EDITORIAL

For reprint orders, please contact: reprints@futuremedicine.com

Alzheimers disease: cerebrolysin and

nanotechnology as a therapeutic
strategy

Hari S Sharma*,1, Dafin F Muresanu2,3 & Aruna Sharma1

First draft submitted: 17 August 2016; Accepted for publication: 26 August 2016;
Published online: 9 November 2016

Alzheimers disease (AD) affects millions
of people worldwide[1] . According to an
estimate in 2015, about 7 million AD
patients live in the USA with the number
expected to increase by 13 million by 2020.
Thus, out of every nine people, one person
is affected by AD in USA[1] , out of which
female patients are significantly higher
than their male counterpart in impart-
ing AD[1,2] . Therefore, new efforts are
needed to contain this dreaded disease and
to explore novel therapeutic strategies for
enhancing quality of life of AD patients.
However, the prevalence of AD can vary
among various races. For example, in USA,
Hispanics are most susceptible to AD fol-
lowed by AfroAmericans than white
Americans[13] . This suggests that genetic
factors are playing an important role in
the development of AD. Apart from racial
differentiation among AD patients, several
external or internal biological factors also
affect the AD process. Thus, hypertension
and diabetes could be a predisposing factor
in AD[4,5] . Furthermore, mild or moder-
ate degree of traumatic brain injury (TBI)
could result in AD like symptoms[6] .
Therefore, military personnel on combat
duty are likely to be more prone to AD
following repetitive mild or moderate head
injury and/or penetrating brain injuries.
The basic mechanisms of development of
AD are still not well known. However, evi-
dence suggests that deposition of amyloid
peptide (AP) within the brain could be
one of the key aspects for the pathogenesis
of the AD[7] . How AP deposits around
the brain microvessels or neurons to induce
neurotoxicity is still not well understood.
According to one theory, AP is present
in low quantities in the healthy brain and
results in accumulation during pathogen-
esis of AD due to inefficient efflux mecha-
nisms at the bloodbrain barrier (BBB)[8] .
On the other hand, a possibility exists that
AP present in plasma could enter into the
brain due to a breakdown of the BBB by
large molecules and deposited into several
KEYWORDS
AP infusion Alzheimers
disease BBB leakage brain
pathology cerebrolysin
diabetes hypertension military
personnel model nanodelivery
neuroprotection neurotrophic
factors post-traumatic stress disorder
traumatic brain injury.
Our observations showed that TiO2
nanowired delivery of cerebrolysin
significantly reduced brain pathology
in disease models of Alzheimer's
disease induced by identical
amyloid peptide infusion.

1
International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences,
Anesthesiology & Intensive Care Medicine, University Hospital, Uppsala University, SE-75421 Uppsala, Sweden
2
Department of Clinical Neurosciences, University of Medicine & Pharmacy, Cluj-Napoca, Romania
3
RoNeuro Institute for Neurological Research & Diagnostic, 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
*Author for correspondence: Tel.: +46 702 011 801; Sharma@surgsci.uu.se part of

