notch cleavage, cells were cultured in serum-containing media and pretreated overnight with a specific NSAID. The next day, media were changed and cultures were treated with the same NSAID for another 24 hours.  
      NSAID toxicity in CHO or HS683 cells was examined using standard MTT-assay (3-(4,5-Dimethyl-2-thiazolylyl)-2,5-diphenyl-2H-tetrazolium Bromide) or [ 3 H]-thymidine incorporation assay. For cell toxicity studies, cells were treated with sulindac sulfide at concentrations up to 100 μM, indomethacin at concentrations up to 200 μM, and ibuprofen at concentrations up to 1 mM.  
     Example 2  
     Antibodies  
      Antibodies used included the following: 5A3 and 1G7, two monoclonal antibodies that recognized non-overlapping epitopes between residues 380-665 of APP; CT15, a polyclonal antibody that recognized the C-terminal fifteen amino acid residues of APP; 26D6, a monoclonal antibody that recognized amino acid residues 1-12 of the Aβ sequence; 9E10, a monoclonal antibody that recognized the myc-epitope sequence; anti-COX-2 antibody, a monoclonal antibody that recognized COX-2; and M-20, a polyclonal antibody that recognized COX-1. The antibodies 5A3, 1G7, CT15, and 26D6 were described by Koo et al. (1996)  J Cell Sci  109:991-8; Sisodia et al. (1993)  J Neurosci  13:3136-42; and Lu et al. (2000)  Nat Med  6:397-404. The monoclonal antibody 9E10 was purchased from Calbiochem-Novobiochem, CA, USA. The monoclonal anti-COX-2 antibody was purchased from BD Transduction Laboratories, CA, USA. The polyclonal antibody M-20 was purchased from Santa Cruz Biotechnology, CA, USA.  
     Example 3  
     ELISA  
      Aβ was detected by sandwich enzyme-linked immunosorbent assay (ELISA) as described by Murphy et al. (2000)  J Biol Chem  275:26277-84. Following NSAID treatment, culture supernatants were collected, and cell debris was removed by centrifugation. Complete protease inhibitor cocktail (Roche Molecular Biochemicals, IN, USA) was added to the media and Aβ 40  and Aβ 42  levels were quantified using end-specific Aβ ELISAs. All measurements were performed in duplicate.  
     Example 4  
     Adenoviral Infection of Embryonic Fibroblasts Derived from COX-1/COX-2 Double-Knockout Mice  
      The adenoviral vector containing a gene encoding APP695 was described by Yuan et al. (1999)  J Neurosci Methods  88:45-54. Primary fibroblasts derived from COX-1/COX-2 double-knockout mice were infected with 100 plaque-forming units (PFU) of viral vector per cell. Infection was performed in serum-free medium for two hours. Medium was changed and cells were treated with NSAIDs as described in Example 1.  
     Example 5  
     Analyses of APP and Notch Processing  
      Expression of holo-APP and APP C-terminal fragments (CTFs) was examined by Western blot analysis using antibody CT-15. APP secretion was examined by Western blotting using a mixture of 5A3/IG7 antibodies. APP turnover was examined by pulse labeling of CHO cells with 150 μCi [ 35 S]-methionine for fifteen minutes followed by a cold chase step for up to four hours. Cell lysates were immunoprecipitated with antibody CT-15, subjected to SDS-PAGE, and analyzed by phosphor imaging.  
      APP surface expression and internalization were measured as described by Koo et al. (1996)  J Cell Sci  109:991-8. Iodinated antibody 1G7, at approximately 3-6 μCi/μg, was applied to confluent layers of CHO cells in binding medium (DMEM, 0.2% BSA, 20 mM HEPES [pH 7.4]) and incubated at 37° C. for thirty minutes. After incubation, cells were rapidly chilled on ice and the reaction was quenched by the addition of ice-cold binding medium. To remove unbound antibody, chilled cells were washed multiple times with ice-cold Dulbecco&#39;s phosphate-buffered saline (Life Technologies Inc.). Antibody bound to cell surface APP was detached by washing with ice-cold PBS (pH 2) for five minutes; this constituted the acid-labile APP antibody pool. Cells were lysed in 0.2 M NaOH; lysates contained the acid-resistant APP antibody pool. Acid-labile and acid-resistant APP antibody counts were measured by γ counting. The ratio of acid-resistant to acid-labile count was a measure of the internalized to the cell surface APP pool.  
      Two Notch-encoding vector constructs were used in examining Notch processing. These were a construct expressing a myc-tagged NH 2 -terminal truncated Notch-1 polypeptide (NotchΔEMV), and a construct expressing only the Notch intracellular cytoplasmic domain (NICD) (see Kopan et al. (1996)  Proc Natl Acad Sci USA  93:1683-8). In the construct expressing a myc-tagged NH 2 -terminal truncated Notch-1 polypeptide, the start codon, a methionine at position 1726, was mutated to a valine to eliminate translation initiation.  
     Example 6  
     Mass Spectrometry  
      Secretion of Aβ peptides was analyzed using immunoprecipitation/mass spectrometry as described by Wang et al. (1996)  J Biol Chem  271:31894-902. Briefly, 1 mL amount of culture supernatant was subjected to immunoprecipitation using the monoclonal antibody 4G8 (Senetek, CA, USA). Molecular masses and concentrations of Aβ peptides were measured using a matrix assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometer. To compare the concentrations of individual Aβ species in culture supernatants, synthetic Aβ 12-28  peptides (Sigma, MO, USA) were added to the supernatant samples as internal standards and relative peak heights were calculated.  
     Example 7  
     Bicine/Urea Aβ Western Blot Analysis  
      Bicine/Urea Aβ western blot analysis was performed as described by Wiltfang et al. (1997)  Electrophoresis  18:527-32. A 1 mL amount of culture supernatant was subjected to immunoprecipitation using monoclonal antibody 26D6. Immunoprecipitates were mixed with sample buffer and heated to 95° C. for five minutes. Eluant samples were separated on Bicine/Urea gels, then transferred to nitrocellulose membranes, and probed with antibody 26D6. Standard Aβ 1-40 , Aβ 1-42  and Aβ 1-38  peptides (Sigma, MO, USA) were used for identification of the Aβ species.  
     Example 8  
     Cells Treated with the Non-Selective COX-Inhibitor Sulindac Sulfide Showed Reductions in Levels of Aβ42 Secretions  
      Cell cultures were treated with increasing concentrations of the NSAID sulindac sulfide. Levels of Aβ 40  and Aβ 42  in culture supernatants were analyzed using ELISA.  FIG. 1  is a graph comparing the Aβ 42 /Aβ 40  ratios of sulindac sulfide-treated CHO cell cultures expressing APP751 and the PS-1 mutant M146L. Aβ 42 /Aβ 40  ratios and total Aβ levels (i.e., the sum of Aβ 40  and Aβ 42  values) were normalized to values obtained from DMSO-treated cells. Results shown were averages of two or three experiments performed in duplicate. CHO cell cultures treated with 40-60 μM sulindac sulfide showed a 50% reduction in Aβ 42 /Aβ 40  ratios. No significant reduction in total Aβ level was observed. Therefore, treatment of CHO cells expressing APP and mutant PS-1 with the NSAID sulindac sulfide reduced the Aβ 42 /Aβ 40  ratio by selectively reducing Aβ 42  secretion in a dose-dependent manner. This was confirmed in CHO cells that expressed wild type APP751 as well as those that expressed mutant APP V717F (data not shown). To rule out potential cell type-specific effects, Aβ secretion in response to sulindac sulfide treatment was examined in the human neuroglioma cell line HS683 that expressed APP695.  FIG. 2  is a graph comparing Aβ 42 /Aβ 40  ratios in HS683 cells expressing APP695 that were treated with DMSO with those of cells treated with various concentrations of sulindac sulfide. A dose-dependent reduction of Aβ 42  secretion, similar to that exhibited by CHO cells, was observed. Sulindac sulfide also reduced Aβ 42  secretion in kidney HEK293 cells and primary mouse embryonic fibroblasts (data not shown). No cell toxicity was observed at sulindac sulfide concentrations up to 100 μM (data not shown).  
     Example 9  
     Cells Treated with Other Non-Selective COX-Inhibitors Such as Ibuprofen and Indomethacin Showed Reductions in Levels of Aβ 42  Secretion  
      Cell cultures were treated with increasing concentrations of the NSAIDs ibuprofen and indomethacin. Aβ 40  and Aβ 42  levels in culture supernatants were analyzed using ELISA as described in Example 3.  FIGS. 3 and 4  are graphs comparing Aβ 42 /Aβ 40  ratios observed for CHO cells expressing APP751 and the PS-1 mutant M146L when treated with various concentrations of ibuprofen and indomethacin, respectively. Aβ 42 /Aβ 40  ratios and total Aβ levels were normalized to values obtained from ethanol-treated cells. Results shown were averages of two or three experiments, each performed in duplicate. Dose dependent reductions in Aβ 42 /Aβ 40  ratios by selective reductions of Aβ 42  secretion were observed for both ibuprofen and indomethacin. A 50% reduction in the Aβ 42 /Aβ 40  ratio was reached at ibuprofen concentrations between 200-300 μM and at indomethacin concentrations between 25-50 μM. Total Aβ levels were not significantly affected at ibuprofen concentrations up to 500 μM (see  FIG. 3 ) and at indomethacin concentrations up to 100 μM (see  FIG. 4 ). No cell toxicity was observed in CHO cells treated with ibuprofen concentrations up to 1 mM or indomethacin concentrations up to 200 μM (data not shown).  
