Ambroxol for the Treatment of Patients With Parkinson Disease With and Without Glucocerebrosidase Gene Mutations: A Nonrandomized, Noncontrolled Trial

Abstract

Importance: Mutations of the glucocerebrosidase gene, GBA1 (OMIM 606463), are the most important risk factor for Parkinson disease (PD). In vitro and in vivo studies have reported that ambroxol increases β-glucocerebrosidase (GCase) enzyme activity and reduces α-synuclein levels. These observations support a potential role for ambroxol therapy in modifying a relevant pathogenetic pathway in PD.

Objective: To assess safety, tolerability, cerebrospinal fluid (CSF) penetration, and target engagement of ambroxol therapy with GCase in patients with PD with and without GBA1 mutations.

Interventions: An escalating dose of oral ambroxol to 1.26 g per day.

Design, setting, and participants: This single-center open-label noncontrolled clinical trial was conducted between January 11, 2017, and April 25, 2018, at the Leonard Wolfson Experimental Neuroscience Centre, a dedicated clinical research facility and part of the University College London Queen Square Institute of Neurology in London, United Kingdom. Participants were recruited from established databases at the Royal Free London Hospital and National Hospital for Neurology and Neurosurgery in London. Twenty-four patients with moderate PD were evaluated for eligibility, and 23 entered the study. Of those, 18 patients completed the study; 1 patient was excluded (failed lumbar puncture), and 4 patients withdrew (predominantly lumbar puncture-related complications). All data analyses were performed from November 1 to December 14, 2018.

Main outcomes and measures: Primary outcomes at 186 days were the detection of ambroxol in the CSF and a change in CSF GCase activity.

Results: Of the 18 participants (15 men [83.3%]; mean [SD] age, 60.2 [9.7] years) who completed the study, 17 (8 with GBA1 mutations and 9 without GBA1 mutations) were included in the primary analysis. Between days 0 and 186, a 156-ng/mL increase in the level of ambroxol in CSF (lower 95% confidence limit, 129 ng/mL; P < .001) was observed. The CSF GCase activity decreased by 19% (0.059 nmol/mL per hour; 95% CI, -0.115 to -0.002; P = .04). The ambroxol therapy was well tolerated, with no serious adverse events. An increase of 50 pg/mL (13%) in the CSF α-synuclein concentration (95% CI, 14-87; P = .01) and an increase of 88 ng/mol (35%) in the CSF GCase protein levels (95% CI, 40-137; P = .002) were observed. Mean (SD) scores on part 3 of the Movement Disorders Society Unified Parkinson Disease Rating Scale decreased (ie, improved) by 6.8 (7.1) points (95% CI, -10.4 to -3.1; P = .001). These changes were observed in patients with and without GBA1 mutations.

Conclusions and relevance: The study results suggest that ambroxol therapy was safe and well tolerated; CSF penetration and target engagement of ambroxol were achieved, and CSF α-synuclein levels were increased. Placebo-controlled clinical trials are needed to examine whether ambroxol therapy is associated with changes in the natural progression of PD.

Trial registration: ClinicalTrials.gov identifier: NCT02941822; EudraCT identifier: 2015-002571-24.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Foltynie reported having received honoraria for speaking at meetings supported by Profile Pharma, BIAL, AbbVie; having served on advisory boards for BIAL, Oxford Biomedica, Living Cell Technologies, and Peptron. Dr Zetterberg reported having served at scientific advisory boards for Roche Diagnostics, Wave, Samumed, and CogRx; having given lectures in symposia sponsored by Alzecure and Biogen; and reported being a cofounder of Brain Biomarker Solutions in Gothenburg AB, a GU Ventures-based platform company at the University of Gothenburg. Dr Limousin reported having received travel support and honoraria from Boston Scientific and Medtronic. Dr Heywood reported having received funding and travel support from Shire Pharmaceuticals; and reported having received honoraria from Freeline Therapeutics. Dr Mills reported having received honoraria from Freeline Therapeutics; and having received travel support from Actelion and Genzyme Sanofi. Dr Libri reported having served on Advisory Boards for Biogen and Nova Laboratories Ltd. Dr Streeter reported being a consultant to Sanofi, Prevail, Inflazome, and Kyowa. No other disclosures were reported.

Figures

Figure 1.. Flow Diagram of Participant Recruitment and Retention

CSF indicates cerebrospinal fluid; GBA1-, negative glucocerebrosidase gene; GBA1+, positive glucocerebrosidase gene; and LP, lumbar puncture.

Figure 2.. Biochemical Changes After Ambroxol Administration

A, Box plot with superimposed data points at baseline (median, 0.321; interquartile range [IQR], 0.142) and 186 days (median, 0.216; IQR, 0.221). Analysis included 17 participants (8 GBA1+ and 9 GBA1–). Mean (SE) change of 0.059 (0.026) nmol/mL per hour (95% CI, –0.115 to –0.002; 2-sided paired t test, P = .04) represents a 19% decrease. B, Box plot (median and IQR) with superimposed data points at baseline and 186 days. Analysis included 17 participants (8 GBA1+ and 9 GBA1–). Mean (SE) change of 50 (17) pg/mL (95% CI, 14-87; 2-sided paired t test, P = .01) represents a 13% increase. C, Box plot (median and IQR) with superimposed data points at baseline and 186 days. Analysis included 17 participants (8 GBA1+ and 9 GBA1–). Mean (SE) change of 88 (22) pmol/L (95% CI, 40-137; 2-sided paired t test, P = .002) represents a 35% increase. All data points are horizontally offset for ease of interpretation. D, Error bars indicate SE of the mean. Analysis included 18 participants (8 GBA1+ and 10 GBA1–). Mean (SE) change between baseline and 186 days of 1.0 (1.4) nmol/mg per hour (95% CI, –2.0 to 4.0; P = .48) represents a 9% increase. CSF indicates cerebrospinal fluid; GBA1-, negative glucocerebrosidase gene; GBA1+, positive glucocerebrosidase gene; and GCase, glucocerebrosidase enzyme.