Assessment of cognitive and neural recovery in survivors of pediatric brain tumors in a pilot clinical trial using metformin
Ramy Ayoub, Rebecca M Ruddy, Elizabeth Cox, Adeoye Oyefiade, Daniel Derkach, Suzanne Laughlin, Benjamin Ades-Aron, Zahra Shirzadi, Els Fieremans, Bradley J MacIntosh, Cynthia B de Medeiros, Jovanka Skocic, Eric Bouffet, Freda D Miller, Cindi M Morshead, Donald J Mabbott, Ramy Ayoub, Rebecca M Ruddy, Elizabeth Cox, Adeoye Oyefiade, Daniel Derkach, Suzanne Laughlin, Benjamin Ades-Aron, Zahra Shirzadi, Els Fieremans, Bradley J MacIntosh, Cynthia B de Medeiros, Jovanka Skocic, Eric Bouffet, Freda D Miller, Cindi M Morshead, Donald J Mabbott
Abstract
We asked whether pharmacological stimulation of endogenous neural precursor cells (NPCs) may promote cognitive recovery and brain repair, focusing on the drug metformin, in parallel rodent and human studies of radiation injury. In the rodent cranial radiation model, we found that metformin enhanced the recovery of NPCs in the dentate gyrus, with sex-dependent effects on neurogenesis and cognition. A pilot double-blind, placebo-controlled crossover trial was conducted (ClinicalTrials.gov, NCT02040376) in survivors of pediatric brain tumors who had been treated with cranial radiation. Safety, feasibility, cognitive tests and MRI measures of white matter and the hippocampus were evaluated as endpoints. Twenty-four participants consented and were randomly assigned to complete 12-week cycles of metformin (A) and placebo (B) in either an AB or BA sequence with a 10-week washout period at crossover. Blood draws were conducted to monitor safety. Feasibility was assessed as recruitment rate, medication adherence and procedural adherence. Linear mixed modeling was used to examine cognitive and MRI outcomes as a function of cycle, sequence and treatment. We found no clinically relevant safety concerns and no serious adverse events associated with metformin. Sequence effects were observed for all cognitive outcomes in our linear mixed models. For the subset of participants with complete data in cycle 1, metformin was associated with better performance than placebo on tests of declarative and working memory. We present evidence that a clinical trial examining the effects of metformin on cognition and brain structure is feasible in long-term survivors of pediatric brain tumors and that metformin is safe to use and tolerable in this population. This pilot trial was not intended to test the efficacy of metformin for cognitive recovery and brain growth, but the preliminary results are encouraging and warrant further investigation in a large multicenter phase 3 trial.
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References
- Miller FD & Kaplan DR Mobilizing endogenous stem cells for repair and regeneration: are we there yet? Cell Stem Cell 10, 650–652 (2012).
- Ming GL & Song H Adult neurogenesis in the mammalian brain: significant answers and significant questions. Neuron 70, 687–702 (2011).
- Lazarini F & Lledo PM Is adult neurogenesis essential for olfaction? Trends Neurosci. 34, 20–30 (2011).
- Wang J et al. Metformin activates an atypical PKC–CBP pathway to promote neurogenesis and enhance spatial memory formation. Cell Stem Cell 11, 23–35 (2012).
- Chow A & Morshead CM Cyclosporin A enhances neurogenesis in the dentate gyrus of the hippocampus. Stem Cell Res. 16, 79–87 (2016).
- Scafidi J et al. Intranasal epidermal growth factor treatment rescues neonatal brain injury. Nature 506, 230–234 (2014).
- Bridger T, MacDonald S, Baltzer F & Rodd C Randomized placebo-controlled trial of metformin for adolescents with polycystic ovary syndrome. Arch. Pediatr. Adolesc. Med 160, 241–246 (2006).
- Benavides S, Striet J, Germak J & Nahata MC Efficacy and safety of hypoglycemic drugs in children with type 2 diabetes mellitus. Pharmacotherapy 25, 803–809 (2005).
- Sun J, Wang Y, Zhang X & He H The effects of metformin on insulin resistance in overweight or obese children and adolescents: a PRISMA-compliant systematic review and meta-analysis of randomized controlled trials. Medicine 98, e14249 (2019).