     Example 10  
     Reduction of Aβ42 Secretion is not Associated with COX-Inhibitory Activity or with all NSAIDs  
      The effect of sulindac sulfone on Aβ 42  secretion was examined. Sulindac sulfone is an oxidation product of the pro-drug sulindac. Like sulindac sulfide, sulindac sulfone inhibits proliferation and induces apoptosis in human cancer cell lines in vitro (see Piazza et al. (1995)  Cancer Res  55:3110-6). In contrast to sulindac sulfide, sulindac sulfone is devoid of any inhibitory effect on COX. Cell cultures were treated with increasing concentrations of sulindac sulfone. Aβ 40  and Aβ 42  levels in culture supernatants were analyzed using ELISA. When CHO cells expressing APP 751 were treated with sulindac sulfone, no changes in Aβ 42 /Aβ 40  ratios were observed with sulindac sulfone concentrations of up to 400 μM (data not shown). The inability to reduce Aβ 42  secretion by the non-COX-inhibitor sulindac sulfone suggested an important mechanistic role for COX inhibition in the selective inhibition of Aβ 42  secretion by NSAIDs.  
      To determine whether reduction of Aβ 42  secretion is a common effect of all NSAIDs, other clinically useful NSAIDs were examined. Naproxen is a non-selective COX-inhibitor with an inhibition profile similar to sulindac and a structure similar to ibuprofen (see Cryer et al. (1998)  Am J Med  104:413-21). Cell cultures were treated with increasing concentrations of naproxen and aspirin. Aβ 40  and Aβ 42  levels in cell culture supernatants were analyzed using ELISA. Aβ 42 /Aβ 40  ratios and total Aβ levels were normalized to values obtained from DMSO-treated cultures. Averages of two or three experiments performed in duplicate are summarized in  FIG. 5 . Treatment of CHO cells expressing APP751 with naproxen, at concentrations up to 400 μM, did not change Aβ 42 /Aβ 40  ratios and did not affect total Aβ levels (see  FIG. 5 ). Similarly, no reductions in Aβ 42  secretion were observed when cultures were treated with aspirin concentrations of up to 3 mM (data not shown). Two selective inhibitors of COX-2, celecoxib and rofecoxib, also were examined to determine if they reduced Aβ 42  secretion. Celecoxib and rofecoxib were prepared from capsules using solvent extraction and recrystallization. NSAIDs were verified using NMR and mass spectrometry. CHO cells expressing APP751 were treated with various concentrations of celecoxib.  FIG. 6  is a bar graph comparing Aβ 42 /Aβ 40  ratios and total Aβ levels in cells treated with ethyl acetate or various concentrations of celecoxib. Results showed that 20 μM celecoxib treatment induced a two-fold increase in Aβ 42 /Aβ 40  ratio. The increase in Aβ 42 /Aβ 40  ratio also was observed when human neuroglioma cells were tested (data not shown). The increase in Aβ 42 /Aβ 40  ratio was not seen in cells treated with rofecoxib at 20 μM (data not shown). Diclofenac and NS-398, two other NSAIDs having preferential activities against COX-2, did not affect Aβ 42 /Aβ 40  ratios or total Aβ levels. Table 1 summarizes selective and non-selective COX-inhibitors that were tested and results of these tests. Reduction of Aβ 42  secretion was not associated with all NSAIDs. (Note: peak NSAID concentrations used in these experiments were higher than what was required for complete inhibition of COX-1 and COX-2 activities in in vitro cell-based assays.)  
               TABLE 1                          Non-selective and selective COX-inhibitors       tested for effect on Aβ42 levels                                                 COX-1/                       COX-2                       selectivity#           Highest       Aβ42/   (1 = equal       Drug   conc. tested   Plasma   Aβ40 ratio   activity)                         Non-selective COX-inhibitors                                         Sulindac   100   (μM)   14.6   (μM)   selective   0.61       sulfide                   decrease                           in Aβ42       Indomethacin   150       1.4       selective   22-58                           decrease                           in Aβ42       Ibuprofen   750       40-111       selective   1.69                           decrease                           in Aβ42       Naproxen   400       1.3       no effect   1.79       Aspirin   3000       111       no effect   166       Meloxicam   100       15       no effect   .01-0.3       Diclofenac*   600       6.1       no effect   .69                 Selective COX-2 inhibitors                                         NS-398*   20               no effect   .07       Celecoxib   20   (μM)   15   (nM)   selective   .003                           increase                           in Aβ42       Rofecoxib*   20   (μM)   3   (nM)   no effect   .001                  
 
      To confirm that NSAID did not reduce Aβ 42  secretion through COX inhibition and though reduction of prostaglandin synthesis, cells devoid of COX-1 and COX-2 activities were treated with sulindac sulfide, and Aβ 42 /Aβ 40  ratios were examined. Primary fibroblasts derived from COX-1/COX-2 double-knockout mice, described by Zhang et al. (1999)  J Exp Med  190:451-59, were infected with an adenovirus vector that encoded APP695 (see Yuan et al. (1999)  J Neurosci Methods  88: 45-54). Fibroblasts infected with the adenovirus vector expressing APP695 were treated with increasing concentrations of sulindac sulfide. Levels of Aβ forms in fibroblast culture supernatants were quantified using ELISA and results are summarized in  FIG. 7 . (Aβ 42 /Aβ 40  ratios and total Aβ levels were normalized to values obtained from DMSO-treated cells. Results were the averages of two or three experiments, each performed in duplicate.) Sulindac sulfide reduced Aβ 42  secretion as well as the Aβ 42 /Aβ 40  ratio of fibroblasts in a fashion similar to that seen with CHO and HS683 neuroglioma cells. Therefore, selective reduction of Aβ 42  was not mediated by COX inhibition.  
     Example 11  
     APP Processing by γ and β-Secretases, APP Turnover, and Notch Intramembrane Cleavage are not Affected by Sulindac Sulfide  
      NSAIDs are the only compounds reported so far that change Aβ 42 /Aβ 40  ratios by selectively decreasing Aβ 42  secretion. To determine if APP processing and notch intramembrane cleavage were affected in cells treated with NSAIDs, the following experiments were performed.  
      CHO cell cultures expressing APP751 were treated with increasing concentrations of sulindac sulfide. Cell lysates were prepared, and steady-state APP levels were examined using 4-12% gradient-gel electrophoresis and western blotting using the polyclonal antibody CT15. When western blot analysis was performed, neither a change in APP levels, nor an increase in CTF levels was observed in response to 60 TM or 80 TM sulindac sulfide treatment compared with levels observed for cells treated with DMSO. Unlike published γ-secretase inhibitors, sulindac sulfide did not induce detectable accumulation of APP CTFs. Therefore, β-secretase cleavage was not significantly affected by sulindac sulfide.  
      When western blot analysis was performed to detect soluble APP (sAPP) in culture supernatants using 5A3/IG7 monoclonal antibodies, results showed that there was no significant change in secretion of the APP ectodomain, (i.e., sAPP), in response to increasing concentrations of sulindac sulfide. Therefore, α-secretase cleavage was not significantly affected by sulindac sulfide.  
      APP turnover in the presence of sulindac sulfide was examined by (1) pulse labeling CHO cells with  35 S-methionine and (2) determination of APP half-life. All values were normalized to a signal obtained at the end of pulse labeling. When the APP half-life in cells treated with DMSO was compared with APP half-life in cells treated with sulindac sulfide at 25 or 125 μM, APP half-life after treatment with 25 or 125 μM sulindac sulfide was similar to APP half-life after treatment with DMSO. Therefore, APP turnover was not altered significantly in the presence of sulindac sulfide.  
      A significant fraction of Aβ is produced and released in the endocytic pathway after internalization of APP from the cell surface (see Koo et al. (1994)  J Biol Chem  269:17386-9). The effect of sulindac sulfide on this endocytic pathway was examined with an APP internalization assay described by Koo et al. (1996)  J Cell Sci  109:991-8. APP internalization was expressed as a ratio of cell surface APP versus internalized APP. When APP internalization in cultures treated with DMSO was compared with APP internalization in cultures treated with sulindac sulfide at 60 or 80 μM, the ratio of cell surface APP to internalized APP was not altered in cells treated with sulindac sulfide compared to cells treated with DMSO alone. Therefore, it was concluded that APP internalization was unchanged after sulindac sulfide treatment.  