10.2217/nmt-2016-0037 2016 Future Medicine Ltd Neurodegener. Dis. Manag. (Epub ahead of print) ISSN 1758-2024
Editorial Sharma, Muresanu & Sharma
brain areas[9,10] . That BBB breakdown is cru-
cial for AP deposits in the brain, and is further
supported by the idea that TBI is well known to
induce breakdown of the BBB alone, results in
AP deposition in the brain and subsequently
induces AD like symptoms[6,11] . Furthermore,
hypertension and/or diabetes also induce the
breakdown of BBB and are associated with the
development of AD[4,5] . These observations are
in line with the theory that the BBB breakdown
In this context, plays important roles in AD pathology.
cerebrolysin is one of the The BBB is a physiologically dynamic entity
multimodal drugs that has that regulates the fluid microenvironment of the
a balanced composition of CNS within a narrow limit[12] . Only essential
several neurotrophic nutrients are able to enter from the blood to the
factors and active peptide brain side across the BBB and excreta in forms
fragments capable of of metabolites are transported out of the brain
reducing the oxidative to the blood via the brainblood barrier[12,13] .
stress response and There are reasons to believe that in AD, both
therefore seems to be the BBB and the brainblood barrier are altered
quite suitable for leading to brain pathology[10] . When BBB func-
Alzheimer's disease tion is broken down, then apart from AP, many
therapy. other toxic elements from the blood side includ-
ing large molecules, for example, serum proteins
leak, leading to immunological, biochemical and
pathological reactions within the brain micro-
environment. Deposition of AP could also lead
to several abnormal reactions within the brain
affecting neuronal, glial and axonal damages
either directly or through stimulation of several
secondary injury cascades[14] .
One of the most intriguing facts of AP-
induced neurotoxicity is the induction of oxi-
dative stress which, in turn, generates the pro-
duction of free radicals [15] . Oxidative stress is
primarily responsible for damaging the cell
membranes of the endothelial cells, the build-
ing blocks of the BBB, along with neuronal, glial
and axonal compartments[16] . The AP together
with membrane cholesterol induces tau phospho-
rylation followed by tau ggregation, apoptosis
and neuronal death[17] . These cellular and intra-
cellular cascades induced by AP in AD result in
various cognitive and sensory motor problems in
AD patients[18] .
Apart from increased oxidative stress and tau
phosphorylation that are neurotoxic in AD, sev-
eral endogenous neuroprotective agents, for exam-
ple, neurotrophic factors derived from brain, glial
or endothelial cells are depleted from the brain,
which makes it more vulnerable to these neuro-
toxic elements[19] . Several studies suggest that
neprilysin, the enzyme responsible for neuropro-
tection, is also depleted in AD[20] . Thus, in the
10.2217/nmt-2016-0037 Neurodegener. Dis. Manag. (Epub ahead of print)
AD brain there is an increased production of neu-
rotoxic factors and a decrease in neuroprotective
elements[10] . Accordingly, any suitable therapeutic
measures for AD require an enhancement of the
neurotrophic factors and neprilysin together with
counteracting oxidative stress generated by AP
deposition.
Under these circumstances, it would appear
that no single compound or receptor blocker drug
alone would be able to thwart AD pathophysiol-
ogy. Thus, multimodal drugs capable of induc-
ing neuroplasticity and neuroregeneration are the
need for an effective treatment of AD patients.
In this context, cerebrolysin is one of the multi-
modal drugs that has a balanced composition of
several neurotrophic factors and active peptide
fragments capable of reducing the oxidative stress
response and therefore seems to be quite suitable
for AD therapy[2123] . This idea is supported by
our experimental observations in the AP (140)
infusion-induced AD rat model.
We induced AD-like symptoms in rats by
intraventricular administration of AP (140) in
the left lateral ventricle in a dose of 250 ng/10l
once daily for 4 weeks[10,2122] . These animals
exhibited profound breakdown of the BBB to
serum proteins along with brain edema forma-
tion and brain pathology[22,23] . In addition,
AP deposits around microvessels, neurons and
glial cells were also evident[2224] . These AD
rats showed pronounced deterioration on sen-
sory motor and cognitive functions as well[24] .
This is evident from their performances on
Rota Rod treadmill, inclined plane angle test,
walking on an inclined mesh grid or finding a
hidden platform under water[24] . Biochemical
measurements of phosphorylated tau protein
show pronounced increase in the cerebral cor-
tex, hippocampus, thalamus and cerebellum in
AD rats[21,22] . On the other hand, neprilysin
enzyme showed 2048% decreases in the above
brain areas in AD from saline control. When
cerebrolysin (2.5 ml/kg intravenously, or 50 l
intracerebroventricular) once daily starting from
1 week after AP infusion that continued for
2 weeks resulted in significant reduction in the
BBB breakdown of serum proteins, tau accumu-
lation, AP deposits and brain pathology after
4weeks of AP infusion. Interestingly, behavio-
ral functions were also improved by cerebrolysin
therapy in AD. This suggests that a multimodal
drug capable of inducing neuroplasticity and
neuroregeneration-like cerebrolysin is the need
of the hour for AD therapy[2123] .
future science group
 Alzheimers disease: cerebrolysin & nanotechnology as a therapeutic strategy Editorial