- Bjornstad P et al. Metformin improves insulin sensitivity and vascular health in youth With type 1 diabetes mellitus. Circulation 138, 2895–2907 (2018).
- Anagnostou E et al. Metformin for treatment of overweight induced by atypical antipsychotic medication in young people with autism spectrum disorder: a randomized clinical trial. JAMA Psychiatry 73, 928–937 (2016).
- Wang J et al. CBP histone acetyltransferase activity regulates embryonic neural differentiation in the normal and Rubinstein–Taybi syndrome brain. Dev. Cell 18, 114–125 (2010).
- Dadwal P et al. Activating endogenous neural precursor cells using metformin leads to neural repair and functional recovery in a model of childhood brain injury. Stem Cell Rep. 5, 166–173 (2015).
- Ruddy RM, Adams KV & Morshead CM Age- and sex-dependent effects of metformin on neural precursor cells and cognitive recovery in a model of neonatal stroke. Sci. Adv 5, eaax1912 (2019).
- Tanokashira D et al. Metformin treatment ameliorates diabetes-associated decline in hippocampal neurogenesis and memory via phosphorylation of insulin receptor substrate 1. FEBS Open Biol. 8, 1104–1118 (2018).
- Ould-Brahim F et al. Metformin preconditioning of human induced pluripotent stem cell-derived neural stem cells promotes their engraftment and improves post-stroke regeneration and recovery. Stem Cells Dev. 27, 1085–1096 (2018).
- Monje ML, Mizumatsu S, Fike JR & Palmer TD Irradiation induces neural precursor-cell dysfunction. Nat. Med 8, 955–962 (2002).
- Monje ML, Toda H & Palmer TD Inflammatory blockade restores adult hippocampal neurogenesis. Science 302, 1760–1765 (2003).
- Redmond KJ, Mahone EM & Horska A Association between radiation dose to neuronal progenitor cell niches and temporal lobes and performance on neuropsychological testing in children: a prospective study. Neuro Oncol. 15, 1455 (2013).
- Roughton K, Kalm M & Blomgren K Sex-dependent differences in behavior and hippocampal neurogenesis after irradiation to the young mouse brain. Eur. J. Neurosci 36, 2763–2772 (2012).
- Riggs L et al. Changes to memory structures in children treated for posterior fossa tumors. J. Int. Neuropsychol. Soc 20, 168–180 (2014).
- Decker AL et al. Smaller hippocampal subfield volumes predict verbal associative memory in pediatric brain tumor survivors. Hippocampus 27, 1140–1154 (2017).
- Scantlebury N et al. White matter and information processing speed following treatment with cranial-spinal radiation for pediatric brain tumor. Neuropsychology 30, 425–438 (2016).
- Krull KR, Hardy KK, Kahalley LS, Schuitema I & Kesler SR Neurocognitive outcomes and interventions in long-term survivors of childhood cancer. J. Clin. Oncol 36, 2181–2189 (2018).
- Rola R et al. Radiation-induced impairment of hippocampal neurogenesis is associated with cognitive deficits in young mice. Exp. Neurol 188, 316–330 (2004).
- Fukuda A et al. Age-dependent sensitivity of the developing brain to irradiation is correlated with the number and vulnerability of progenitor cells. J. Neurochem 92, 569–584 (2005).
- Hellstrom NA, Bjork-Eriksson T, Blomgren K & Kuhn HG Differential recovery of neural stem cells in the subventricular zone and dentate gyrus after ionizing radiation. Stem Cells 27, 634–641 (2009).
- Ruddy RM, Derkach D, Dadwal P & Morshead CM Cranial irradiation in juvenile mice leads to early and sustained defects in the stem and progenitor cell pools and late cognitive impairments. Brain Res. 1727, 146548 (2019).
- Sorrells SF et al. Human hippocampal neurogenesis drops sharply in children to undetectable levels in adults. Nature 555, 377–381 (2018).
- Moreno-Jiménez EP et al. Adult hippocampal neurogenesis is abundant in neurologically healthy subjects and drops sharply in patients with Alzheimer’s disease. Nat. Med 25, 554–560 (2019).