      Notch intramembrane cleavage and formation of NICD were analyzed in kidney HEK293 cells. The myc-tagged NotchΔEMV construct encoding a constitutively cleaved Notch variant was transiently transfected into HEK293 cells. Cell cultures were treated with 125 μM sulindac sulfide for 36 hours. Then they were pulse labeled with  35 S-methionine for thirty minutes and chased for two hours. Cell lysates were prepared and subjected to immunoprecipitation with monoclonal antibody 9E10. Immunoprecipitated proteins were subjected to SDS-PAGE and phosphor imaging analyses. When amounts of NICD immunoprecipitated from lysates of cells treated with DMSO were compared with amounts immunoprecipitated from lysates of cells treated with sulindac sulfide, results showed that treatment with sulindac sulfide did not impair Notch cleavage and NICD formation. (Cells transfected with a construct encoding only the NICD domain were used for identification of the cleavage fragment.) Similarly, treatment with 500 μM ibuprofen or 150 μM indomethacin did not cause accumulation of APP-CTFs or inhibition of Notch cleavage (data not shown). Overall, these results demonstrated that NSAID treatment did not significantly perturb APP processing or γ-secretase activity. This, however, did not rule out modulation of γ-secretase activity as a mechanism of action for NSAIDs. The selective reduction in Aβ 42  secretion could be reflected only in minor changes of γ-secretase activity that may not be detectable in the assays described above.  
     Example 12  
     Reduction in Aβ 42  Secretion was Accompanied by a Dose-Dependent Increase in Aβ 1-38  Species  
      To examine Aβ species secreted by cells treated with sulindac sulfide, immunoprecipitation and mass spectrometry analyses were performed.  FIG. 8  is two representative mass spectra of Aβ species secreted by CHO cells expressing APP751 after treatment with DMSO or after treatment with 100 μM sulindac sulfide. After treatment with 75-100 μM sulindac sulfide, a strong reduction in Aβ 42  secretion was observed. Levels of Aβ 40 , however, were largely unaffected. Various Aβ species including Aβ 1-42 , Aβ 1-39 , Aβ 1-38 , and Aβ 1-37  were quantified.  FIG. 9  is a bar graph comparing ratios of each of these species to Aβ 1-40 , i.e. Aβ 1-x /Aβ 1-40  ratios, at 75 or 100 μM sulindac sulfide. Duplicate measurements were used in generating the bar graph. Reductions in Aβ 42 /Aβ 40  ratios were accompanied by two-fold increases in Aβ 1-38 /Aβ 1-40  ratios. Increases in Aβ 1-38  levels were dose-dependent. Other Aβ peptide levels did not vary consistently between cells treated with DMSO or with sulindac sulfide.  
      Mass spectrometry results demonstrating reductions in Aβ 42  secretion with concomitant increases in Aβ 1-38  secretion were confirmed by immunoprecipitation. AP polypeptides were immunoprecipitated from culture supernatants of CHO cells expressing APP751 and mutant PS-1. Immunoprecipitates were separated on an SDS-urea gel system that can resolve individual Aβ species (see Wiltfang et al. (1997)  Electrophoresis  18:527-32). Standard Aβ 1-38 , Aβ 1-40 , and Aβ 1-42  peptides were included for identification of different Aβ species. When changes in Aβ 38 , Aβ 40 , and Aβ 42  levels in CHO cells treated with DMSO were compared with those in cells treated with 60 μM or 80 μM of sulindac sulfide, a reduction in the intensity of an immuno-reactive band corresponding to Aβ 42  was observed. This reduction was matched by an equivalent increase in the intensity of an immuno-reactive band corresponding to Aβ 1-38 .  
      Two potential mechanisms may explain this unprecedented change in Aβ production after NSAID treatment. Sulindac sulfide could reduce Aβ 42  secretion by shifting γ-secretase activity towards production of Aβ 1-38 . Alternatively, it may stimulate a novel proteolytic activity that converts Aβ 42  into shorter Aβ species such as Aβ 1-38 .  
      Koo et al. (1994)  J Biol Chem  269:17386-9 and others reported that APP processing in the endocytic pathway leads to the generation and release of both Aβ 40  and Aβ 42  into culture supernatant. To examine the intracellular pool of Aβ 42  in APP mutants that lack the endocytic signal, CHO cells expressing an internalization-deficient APP polypeptide lacking 43 amino acids in the cytoplasmic tail were used (Perez et al. (1999)  J Biol Chem  274:18851-6). Levels of cellular and secreted Aβ 42  and Aβ 40  in cells expressing wild type APP and in cells expressing mutant APP were compared using ELISA. Results indicated that in the absence of the cytoplasmic tail, levels of Aβ 40  and Aβ 42  secreted by cells expressing mutant APP were diminished compared to cells expressing wild type APP. In addition, in the absence of a cytoplasmic tail, cellular Aβ 40  levels were reduced while cellular Aβ 42  levels were not reduced.  
     Example 13  
     NSAID Treatment of Tg2576 Transgenic Mice  
      NSAIDs were dissolved in an appropriate vehicle. Dimethyl sulfoxide (DMSO), ethanol, and ethyl acetate are some examples. The NSAID solution was mixed with Kool-Aid and administered orally using a medicine dropper. For three days, equal doses were administered every four hours, totaling 50 mg/kg/day. At two hours after the final doses were administered, animals were sacrificed, and SDS soluble Aβ 40  and Aβ 42  were analyzed using ELISA.  
     Example 14  
     Treatment of Animals with Ibuprofen Reduces Aβ 42  Levels  
      To determine whether acute ibuprofen treatment of mice would reduce Aβ 42  levels, three month-old Tg2576 mice expressing APP695 containing the “Swedish” mutation (APP695NL) were used. Three month old mice have high levels of soluble Aβ in the brain but no Aβ deposition (see Hsiao et al. (1996)  Science  274:99-102). Mice were given naproxen, ibuprofen, or meclofenamic acid as described in Example 13. Mice treated with ibuprofen (n=12) were compared with those untreated (n=11), treated with naproxen (n=7), or treated with meclofenamic acid (n=4). Brain levels of SDS-soluble Aβ 40  and Aβ 42  were measured using ELISA. Table 2 summarizes Aβ 40  and Aβ 42  levels determined for the control group and the naproxen, ibuprofen, and meclofenamic acid-treated groups. Treatment with ibuprofen or meclofenamic acid for three days resulted in approximately 30% reduction in Aβ 42  levels in the brain, while no change was observed in Aβ 40  levels (see  FIG. 10 ). No reduction in Aβ 42  levels was observed for naproxen-treated mice. These data were consistent with the rapid onset of Aβ 42  reduction in cell culture studies and illustrated that cell culture experiments were able to predict in vivo efficacy. In addition, these data suggested that ibuprofen treatment could prevent amyloid pathology by decreasing Aβ 42 /Aβ 40  ratio in the brain.  
               TABLE 2                          Brain levels of Aβ after acute dosing of Tg2576 mice (mean ± SD)                                     Control   Naproxen   Ibuprofen   Meclofenamic           (n = 11)   (n = 7)   (n = 12)   acid (n = 4)                                             Aβ40   2603 ± 314    2786 ± 179    2620 ± 246    2932 ± 289        (fmol/gm)       Aβ42   1074 ± 145    1182 ± 93     734 ± 302*    679 ± 343**       % Aβ42   29.3 ± 2.9    29.8 ± 1.6    21.5 ± 7.7*    18.6 ± 8.7**                 *= p &lt; 0.05;            **= p &lt; 0.01, Dunnett&#39;s test             
 
     Example 15  
     NSAIDs, NSAID Derivatives, and NSAID Analogues  
      NSAIDs that are screened for the ability to reduce Aβ 42  levels include: FDA-approved NSAIDs, NSAIDs derivatives, and NSAID analogues most potent for reducing Aβ 42  levels, newly synthesized derivatives and analogues of the most potent NSAIDs, and NSAIDS known to target pathways other than COX pathways. FDA-approved NSAIDs include ibuprofen, naproxen, dicolfenac, aspirin, indomethacin, fenoprofen, flurbiprofen, ketorolac. Derivatives of the most potent NSAIDs include aryl propionic acid derivatives such as ibuprofen and fenoprofen, and the anthranilic acid derivatives (also called amino carboxylic acid derivatives) such as the meclofenamic acid series and flufenamic acid. (NSAIDs in both series share a similar core structure of either a diphenyl ketone or dephenyl ether.) Other derivatives or analogues that are screened for the ability to reduce Aβ 42  levels include flufenamic acid, indomethacin, and meclofenamic acid derivatives and analogues (see  FIG. 11  and Kalgutkar et al. (2000)  J of Med Chem  43:2860-70). Newly synthesized NSAID derivatives or analogues include novel biphenyl amines ( FIG. 12 ) and diphenyl ketones. Examples of NSAIDs that target additional pathways to COX include LOX inhibitors.  