However, hypertension, diabetes, repeated
stressors or TBI often complicates the patho-
physiology of AD[2223,2526] . Thus, we devel-
oped animal models of hypertension, diabe-
tes, repeated emotional stress and/or TBI and
induced AD-like symptoms in these disease
animals and compared the results with healthy
animals following AP infusion in identical
manner[2227] . We found that when AP infu-
sion was made in diseased animals or follow-
ing TBI, the brain pathology is exacerbated by
twofold to fourfold as compared with identical
infusion of AP in the healthy animals. These
observations suggest that TBI, hypertension,
diabetes or emotional stressors aggravate AD
pathology. Interestingly, in these diseased ani-
mals, identical doses of cerebrolysin that was
given in healthy animals did not reduce brain
pathology and behavioral symptoms effectively.
This suggests that in diseased animal models
with AD modulation of drug doses are needed
for effective therapy.
To further enhance the efficacy of cer-
ebrolysin in disease models of AD, we used
nanodelivery of the drug and compared its
effectiveness with the normal delivery of cer-
ebrolysin[2425,27] . Utilizing nanodelivery allows
drugs to enter the brain more effectively and
induce a sustained release of the compound over
long periods of time[10] ; therefore, it is quite
likely that nanodelivery of cerebrolysin could
have better neuroprotective efficacy in disease
models of AD.
Our observations showed that TiO2 nanow-
ired delivery of cerebrolysin significantly reduced
brain pathology in disease models of AD induced
by identical AP infusion. Nanodelivery of cer-
ebrolysin also reduced behavioral disturbances
in diseased models of AD[24] . This suggests
that nanodelivery of drugs could provide a
novel option for treating AD and be used to
achieve better therapeutic results in patients in
future. It appears that nanodelivery of drugs also
depends on the choice of nanoparticles used to
deliver drugs. This is apparent from our find-
ings that when cerebrolysin was delivered in TBI
model of AD using TiO2-nanowired delivery
of poly(lactic-co-glycolic) acid (PLGA)nano-
particles encapsulated cerebrolysin in identi-
cal manner; TiO2 nanowired cerebrolysin has
superior neuroprotective effects in TBI model
of AD[27] . However, further research using
different nanocarriers for drug or cerebrolysin
delivery is needed to understand these points.
This is a feature currently being investigated in
our laboratory.
Disclaimer
The views expressed in this report are solely of the authors
and in no way represent official positions of any granting
authority or government organizations listed in the
financial and competing interests disclosure.
Financial & competing interests disclosure
Supported by grants from the Air Force Office of Scientific
Research (EOARD, London, UK) and Air Force Material
Command, USAF, under Grant No. FA8655-05-1-3065;
supported by grants from the Alzheimers Association
(IIRG-09-132087) and the RM Kohrman Memorial
Fund; Swedish Medical Research Council (No. 2710-HSS),
Gran Gustafsson Foundation, Stockholm, Sweden (HSS),
Astra Zeneca, Mlndal, Sweden (HSS/AS), the University
Grants Commission, New Delhi, India (HSS/AS),
Ministry of Science & Technology, Government of India
(HSS/AS), Indian Medical Research Council, New Delhi,
India (HSS/AS), and India-EU Co-operation Program
(AS /HSS) and Society for Neuroprotection and
Neuroplasticity (SSNN), Romania. The authors have no
other relevant affiliations or financial involvement with
any organization or entity with a financial interest in or
financial conflict with the subject matter or materials
discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of
this manuscript.