- Lebel C & Beaulieu C Longitudinal development of human brain wiring continues from childhood into adulthood. J. Neurosci 31, 10937–10947 (2011).
- Chang A, Nishiyama A, Peterson J, Prineas J & Trapp BD NG2-positive oligodendrocyte progenitor cells in adult human brain and multiple sclerosis lesions. J. Neurosci 20, 6404–6412 (2000).
- Gershon RC et al. NIH Toolbox for assessment of neurological and behavioral function. Neurology 80, S2–S6 (2013).
- Talley JL Children’s Auditory Verbal Learning Test-2. Professional Manual (Psychological Assessment Resources, 1993).
- Schmidt M Rey Auditory Verbal Learning Test: RAVLT: a handbook (Western Psychological Services, 1996).
- CANTAB® (cognitive assessment software; ) (Cambridge Cognition, 2018).
- Grizzle JE The two-period change-over design and its use in clinical trials. Biometrics 21, 467–480 (1965).
- Fieremans E, Jensen JH & Helpern JA White matter characterization with diffusional kurtosis imaging. Neuroimage 58, 177–188 (2011).
- Jelescu IO et al. In vivo quantification of demyelination and recovery using compartment-specific diffusion MRI metrics validated by electron microscopy. Neuroimage 132, 104–114 (2016).
- Smith SM et al. Tract-based spatial statistics: voxelwise analysis of multi-subject diffusion data. Neuroimage 31, 1487–1505 (2006).
- Pereira AC et al. An in vivo correlate of exercise-induced neurogenesis in the adult dentate gyrus. Proc. Natl Acad. Sci. USA 104, 5638–5643 (2007).
- Kahalley LS et al. Superior intellectual outcomes after proton radiotherapy compared with photon radiotherapy for pediatric medulloblastoma. J. Clin. Oncol 38, 454–461 (2020).
- Moxon-Emre I et al. Impact of craniospinal dose, boost volume, and neurologic complications on intellectual outcome in patients with medulloblastoma. J. Clin. Oncol 32, 1760–1768 (2014).
- Wellek S & Blettner M On the proper use of the crossover design in clinical trials: part 18 of a series on evaluation of scientific publications. Dtsch. Arztebl. Int 109, 276–281 (2012).
- Zammit AR et al. Roles of hippocampal subfields in verbal and visual episodic memory. Behav. Brain Res 317, 157–162 (2017).
- Zheng F et al. The volume of hippocampal subfields in relation to decline of memory recall across the adult lifespan. Front. Aging Neurosci 10, 320 (2018).
- Leszczynski M How does hippocampus contribute to working memory processing?. Front. Hum. Neurosci 5, 168 (2011).
- Curtis E et al. A first-in-human, phase I study of neural stem cell transplantation for chronic spinal cord injury. Cell Stem Cell 22, 941–950 (2018).
- Gupta N et al. Neural stem cell engraftment and myelination in the human brain. Sci. Transl. Med 4, 155ra137 (2012).
- Ou Z et al. Metformin treatment prevents amyloid plaque deposition and memory impairment in APP/PS1 mice. Brain Behav. Immun 69, 351–363 (2018).
- Gantois I et al. Metformin ameliorates core deficits in a mouse model of fragile X syndrome. Nat. Med 23, 674–677 (2017).
- Luchsinger JA et al. Metformin in amnestic mild cognitive impairment: results of a pilot randomized placebo controlled clinical trial. J. Alzheimers Dis 51, 501–514 (2016).
- Lin Y et al. Evaluation of metformin on cognitive improvement in patients with non-dementia vascular cognitive impairment and abnormal glucose metabolism. Front. Aging Neurosci 10, 227 (2018).
- Dy ABC et al. Metformin as targeted treatment in fragile X syndrome. Clin. Genet 93, 216–222 (2018).
- Gibson EM et al. Neuronal activity promotes oligodendrogenesis and adaptive myelination in the mammalian brain. Science 344, 1252304 (2014).
- Sato Y et al. Grafting neural stem and progenitor cells into the hippocampus of juvenile, irradiated mice normalizes behavior deficits. Front. Neurol 9, 715 (2018).