      Once a set of NSAIDs, NSAID derivatives, or NSAID analogues having potent ability to reduce Aβ 42  levels is obtained, a pharmacophore search is performed to identify other NSAIDs structurally similar to those in the set. If a large number of candidates are identified, the structurally similar NSAIDs are subjected to a secondary structural screen using a computer-based molecular docking algorithm known as EUDOC. In the second structural screen, crystal structures and COX-1/COX-2 binding pockets are used to identify a subset consisting of NSAIDs structurally similar to those that have potent ability to reduce Aβ 42  levels but do not bind COX-1 or COX-2. NSAIDs predicted to bind to COX and those predicted to not bind to COX are used as controls.  
      NSAIDs, NAID derivatives, and NSAID analogues can be obtained commercially or they can be chemically synthesized. Novel NSAIDs, NSAID derivatives, or NSAID analogues with unknown effects on COX activity are tested using in vitro COX-1 and COX-2 assays to determine if there is an affect on COX activity. Commercially available kits from Oxford biochemicals are used for COX inhibition assays.  
     Example 16  
     Determination of Optimal Screening Interval for Detecting Selective Reduction of β42 Levels  
      To determine the optimal treatment interval for examining selective reduction of Aβ 42  levels, CHO-APP695NL,I,his cell cultures were treated with the vehicle, or treated with ibuprofen or meclofenamic acid for six, twelve, or twenty-four hours. Aβ 40  and Aβ 42  levels in culture supernatants were determined for each time points using ELISA.  FIG. 13  is a bar graph demonstrating that selective reduction of Aβ 42  was detectable at six hours when cells were treated with meclofenamic acid. Similar results were observed for ibuprofen (data not shown).  
     Example 17  
     Primary In Vitro Screening  
      In a primary screen, the effects of NSAIDs on Aβ 42  secretion by a CHO cell line that expressed APP(CHO-APP695NL,I,his) were examined. Duplicate cell cultures were treated with (a) a vehicle, (b) 10 μM of NSAID, or (c) 100 μM of NSAID.  
      To determine Aβ 40  and Aβ 42  levels, six-hour culture supernatants taken from cells grown in a single well of a twenty-four-well plate were used in end-specific Aβ 40  and Aβ 42  ELISAs (Suzuki, et al. (1994)  Sci  264:336-1340). Aβ 40  and Aβ 42  levels of cultures treated with NSAID were compared with those of cultures treated with the vehicle alone. Concentrations of 100 μM Ibuprofen and 10 μM meclofenamic acid were used as positive controls. Results, in Table 3, indicated that some NSAIDs selectively reduce Aβ 42  levels, but at the concentrations tested, many do not. NSAIDs were classified based on a 20% change in Aβ levels observed in NSAID-treated versus vehicle treated cells. Classification was made based on a 20% change because the data showed a 10% accuracy variance. When classification was made based on a 20% change, all NSAIDs screened, with the exception of two, were classified in the same category with repeated testing. Two NSAIDs, shown in bold italic, gave results that altered their categorization upon re-screening; classification was resolved after a third test. These results confirmed the data described in Examples 8-10, as the NSAIDs that were shown to selectively lower Aβ 42  initially also reduced Aβ 42  in this screen. Of the newly synthesized biphenyl amines, meclofenamic, mefenamic, and flufenamic acid selectively reduced Aβ 42  levels, while tolfenamic acid did not. NSAIDs that caused either selective reduction of Aβ 42  levels or reduction in both Aβ 40  and Aβ 42  levels are subjected to a secondary screen.  
               TABLE 3                          Effects of NSAIDs on secreted Aβ.                                         % Control   % Control   % Control       Compound   Type   Aβ40   Aβ42   % Aβ42                                         ↓Aβ42 no effect                       on Aβ40       Sulindac Sulfide 10 μM   Cox-1,2   97%   57%   65%       Flufenamic Acid 10 μM   Cox-1,2   99%   64%   70%       Ibuprofen 100 μM   Cox-1,2   95%   74%   81%       Ibuprofen 10 μM   Cox-1,2   102%   80%   82%       Flurbiprofen 100 μM   Cox-1,2   93%   70%   80%       Fenoprofen 100 μM   Cox-1,2   102%   60%   63%       Mefenamic Acid 100 μM   Cox-1,2   116%   78%   72%       Indomethacin 100 μM   Cox-1,2   101%   69%   68%       ↓Aβ42 &gt; ↓Aβ40       NPPB 10 μM   Cox-1,2   81%   48%   66%       Carprofen 100 μM   Cox-1,2   58%   48%   86%       Meclofenamic   Cox-1,2   39%   13%   37%       Acid 10 μM       ↓Aβ40 no effect       on Aβ42       APHS 10 μM   Cox2 &gt;   50%   114%   178%           Cox1       Resveratrol 10 μM   Cox-1   75%   107%   130%       ↓Aβ40 and ↑Aβ42       Meloxicam 10 μM   Cox-1,2   64%   122%   158%       SC560 10 μM   Cox-1 &gt;   47%   166%   227%           Cox-2       Guaiazulene 100 μM   Cox-1,2   70%   124%   156%       ↑Aβ42       NS398; 10 μM   Cox-2 &gt;   101%   146%   132%           Cox-1       Ketorlolac 10 μM   Cox-1,2   84%   131%   142%       Benzydamine 100 μM   Cox-1,2   90%   128%   132%       ↑Aβ40 and/or ↑Aβ42       Suprofen 100 μM   Cox-1,2   126%   129%   102%       Indoprofen 100 μM   Cox-1,2   116%   126%   107%       Nabumetone 100 μM   Cox-1,2   157%   103%   70%       Piroxicam 100 μM   Cox-1,2   142%   101%   75%       No Effect on Aβ       Acetylsalicylic   Cox-1 &gt;   93%   99%   104%       acid 100 μM   Cox-2       Ketoprofen 100 μM   Cox-1,2   88%   107%   117%       Fenbufen 100 μM   Cox-1,2   100%   109%   107%       Naproxen 100 μM   Cox-1,2   107%   112%   104%       Isoixicam 100 μM   Cox-1,2   109%   112%   103%       Tenoxicam 100 μM   Cox-1,2   80%   92%   112%       Tolfenamic Acid 100 μM   Cox-1,2   84%   95%   110%       Diclofenac; 100 μM   Cox-1,2   88%   87%   100%       Etodolac 100 μM   Cox-1,2   85%   109%   120%       Acemetacin 100 μM   Cox-1,2   110%   101%   93%       Niflumic Acid   Cox-1,2   120%   107%   85%       Dapsone   Anti-   99%   80%   84%           Bacterial       Sulindac Sulfone   No-Cox   109%   97%   92%       Nimesulide   Cox-1,2   105%   116%   116%       Suxibuzone   Cox-1,2   82%   107%   129%       Diflunisal   Cox-1,2   90%   103%   112%                  
 
     Example 18  
     Secondary and Tertiary In Vitro NSAID Screening  
      In a secondary screen, an extended dose-response study in which CHO cell cultures are treated with 1 nM to 1 mM of NSAID is performed. Dose response studies are used to estimate IC 50  values for maximum reduction of Aβ levels as well as to identify NSAIDs that have toxic effects. A secondary screen is performed for all FDA-approved NSAIDs that reduce Aβ 42  levels in cell cultures.  
      In a tertiary screen, Aβ production, sAPP production, and toxicity in a human H4 neuroglioma cell line that expressed APP are examined for all FDA-approved NSAIDs and novel NSAIDs that selectively reduce Aβ 42  levels. Three doses of each NSAID are tested. The first is a dose that is expected to cause maximum reduction of Aβ 42  levels. The second dose is one that reduces Aβ 42  levels by 50% of the maximum value, while the third dose is one that reduces Aβ 42  levels by 10-20% of the maximum value. Tertiary screens are performed on the most potent NSAIDs identified by secondary screens.  
      NSAID toxicity is measured using an MTS assay (see Example 1) and a lactate dehydrogenase (LDH) release assay (Promega Corp, Madison, Wis.).  
     Example 19  
     Acute Single-Dose Studies to Identify NSAIDs having In Vivo Activity  
      To determine whether NSAIDs that selectively reduce SDS-soluble Aβ 42  levels in cell culture studies also reduce brain Aβ 42  levels, in vivo studies using Tg2576 mice are performed.  
      Mice of either sex are used for acute studies. Each experimental group, however, is performed using mice of the same sex. Power calculations, based on past measurements of variability of Tg2576 brain Aβ levels, indicate that an “n” of five mice per study group gives an 80% chance of detecting a difference of 20% or more at p&lt;0.05. These calculations are supported by experiments on wortmanin treated and Aβ 42  immunized Tg2576 mice, in which significant changes in Aβ levels, even between groups of three to four mice, were noted (Haugabook et al. (2000)  Faseb J ). Although in most studies there are five mice per experimental group, in some instances, additional mice are used to account for loss due to death or illness. The use of additional mice also increases the power of ancillary studies such as those involving behavior, as sometimes, the number of mice needed to obtain a useful result is not known.  