References
Papers of special note have been highlighted as:
of interest; of considerable interest
1 Alzheimers Association 2015 Alzheimers
disease facts and figures. Alzheimers Dement.
11(3), 332 (2015).
Describes in detail treatment, epidemiology
and future strategies.
2 Shen N, Chen B, Jiang Y etal. An updated
analysis with 85,939 samples confirms the
association between CR1 rs6656401
polymorphism and Alzheimers disease. Mol.
Neurobiol. 51(3), 10171023 (2015).
3 Yang Z, Levey A. Gender differences: a
lifetime analysis of the economic burden of
Alzheimers disease. Womens Health Issues
25(5), 436440 (2015).
4 Domnguez RO, Pagano MA, Marschoff ER,
Gonzlez SE, Repetto MG, Serra JA.
Alzheimer disease and cognitive impairment
associated with diabetes mellitus Type 2:
associations and a hypothesis. Neurologia
29(9), 567572 (2014).
5 Kruyer A, Soplop N, Strickland S, Norris EH.
Chronic hypertension leads to
neurodegeneration in the TgSwDI mouse
model of Alzheimers disease. Hypertension
66(1), 175182 (2015).
Shows association of hypertension and
Alzheimers disease.

future science group www.futuremedicine.com 10.2217/nmt-2016-0037

Editorial Sharma, Muresanu & Sharma
6 Weiner MW, Veitch DP, Hayes J
etal.;Department of Defense Alzheimers
Disease Neuroimaging Initiative. Effects of
traumatic brain injury and posttraumatic
stress disorder on Alzheimers disease in
veterans, using the Alzheimers Disease
Neuroimaging Initiative. Alzheimers Dement.
10(Suppl. 3), S226S235 (2014).
Shows that traumatic brain injury is one of
the predisposing factors in Alzheimers
disease.
Blennow K, Mattsson N, Schll M, Hansson
7 Amyloid -peptide (142)-induced oxidative
O, Zetterberg H. Amyloid biomarkers in
Alzheimers disease. Trends Pharmacol. Sci.
36(5), 297309 (2015).
8 Do TM, Dodacki A, Alata W etal.
Age-dependent regulation of the blood-brain
barrier influx/efflux equilibrium of amyloid-
peptide in a mouse model of Alzheimers
disease (3xTg-AD). J. Alzheimers Dis. 49(2),
287300 (2015).
9 Gosselet F, Saint-Pol J, Candela P, Fenart L.
Amyloid- peptides, Alzheimers disease and
the bloodbrain barrier. Curr. Alzheimer Res.
10(10), 10151033 (2013).
10 Sharma HS, Castellani RJ, Smith MA,
Sharma A. The bloodbrain barrier in
Alzheimers disease: novel therapeutic targets
and nanodrug delivery. Int. Rev. Neurobiol.
102, 4790 (2012).
Shows that nanomedicine is effective in
Alzheimers disease.
11 Alluri H, Wiggins-Dohlvik K, Davis ML,
Huang JH, Tharakan B. Bloodbrain barrier
dysfunction following traumatic brain
injury. Metab. Brain Dis. 30(5), 10931104
(2015).
12 Sharma HS. Bloodcentral nervous system
barriers: the gateway to neurodegeneration,
neuroprotection and neuroregeneration. In:
Handbook of Neurochemistry and Molecular
Neurobiology: Brain and Spinal Cord
Trauma. Lajtha A, Banik N, Ray SK (Eds).
Springer Verlag, Berlin, Germany, 363457
(2009).
10.2217/nmt-2016-0037
Shows bloodbrain barrier is the key for
almost all neurological diseases.
13 Sharma HS, Westman J. The BloodSpinal
Cord and Brain Barriers in Health and Disease.
Elsevier Academic Press, San Diego, CA,
USA, 1617 (2004).
14 Kam TI, Gwon Y, Jung YK. Amyloid beta
receptors responsible for neurotoxicity and