- Babona-Pilipos R, Popovic MR & Morshead CM A galvanotaxis assay for analysis of neural precursor cell migration kinetics in an externally applied direct current electric field. J. Vis. Exp 2012, 4193 (2012).
- Coles-Takabe BL et al. Don’t look: growing clonal versus nonclonal neural stem cell colonies. Stem Cells 26, 2938–2944 (2008).
- Nusrat L et al. Cyclosporin A-mediated activation of endogenous neural precursor cells promotes cognitive recovery in a mouse model of stroke. Front. Aging Neurosci 10, 93 (2018).
- Spiller HA & Quadrani DA Toxic effects from metformin exposure. Ann. Pharmacother 38, 776–780 (2004).
- Hsia Y et al. Unlicensed use of metformin in children and adolescents in the UK. Br. J. Clin. Pharmacol 73, 135–139 (2012).
- Vakil E, Greenstein Y & Blachstein H Normative data for composite scores for children and adults derived from the Rey Auditory Verbal Learning Test. Clin. Neuropsychol 24, 662–677 (2010).
- Riggs L et al. Exercise training for neural recovery in a restricted sample of pediatric brain tumor survivors: a controlled clinical trial with crossover of training versus no training. Neuro Oncol. 19, 440–450 (2017).
- Dale AM, Fischl B & Sereno MI Cortical surface-based analysis. I. Segmentation and surface reconstruction. Neuroimage 9, 179–194 (1999).
- Fischl B, Liu A & Dale AM Automated manifold surgery: constructing geometrically accurate and topologically correct models of the human cerebral cortex. IEEE Trans. Med. Imaging 20, 70–80 (2001).
- Ades-Aron B et al. Evaluation of the accuracy and precision of the diffusion parameter EStImation with Gibbs and NoisE removal pipeline. Neuroimage 183, 532–543 (2018).
- Veraart J et al. Denoising of diffusion MRI using random matrix theory. Neuroimage 142, 394–406 (2016).
- Veraart J, Fieremans E & Novikov DS Diffusion MRI noise mapping using random matrix theory. Magn. Reson. Med 76, 1582–1593 (2016).
- Kellner E, Dhital B, Kiselev VG & Reisert M Gibbs-ringing artifact removal based on local subvoxel-shifts. Magn. Reson. Med 76, 1574–1581 (2016).
- Andersson JLR & Sotiropoulos SN An integrated approach to correction for off-resonance effects and subject movement in diffusion MR imaging. Neuroimage 125, 1063–1078 (2016).
- Collier Q, Veraart J, Jeurissen B, den Dekker AJ & Sijbers J Iterative reweighted linear least squares for accurate, fast, and robust estimation of diffusion magnetic resonance parameters. Magn. Reson. Med 73, 2174–2184 (2015).
- Avants BB et al. The Insight Toolkit image registration framework. Front. Neuroinformatics 8, 44 (2014).
- Engvig A et al. Memory training impacts short-term changes in aging white matter: a longitudinal diffusion tensor imaging study. Hum. Brain Mapp 33, 2390–2406 (2012).
- Jenkinson M & Smith S A global optimisation method for robust affine registration of brain images. Med. Image Anal 5, 143–156 (2001).
- Jenkinson M, Bannister P, Brady M & Smith S Improved optimization for the robust and accurate linear registration and motion correction of brain images. Neuroimage 17, 825–841 (2002).
- Shirzadi Z, Crane DE, Robertson AD & Maralani PJ Automated removal of spurious intermediate cerebral blood flow volumes improves image quality among older patients: a clinical arterial spin labeling investigation.J. Magn. Reson. Imaging 42, 1377–1385 (2015).
- van Osch MJ et al. Quantitative cerebral perfusion MRI and CO2 reactivity measurements in patients with symptomatic internal carotid artery occlusion. Neuroimage 17, 469–478 (2002).
- Hendrikse J et al. Internal carotid artery occlusion assessed at pulsed arterial spin-labeling perfusion MR imaging at multiple delay times. Radiology 233, 899–904 (2004).
- Faul F, Erdfelder E, Lang A-G & Buchner A G *Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Res, Methods 39, 175–191 (2007).
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