      NSAIDs are prepared and administered to three-month-old Tg2576 mice as described in Example 13. To avoid extensive testing of NSAIDs that are not active in vivo, high doses of NSAIDs are used initially. NSAIDs are administered every four to eight hours; exact doses and dose schedules are determined from LD 50  values, half-lives, and in vitro dose response studies. In general, a maximum dose that is non-toxic, typically ranging from 1/10 to ⅕ of the LD 50  value of the NSAID, is used. If the LD 50  and other pharmacokinetic data of a given NSAID are unknown, their values are estimated using those of the nearest structural analogue.  
      To monitor toxicity, weights of a mouse before and after the study are compared. In addition, one mouse from each treatment group is subjected to a liver function test (LFT) in which blood levels of two liver enzymes, SGOT and SGPT, are determined. SGOT and SGPT are sensitive markers of liver toxicity. Furthermore, renal function, indicated by blood urea nitrogen (BUN) levels, is determined. Tests for liver and renal functions are performed by Anilitics (Gaithersburg, Md.), a company that specializes in these tests. Those NSAIDs having toxic effects at high doses are not used in long-term studies unless their effectiveness and lack of toxicity at lower doses are established.  
      Following a three-day administration schedule, mice are sacrificed; Aβ levels in plasma, brain, and CSF are determined; levels of NSAIDs in plasma are determined; and mice are examined for signs of toxicity. NSAIDs that selectively reduce SDS-soluble Aβ 42  levels by more than 20-30% are examined in multiple dose response studies.  
     Example 20  
     Multiple-Dose Studies to Identify Doses Useful for In Vivo Long-Term Animal and Human Studies  
      NSAIDs that reduce Aβ 42  levels in vivo, at high doses, are administered to groups of three mice at high, medium, and low doses using the same dosing regimen described in Example 19. A high dose is the amount used in the single dose screen of Example 19, while medium and low doses are determined by inference from in vitro dose response studies described in Example 18. Those NSAIDs more potent than ibuprofen in vitro, (i.e., those that have IC 50  values required for maximum reduction of Aβ 42  levels that are less than a mid TM value) are examined over a wide range of doses. For example, doses representing 1/50 to 1/10 of the IC 50  value are used in the multiple dose analysis. NSAIDs having similar in vitro IC 50  values to ibuprofen are tested over a more limited range. For example, doses representing 1/10 to ⅓ of the IC 50  value are used in the multiple dose analysis. Analyses of Aβ are performed as described for single dose studies. To identify plasma NSAID levels that correlate with Aβ 42  reduction in vivo, a plasma NSAID level is determined for each dose examined using the HPLC method described in reference 64 and adapted for each particular NSAID. Data pertaining to plasma NSAID levels in these multiple dose studies are used as reference values for both long-term animal studies where NSAIDs are administered in feed, as well as for subsequent human studies.  
     Example 21  
     Effects of NSAIDs on In Vivo COX Activity  
      To determine if concentrations of NSAIDs used are sufficient to mediate anti-inflammatory effects, novel NSAIDs are examined for their in vivo COX inhibitory activities and anti-inflammatory activities. For this study, the carrageneenan-induced footpad edema assay, described in Kalgutkar et al. (2000)  J of Med Chem  43:2860-70, is performed on mice prior to sacrifice. For NSAIDs that do not reduce Aβ 42  levels, the assays are performed on mice treated with NSAIDs at levels equivalent to that administered in long-term studies.  
     Example 22  
     NSAIDs Used in Long-Term Preventative and Therapeutic Studies  
      To determine whether the effects of NSAIDs on amyloid deposition in an animal model are attributable to direct inhibition of Aβ 42  accumulation, or reduction in inflammatory processes in the brain, or both, the following groups of NSAIDs are examined in long-term preventative and therapeutic tests. NSAIDs that selectively reduce Aβ 42  levels but lack anti-inflammatory properties, NSAIDs that selectively reduce Aβ 42  levels and have anti-inflammatory properties, or NSAIDs that have no effect on Aβ 42  levels but have anti-inflammatory properties are examined in both preventative and therapeutic studies. Ibuprofen is used to examine indirect inflammatory-mediated effects on Aβ deposition and direct effects caused by reduction of Aβ 42  levels, since it reduces Aβ 42  levels and has anti-inflammatory properties. Celecoxib and naproxen, non-selective and selective Cox inhibitors, respectively, that do not cause reduction of Aβ 42  levels are used to examine Aβ 42 -independent inflammatory-mediated effects. NSAIDs examined in both preventative and therapeutic studies include those that exhibit one of these three properties: selectivity for Aβ 42  reduction relative to COX inhibition, Aβ 42  reduction and COX-2 selectivity, or solely increased potency for Aβ 42  reduction in vivo.  
     Example 23  
     Long-Term NSAID Dosing for Preventative and Therapeutic Trials  
      Long-term dosing of mice is achieved through feed. Feed containing the desired concentration of NSAID can be obtained from commercial entities. Prior to long-term preventative or therapeutic studies, successful administration of a chosen dose of NSAID through feed is verified using the following experiment. First, an NSAID concentration effective in reducing Aβ 42  levels in acute studies, when administered by dropper, is chosen. This concentration corresponds to the lowest dose that can generate a maximum reduction in Aβ 42  levels. In the case of an NSAID that does not reduce Aβ 42  levels, a concentration sufficient to cause anti-inflammatory effects is chosen. In the case of ibuprofen, the dose that reduces Aβ 42  levels also is a dose that causes anti-inflammatory effects. Feed containing the chosen concentration of NSAID is used in a short-term trial to compare mice given NSAID by dropper to mice given NSAID incorporated into feed. The reduction in Aβ 42  levels as well as peak plasma levels of NSAID are determined for mice given NSAID by dropper and mice given NSAID through feed. If levels of Aβ 42  reduction and peak plasma levels of NSAID in the two groups are comparable, then the chosen amount of NSAID is achieved through feeding, and long-term preventative or therapeutic studies are performed. If levels of Aβ 42  reduction and peak plasma levels of NSAID in the two groups are not comparable, then the concentrations of NSAID in feeds are altered appropriately until reduction in Aβ 42  levels and peak plasma levels of NSAID in the two groups of mice are comparable.  
     Example 24  
     Determination of Peak Plasma Levels of NSAIDs  
      Techniques for determination of ibuprofen, fenoprofen, and meclofenamic acid levels in plasma are described in Canaparo et al. (2000)  Biomedical Chromatography  14:219-26; and Koup et al. (1990)  Biopharmaceutics  &amp;  Drug Disposition  11:1-15. In general, an internal standard is added to a plasma sample. The sample is acidified and subjected to organic solvent extraction. The organic phase is dried, dissolved in a small volume, and subjected to HPLC using a C18 column. Calibration and standardization are carried out using untreated plasma spiked with NSAID for construction of a calibration curve.  
     Example 25  
     CSF Collection  
      Mice are anesthetized with pentobarbital (30-50 mg/kg). An incision from the top of the skull to the mid-back is made and the musculature from the base of the skull to the first vertebrae is removed to expose the meninges overlying the cisterna magna. The animal is placed on a narrow platform in an inverted fashion beneath a dissecting microscope. The tissue above the cisterna magna is excised with care not to puncture the translucent meninges. The surrounding area is cleaned gently with the use of cotton swabs to remove any residual blood or other interstitial fluid. The dilated cisterna magna containing CSF is easily visible at this point. In addition to the cerebellum, brain stem, and spinal cord, an extensive vascular network also is visible. A micro needle and a polypropylene narrow bore pipette are aligned just above the meninges. With care not to disrupt any of the underlying vasculature, the micro needle is slowly inserted into the cistern. The CSF, which is under a positive pressure due to blood pressure, respiration, and positioning of the animal, begins to flow out of the needle entry site once the micro needle is removed. The micro needle then is pulled slowly backwards and the narrow bore pipette is used to collect the CSF as it exits the compartment. Once the needle is completely removed, the pipette is lowered into the puncture site and used to remove any remaining CSF. The primary collection usually takes less than 15 seconds for completion. The cistern will refill with several TL of CSF within two minutes. A second collection is performed to increase the net yield. At the end of the procedure, the emptied cistern is collapsed due to the removal of CSF. CSF is not collected past the first two minutes. The isolated CSF is transferred quickly into a pre-chilled polypropylene tube on ice. Less than 5% of samples contain visible blood contamination.  
     Example 26  
     Biochemical, Histochemical, Behavioral, and Toxicology Evaluations of Long-Term NSAID Treatment  
      When mice are sacrificed, one hemi-brain is processed for biochemical analyses and the other for immunohistochemical and histochemical analyses.  
      Aβ 40 , Aβ 42 , and total Aβ levels in mice brains are determined. Both SDS-soluble and SDS-insoluble formic acid-soluble fractions are examined. ELISA, described in Kawarabayashi et al. (2001)  J Neur  21:372-381, and the BAN50 system, described in Suzuki et al. (1994)  Sci  264: 1336-1340, are used. Both Aβ 40  and Aβ 42  polyclonal capture antibodies and end-specific polyclonal antibodies are available. Changes in levels of different Aβ species due to NSAID treatments are examined by imunoprecipitation-mass spectral analysis. Aβ levels in plasma and CSF are determined at the time of sacrifice.  