cellular defects in Alzheimers disease. Cell
Mol. Life Sci. 71(24), 48034813 (2014).
15 Butterfield DA, Swomley AM, Sultana R.
stress in Alzheimer disease: importance in
disease pathogenesis and progression. Antioxid.
Redox. Signal 19(8), 823835. (2013).
Shows the role of oxidative stress in
Alzheimers disease.
16 Wang HC, Lin YJ, Shih FY etal. The role of
serial oxidative stress levels in acute traumatic
brain injury and as predictors of outcome.
World Neurosurg. 87, 463470 (2016).
17 Oliveira JM, Henriques AG, Martins F,
Rebelo S, da Cruz e Silva OA. Amyloid-
modulates both APP and tau
phosphorylation. J. Alzheimers Dis. 45(2),
495507 (2015).
18 Albers MW, Gilmore GC, Kaye J etal. At the
interface of sensory and motor dysfunctions
and Alzheimers disease. Alzheimers Dement.
11(1), 7098 (2015).
Shows sensory, motor and cognitive deficits
in Alzheimers disease.
19 Sopova K, Gatsiou K, Stellos K, Laske C.
Dysregulation of neurotrophic and
haematopoietic growth factors in Alzheimers
disease: from pathophysiology to novel
treatment strategies. Curr. Alzheimer Res.
11(1), 2739 (2014).
20 Nilsson P, Loganathan K, Sekiguchi M etal.
Loss of neprilysin alters protein expression in
the brain of Alzheimers disease model mice.
Proteomics 15(19), 33493355 (2015).
Shows the role of neprilysin in Alzheimers
disease.
Neurodegener. Dis. Manag. (Epub ahead of print)
21 Sharma HS, Castellani RJ, Smith MA etal.
Cerebrolysin, a novel drug for the treatment
of Alzheimers disease. An experimental study
using nanowired delivery. J. Nutr. 6(9),
3146 (2012).
22 Sharma A, Muresanu DF, Castellani RJ,
Smith MA, Sharma HS. Hyperthermia
exacerbates amyloid--peptide infusion
induced Alzheimers disease pathology and
behavioral disturbances. J. Nutr. 17(9),
59845 (2013).
23 Sharma HS, Muresanu DF, Castellani RJ
etal. Diabetes exacerbates Alzheimers disease
induced brain pathology. Possible
neuroprotective effects of cerebrolysin.
J.Nutr. 17(9), 69849 (2013).
24 Sharma HS, Lafuente JV, Muresanu DF etal.
TiO2 nanowired delivery of cerebrolysin
neurtralizes amyloid--peptide infusion
induced Alzheimer pathology. An
experimental study using behavioral and
morphological approaches. J. Prev. Alzheimers
Dis. 1(3), 232233 (2014).
25 Sharma A, Lafuente JV, Muresanu DF etal.
Traumatic brain injury exacerbates amyloid-
beta peptide induced brain pathology in
Alzheimers disease. Superior neuroprotective
effects of TiO2 nanowired mesenchymal cells
with poly (d-l-lactide-co-glycolide)
nanoparticles loaded cerebrolysin delivery.
J.Prev. Alzheimers Dis. 2(4), 377378 (2015).
26 Sharma HS, Lafuente JV, Muresanu DF etal.
Repeated emotional stress exacerbates
amyloid-beta peptide induced brain pathology
in Alzheimers disease. Potential
neuroprotective effects of nanowired delivery
of cerebrolysin. J. Prev. Alzheimers Dis. 2(4),
376377 (2015).
27 Sharma A, Lafuente JV, Muresanu DF etal.
Chronic hypertension exacerbates amyloid--
peptide induced brain pathology and
oxidative stress. Superior neuroproetctective
effects of TiO2 nanowired cerebrolsyin vs.
poly (d-l-lactide-co-glycolide) nanoperticles
loaded delivery. J. Prev. Alzheimers Dis. 1(3),
234 (2014).
future science group