      To examine total plaque burden, brain sections are stained with anti-Aβ antibodies. Antibodies to all Aβ species as well as end specific Aβ 40  and Aβ 42  antibodies are used. Cored plaques are detected by staining with thioflavin. Plaque number and amyloid burden are calculated as described in the Sigma ScanPro image analysis software (see Haugabook et al. (2000)  Faseb J ). Plaque types and extent of vascular and parenchymal amyloid depositions are examined.  
      Inflammation is examined by biochemical and histochemcial techniques. Astrocytosis is examined using immunohistochemical staining and Western blotting of the SDS-extract for GFAP. Microglial activation is examined using staining techniques for anti-phophotyrosine as described in Lim et al. (2000)  J Neurosci  20:5709-14. Alternatively, microglia are immunostained using a pan MHC antibody or using SMI-312 GS lectin as described in Frautschy et al. (1998)  Am J of Path  152:307-17. Inflammatory markers such as α1ACT and APOE are examined using Western blot analysis of the SDS-extract, while IL-1 and IL-6 are examined using commercially available ELISA kits.  
      To examine neuronal loss and tau pathology, sections from brains are stained using haematoxylon and eosin. Sections are examined for overt pathological signs and neuronal loss. Marked neuronal loss is quantitated using stereological counting. Tau pathology is assessed using immunohistochemical staining by several anti-phosphorylated tau antibodies.  
      For behavioral studies, a modified version of the Morris watermaze is used to detect learning and memory impairments related to amyloidosis in mice over-expressing APP (see Chen et al. (2000)  Nature  408:975-979). Testing is conducted in fully counterbalanced, age-matched squads of mice (five to seven per group); trial blocks are run at the same time each day, during the light cycle. Subjects run in a fixed order each day with an inter-trial interval of approximately fifteen minutes. Trial spacing minimizes effects of hypothermia and fatigue that often are seen in older animals (see Rick et al. (1996)  J Gerontol A Biol Sci Med Sci  51:B253-60). The first day of testing consists of swimming to a visible platform. This assesses motivation, and visual and swimming ability. One trial is performed from a fixed starting position to each of four separate cued platform locations. In subsequent days, up to ten trials per day are performed using a learning criterion of three consecutive trials with less than twenty escape latency (see Chen et al. (2000)  Nature  408:975-979). No probe trial is necessary since the only dependent variable measured is trials to reach criterion (TTC). Once an animal reaches criterion on one platform location, it is immediately switched to a new location. Testing is continued until five platform locations have been learned. Deficits in TTC are apparent in this paradigm primarily on the last two platform locations. These data are used with neuropathological data to assess the mice (see Chen et al. (2000)  Nature  408:975-979).  
      Evaluation of neurological and sensorimotor skills is performed on the first day of testing, before the cued platform trial. A standard test battery is administered. This consists of (a) ten minutes in an automated open field, (b) examination of righting and grasping reflexes, (c) latency to fall when suspended from a wire by the forepaws, and (d) rotorod performance. These tests screen basic functions such as strength, balance, and locomotor/exploratory behavior that can affect watermaze performance (Rick et al. (1996)  J Gerontol A Biol Sci Med Sci  51: B253-60; Murphy et al. (1995)  Neur Learn Mem  64:181-6; Bickford et al. (1997)  Neur Aging  18, 309-18; Cammisuli et al. (1997)  Behav Brain Res  89:179-90; and Lewis et al. (2000)  Nat Genet  25:402-5). In this way, effects of strength, balance, and locomotor/exploratory behavior on watermaze performance are accounted for.  
      As in acute studies, appropriate plasma markers are tested intermittently on a few NSAID treated mice to monitor liver and renal functions in both preventative and therapeutic trails. Weights of the mice are monitored bi-weekly, and complete blood counts are performed every two to three months. At the time of sacrifice, the GI tract is examined for signs of ulceration using a dissecting microscope as described in Kalgutkar et al. (2000)  J of Med Chem  43:2860-70.  
     Example 27  
     Determination of the Effects of NSAIDs on Aβ Deposition—Long-Term Preventative Trial  
      NSAIDs that selectively reduce Aβ 42  levels in acute studies are examined in a preventative trial to determine if they can prevent Aβ deposits. Six-month-old Tg2576 mice are used in preventative trials since Aβ deposit has not yet taken place. NSAID treatment of mice at this age corresponds to treating humans before signs of clinical disease occur.  
      Tg2576 mice are treated with experimentally optimized doses of NSAID for three, six, and twelve months. Each treatment group consists of a minimum of twenty animals, five of which are examined at each of the three time points. The remaining five mice are included in case of illness or death during long-term dosing. Three to four mice are placed into a treatment group each month until groups of twenty animals are established. At the time of sacrifice, tissues obtained for analysis are stored until all the mice within an experimental group have been sacrificed. Therefore, all samples from mice within one experimental group are examined simultaneously. For ibuprofen, naproxen, and control groups, twenty-seven mice are used per experimental group. The extra mice are treated for twelve months after which time behavioral patterns and additional pathologic parameters are examined.  
      The following NSAIDs are used in preventative trials: ibuprofen which reduces Aβ 42  levels, has anti-inflammatory activity, and has a short-half life; meclofenamic acid which is more potent at reducing Aβ 42  levels in vitro, and has anti-inflammatory activity; sulindac which reduces Aβ 42  levels, has anti-inflammatory activity, and has an extended-half-life; naproxen which has no effect on Aβ 42  levels, but has anti-inflammatory activity, and COX-1 and COX-2 inhibitory activities; and celecoxib which is an anti-inflammatory COX-2 selective agent. In addition, other NSAIDs that reduce Aβ 42  levels but show selectivity for this effect over inhibitory effects on COX-1, COX-2, or both are included in this study. At three, six, and twelve months of treatment with NSAIDs, mice are analyzed for behavioral alterations; then they are sacrificed and biochemical analyses are performed as described in Example 26.  
     Example 28  
     Alteration of Aβ Deposits by NSAIDs—Long Term Therapeutic Trial  
      To determine whether Aβ deposition, the effects of Aβ deposition, or both can be altered once Aβ has accumulated to a high level, NSAIDs that selectively reduce Aβ 42  levels in acute studies are examined in a therapeutic trial. Effects of treatment with NSAIDs that reduce Aβ 42  levels are compared to effects of treatment with NSAIDs that do not reduce Aβ 42  levels such as the non-selective COX inhibitor naproxen and the selective COX inhibitor celecoxib. Sixteen-month-old Tg2576 mice are treated with experimentally optimized doses of NSAIDs for three or six months. Sixteen-month-old mice have large amounts of Aβ in the brain and therefore, are representative of human patients with clinical signs of AD. Amyloid deposition, behavior, and AD-like pathology are examined as described in Example 26. Fourteen mice per treatment group are used; at least five treated and five control mice are compared.  
     Example 29  
     Statistical Analysis  
      Mann-Whitney and Dunnet&#39;s tests are used for comparisons between groups of treated and untreated mice. A number of correlative comparisons are made. Variables and outcomes used in statistical analysis for each study are the following. For in vitro screening experiments, variables include: Aβ levels in media, NSAID concentrations, toxicity, and COX inhibitory activity; while primary outcomes include reduction in Aβ 42  levels and COX inhibitory activity. In acute single-dose studies, variables include: Aβ levels in brain, plasma, and CSF; NSAID concentrations in plasma and brain; and dose of NSAID. Primary outcomes of acute single-dose studies include reduction in brain Aβ 42  levels and plasma levels of NSAID, while secondary outcomes includes correlation of brain, CSF, and plasma AP levels. In long-term studies, variables include: Aβ levels in brain, plasma, and CSF; NSAID concentrations in plasma (and brain, if possible); dose of NSAID; amyloid burden; extent of inflammatory response; behavioral performance; and toxicity. Primary outcomes of long-term studies include effects on Aβ levels in the brain, while secondary outcomes include evaluation of inflammatory response, behavior, toxicity, and correlative analyses.  
     Example 30  
     Clinical Investigations in Amyloid-Reducing Actions of NSAIDs  
      The most promising FDA-approved NSAIDs, determined by preclinical studies, are examined for amyloid reducing actions in healthy subjects as well as subjects with mild to moderate Alzheimer&#39;s disease (AD). These studies are performed in three-group parallel design; each group consists of twelve subjects. Subjects are treated with an NSAID or a matching placebo several times a day, depending on the NSIAD, for fourteen days. Study NSAIDs are purchased and over-encapsulated by the San Diego VAMC Pharmacy service or by another compounding pharmacy. Placeboes are similarly encapsulated.  
      AD subjects are selected based on the following criteria. Subjects consist of men and women, ages 60-85, who are diagnosed with probable AD using the National Institute of Neurologic Communicative Disorders and Stroke-Alzheimer&#39;s Disease and Related Disorders Association (NINCDS-ADRDA) test (McKhann et al. (1984)  Neurology  34:939-944) or have mild to moderate dementia as determined by the Mini-Mental State Examination (MMSE, Mohs et al. (1996)  Int Psychogeriatr  8:195-203). MMSE scores in the range of 15-25 indicate mild to moderate dementia. AD subjects have caregivers that can ensure compliance with medication regimens and with study visits and procedures.  
      Non-demented control subjects consist of men and women ages 60-80. Control subjects lack significant cognitive or functional complaints, or depression as determined by the Geriatric Depression Scale (GDS), and have MMSE scores in the range of 27-30. Control subjects have the same general requirements as AD subjects with the exception that caregivers are not required. Both AD subjects and control subjects have good general health, i.e., subjects do not have serious or life-threatening comorbid conditions.  
      Subjects who have medically active major inflammatory comorbid condition(s) such as rheumatoid arthritis, or those who have peptic ulcer, gastro-intestinal bleeding, or intolerance of NSAIDs in the past are excluded from the study. Those who have contra-indications to lumbar puncture, such as severe lumbar spine degeneration, sepsis in the region of the lumbar spine, or a bleeding disorder are excluded from participation in the study. In addition, subjects who currently or recently use medications such as NSAIDs, prednisone, or immunosuppressive medications such as cyclophosphamide that could interfere with the study are excluded. Recently is defined as within one month before undergoing the baseline visit (see next paragraph). Subjects undergoing acetylcholinsterase inhibitor (AChE-I) treatments for AD are not excluded if these subjects have been on stable doses for at least four weeks. Similarly, AD subjects taking antioxidants such as vitamin E, vitamin C, or Gingko biloba are not excluded if they have been on stable doses for at least four weeks. Subjects who use NSAIDs or aspirin on a regular basis are excluded. If needed, analgesics such as paracetamol (Tylenol) are provided during the fourteen-day study.  
      The study procedure consists of three in-clinic visits: an initial screening visit, a baseline visit, and a follow-up visit at fourteen days. During the screening visit, information needed to assess eligibility is obtained and MMSE is administered.  
      During the baseline visit, which takes place within two weeks of the screening visit, physical examinations and lumbar punctures are performed. Blood samples are drawn for laboratory tests such as APO-E genotyping and for plasma preparation (see Example 31). At this time, subjects or caregivers, in the case of AD subjects, are given a fourteen-day supply of study NSAID along with instructions about timing of doses and potential adverse effects. (For AD subjects, caregivers are required to accompany subjects to each visit, and are responsible for monitoring and supervising administration of study NSAIDs.) A calendar is provided on which times of medications and potential adverse symptoms are recorded.  
      The NSAID treatment regimen consists of a fourteen-day treatment with NSAIDs in the form of capsules taken two or three times a day with meals. A high and a low study dose of NSAID are used. For ibuprofen, study doses of 800 mg and 400 mg are used. A study dose of 800 mg consists of two 400 mg ibuprofen tablets, while a study dose of 400 mg consists of one 400 mg ibuprofen capsule and one placebo capsule. For sulindac, a study dose of 200 mg twice a day for a total of 400 mg per day is used. For meclofenamic acid, study doses of 100 mg and 400 mg per day are tested. NSAIDs are pre-packed into a day-by-day plastic medication dispenser.  
      During the follow-up visit, twelve or fourteen days after beginning treatment, vital signs and adverse side effects of study NSAIDs are assessed. Surplus NSAIDs are returned and counted. In addition, lumbar punctures are performed and blood samples are drawn for laboratory tests and for plasma preparations.  
      Visits during which lumbar punctures are performed and blood samples are drawn are scheduled for mornings with overnight fasting to avoid obtaining post-prandial or hyperlipemic plasma samples, which can influence levels of Aβ 40  and Aβ 42 . Table 4 summarizes biological markers that are analyzed from plasma and CSF samples.  
               TABLE 4                          Plasma and CSF biological markers                                         Volume       Assay   Method   Volume of CSF   of Plasma               Protein,       1 mL           glucose, cells       Aβ 40     ELISA   100 TL × 2   100 TL × 2               (in duplicate)       Aβ 42     ELISA   100 TL × 2   100 TL × 2               (in duplicate)       Aβ 38     Mass Spectrometry   1 mL       Isoprostanes   Gas Chromatography/   2 mL           Mass Spectrometry       M-CSF   ELISA   50 TL × 2               (in duplicate)       MCP-1   ELISA   50 TL × 2               (in duplicate)       Tau,   ELISA   50 TL × 2       P-tau181       (in duplicate)               50 TL × 2               (in duplicate)       Plasma levels   HPLC       1 mL       of NSAIDs                  
 
     Example 31  
     Collection of Plasma and CSF  
      Plasma samples are prepared within 15-30 minutes after blood samples are drawn. Plasma samples are frozen at −70° C. until used. At least 6 mL of CSF and, whenever possible, 10-15 mL are drawn from each subject. Total cell, protein, and glucose estimations are performed. Samples are identified by a study ID number, and technicians who run ELISAs or other assays are blinded to the identity of the subjects or the treatment conditions.  
     Example 32  
     Specific Assays  
      ELISA is used to determine Aβ 40  and Aβ 42  levels in CSF. Batches of samples are assayed simultaneously in duplicate on microplates according to established procedures (3). In Aβ 42  detection, two antibodies are used: (1) a monoclonal antibody that recognizes an epitope within the first five amino acids of Aβ is used for capture and (2) an end-specific monoclonal antibody that recognizes Aβ ending at amino acid 42 and conjugated to horse radish peroxidase is used for detection. CSF levels of Aβ 38  are measured by mass spectroscopy as described in Example 6. CSF isoprostanes are measured by gas-chromatography/negative chemical ionization mass spectroscopy using internal standards for calibration Montine et al. (1999)  Neurology  52:562-565). CSF levels of MCSF, MCP-1, tau, and P-tau 181 are determined. Commercially available ELISA kits are used for M-CSF (R&amp;D Diagnostics) and MCP-1 (Pharmingen, San Diego) determinations. CSF tau and P-tau 181 are determined using ELISA kits from Innogenetics, Inc., Plasma levels of specific NSAIDs are determined by HPLC methods described in published procedures (Canaparo et al. (2000)  Biomed Chromatogr  14:219-26).  
     Example 33  
     Analysis of Clinical Data  
      Reduction in Aβ 42  levels due to NSAIDs treatment is detected as decreases in Aβ 42  levels in CSF and/or plasma. Therefore, subjects with AD or elderly control subjects who receive NSAID treatments show serial decreases in CSF and/or plasma Aβ 42  levels, while those who take a placebo will not show serial changes in CSF and/or plasma Aβ 42  levels.  
      To assess comparability between groups of subjects at baseline, demographic data (e.g. age and gender), dementia severity (MMSE score), and APO-E e4 allele frequency are compared between placebo groups, and groups of subjects with AD or elderly controls that are treated with NSAIDs. Continuous variables are compared by ANOVA and frequencies of categorical variables such as gender and APO-E genotype are compared using Chi-squared or Fisher&#39;s exact test.  
      Changes in levels of biomarkers of interest between baseline samples to follow-up samples are calculated for each subject. Descriptive statistics are used to determine whether levels of biomarkers at baseline are normally distributed. If they are, then mean changes in each treatment group are compared with each placebo group using ANOVA._If they are not normal, then data transformation is applied or non-parametric statistics are used to compare changes in biomarker levels between different groups of subjects.  
      To determine whether changes in Aβ 42  levels are accompanied by changes in Aβ 40  and Aβ 38  levels, CSF Aβ levels in placebo groups are compared to that in treatment groups using ANOVA. Levels of biomarkers related to microglial function (e.g. M-CSF and MCP-1), oxidative damage in the brain (e.g. F-2 isoprostanes), and neuronal degeneration (e.g. tau and P-tau181) are compared before and after treatment as well as between groups treated with placebo or with NSAID. If levels of biological markers change after treatment with NSAID, the change is examined in relation to variables such as age, gender, APO-E genotype, and plasma NSAID levels. Scatter-plots and appropriate statistical comparisons are used.  
     Example 34  
     Statistical Power Calculations  
      Published data indicate that CSF Aβ 42  levels remain stable on repeated lumbar punctures. The power to detect differences between subjects treated with NSAIDs and subjects treated with placeboes depends on magnitudes of changes in biomarker levels after treatment relative to baseline.  
      In published longitudinal data for CSF Aβ 42  levels in an AD patient group of 53 (see Andreasen et al. (1999)  Arch Neurol  56:673-80), baseline CSF Aβ 42  level (mean±SD) was 709±304 pg/ml and follow-up (10 months later) CSF Aβ 42  level was 701±309 pg/mL. The correlation between the first and second CSF Aβ 42  level was R=0.90. No published longitudinal CSF Aβ 42  data are available in healthy subjects. In two studies that included healthy subjects, the values for CSF Aβ 42  levels were 1485±473 pg/mL (see Galasko et al. (1998)  Arch Neurol  55:937-45) and 1678±436 pg/mL (see Andreasen et al. (1999)  Arch Neurol  56:673-80).  
      The power calculation uses the following assumptions: (1) levels are stable over time as described in Andreasen et al. (1999)  Arch Neurol  56:673-80 and (2) variance of change is similar. The standard deviation is calculated as square root of ((1−correlation)*2*SDˆ2). A pre-post correlation of 0.8 for CSF Aβ 42  level is assumed.  
      If the change in pre-post mean CSF Aβ levels is assumed to be approximately zero in the placebo group, then effect size depends on the mean level of Aβ 42  at baseline. For example, for elderly controls, if the mean CSF Aβ 42  level is 1485 pg/mL (see Galasko et al. (1998)  Arch Neurol  55:937-45), then a 0.25 effect size represents an increase or decrease of the mean by 371 pg/mL due to treatment.  
      For power calculations, the following are assumed: (1) alpha=0.05, (2) power=0.80, and (3) two-group studies in which equal numbers of subjects exposed to placebo and treatment are used. For power calculations with an effect size of 0.25, a sample size (N) of 11 in each of the two groups is required. With effect size of 0.2, an N of 16 is required in each group.  
      Twelve subjects per group are used for each study allowing for detection of an effect size of 0.25 or higher. In pre-clinical studies, several NSAIDs (including ibuprofen and meclofenamic acid) reduced Aβ 42  levels in supernatants from cultured cells and in brain tissues of transgenic mice by over 25%. In long-term transgenic mouse studies using ibuprofen, reported in (Lim et al. (2000)  J Neurosci  20:5709-14), Aβ levels in the brain were about 38% lower when treated than untreated.  
      If the variance in CSF Aβ 42  levels between subjects or on repeated lumbar puncture is greater than in these projections, then sample size is re-assessed and group size is modified as needed. A similar set of calculations using published data on CSF Aβ 42  levels in AD patients shows that groups of twelve patients are sufficient to detect a 25% effect size.  
      Published longitudinal CSF data are available for CSF tau in AD. Sunderland et al. (1999)  Biol Psychiatry  46:750-755 studied twenty-nine patients with AD having baseline CSF tau (mean±SD) of 548±355 pg/mL, follow-up CSF tau at twelve months of 557±275 pg/mL, and an R-value of 0.85.  
      The decision to use twelve subjects per group is derived from Aβ data. Again, assuming CSF tau remains stable and unchanged on average in the absence of treatment, an effect size for a decrease in CSF tau by at least 33% relative to baseline is 183 pg/mL of tau.  
      In a two-group study design with (1) equal subject numbers receiving placebo and treatment, (2) N=12 per group, and (3) assuming α=0.05, then power is 73% for detecting an effect size of 33% or greater for tau.  
      With the exception of plasma Aβ levels that remained stable as indicated by preliminary ibuprofen studies, the degree of variation of longitudinal measurements of other biomarkers is not known. Ibuprofen studies in healthy elderly and subjects with mild AD are performed first, then sample sizes are reassessed for all biomarkers measured and necessary changes are incorporated in to other NSAID studies.  
     Example 35  
     Placebo-Controlled Study of NSAIDs with A Lowering Actions  
      A double-blind randomized placebo-controlled study is performed using sixty AD subjects treated with a placebo, ibuprofen, or another FDA-approved NSAID with Aβ-reducing action at a well-tolerated dose for 48 weeks. Specific NSAIDs and doses are selected based on results obtained in Example 30.  
      Subjects are 50-90 years of age and have diagnoses of probable AD as indicated by the NINCDS-ADRDA test. Subjects have an MMSE range of 15-25, good general health, i.e., no life threatening or major medical illnesses; and caregivers who can supervise medication regimens and provide collateral information. Additional screening criteria are as described in Example 30.  
      Initially, subjects are assessed for eligibility in a screening visit. MMSEs and physical examinations are performed. Blood samples are obtained for routine laboratory tests. Block randomization is used to assign patients to placebo or active treatment groups. Assignment is determined according to baseline MMSE scores so that dementia severity is similar in the placebo and active treatment groups.  
      During the baseline visit, scheduled within two weeks of the screening visit, vital signs are assessed, lumbar punctures are performed, and blood samples are drawn for APO-E genotyping and for plasma preparation (see Example 31). CSF levels of Aβ 40 , Aβ 42 , isoprostanes, tau, and P-tau as well as plasma levels of Aβ 40  and Aβ 42  are determined. In addition, cognition is assessed using the Alzheimer&#39;s Disease Assessment Scale—cognitive component (ADAS-cog, see Galasko et al. (1997)  Alzheimer Dis Assoc Disord  11; Suppl 2:S33-9) and MMSE, while functional ability is assessed using the Alzheimer&#39;s Disease Cooperative Study Activities of Daily Living Scale (ADCS-ADL) (see McKhann et al. (1984)  Neurology  34:939-944). At this time, caregivers of subjects are given a twelve-week supply of study NSAID along with instructions on timing of doses and potential adverse effects.  
      At the 12-week visit, vital signs, stool guaiac, and adverse side effects are assessed. Unused NSAID is counted. At the 24-week visit, assessment procedures identical to those of the baseline visit are performed. A count of unused NSAIDs and an inquiry about adverse events are made. At the 36-week visit, assessment procedures identical to the 12-week visit are performed, while at the 48-week visit, assessment procedures identical to those of the baseline visit are performed. A count of unused NSAIDs and inquiry about adverse events are made. Table 5 summarizes the examinations performed at each visit in the study.  
               TABLE 5                          Schedule of events                                                     12   24   36   48           Screen   Baseline   week   week   week   week                                                     Check entry criteria,   X                           obtain consent       Screening blood tests   X       Demographics,   X       medical history       Vital signs   X   X   X   X   X   X       Rectal examination,   X       X   X   X   X       stool guaic       MMSE   X   X       X       X       ADAS-cog, ADCS       X       X       X       ADL       Dispense medications       X   X       X       Adverse events, pill           X   X   X   X       count       Lumbar puncture,       X       X       plasma for Aβ       Blood drawn for safety       X       X       X       laboratory tests                  
 
      In addition, each subject/caregiver is interviewed by telephone at 4, 8, 16, and 20 weeks to inquire about continuation in the study, medication usage, and adverse events.  
     Example 36  
     Statistical Analyses of Placebo-Controlled Studies  
      Statistical analyses involve the comparison of cognitive (ADAS-cog, MMSE), functional (ADCS-ADL), and biomarker data of subjects before and after treatment. Subjects treated with NSAID for 48 weeks are expected to exhibit less cognitive and functional decline relative to subjects who are treated with placebo. NSAID treatments are expected to associate with improved biomarker indices in CSF and possibly in plasma.  
      Differences (Δs) between final and initial ADAS-cog and ADCS-ADL scores are referred to as primary outcome measures. Mean Δs for placebo and treatment groups are compared by ANOVA. To control for subjects who fail to complete the study, a Last Observation Carried Forward (LOCF) analysis is performed.  
      Changes in CSF levels of Aβ 42 , tau, P-tau181, F-2-isoprostanes, and plasma Aβ 42  and Aβ 40  are similarly analyzed as outcome measures using ANOVA, or a non-parametric test (e.g. Kruskal-Wallis) if the data are not normal. Correlations between changes in biomarker measures and in clinical measures at 24 weeks are examined by scatter-plots and correlational analyses.  
     Example 37  
     Cell Culture Studies of Flurbiprofen  
      APP695-transfected H4 cells were treated with either the R or S enantiomers of flurbiprofen or with racemic mixtures (R+S) of flurbiprofen. Similar effects on Aβ 42  production were observed in APP695-transfected H4 cells as shown in  FIG. 14 . Aβ 42  levels were lowered by 50% in the presence of 100 μM of the racemic mixture. Similarly, Aβ 42  levels were lowered by 20% in the presence of 10 μM of R-flurbiprofen, 49% in the presence of 100 μM R-flurbiprofen, and Aβ 42  levels were lowered by 58% in the presence of 100 μM S-flurbiprofen. In contrast, levels of Aβ 40  production by these cells were not altered when the cells were exposed to the R, S, or racemic mixture of flurbiprofen.  
     Example 38  
     Acute Dosing in Tg2576 Mice  
      Three-month old Tg2576 mice were treated for three days with 100 mg/kg/day of R-flurbiprofen, S-flurbiprofen, or the racemic mixture (R+S) flurbiprofen. Compounds were administered orally. Levels of Aβ 42  in brains of animals treated with flurbiprofen were compared with those treated with vehicle alone. As shown in  FIG. 15 , R-flurbiprofen was more effective at lowering brain Aβ 42  in this acute dosing paradigm than S-flurbiprofen. In contrast, R-flurbiprofen and the racemic mixture had a similar effect on Aβ 42  levels in mice brains.  
     Other Embodiments  
      It is to be understood that while the invention has been described in conjunction with the detailed description thereof, the foregoing description is intended to illustrate and not limit the scope of the invention, which is defined by the scope of the appended claims. Other aspects, advantages, and modifications are within the scope of the following claims.