Medical Hypotheses (2007) 69, 1272–1276

http://intl.elsevierhealth.com/journals/mehy

Elevated butyrylcholinesterase and

acetylcholinesterase may predict the development
of type 2 diabetes mellitus and Alzheimer’s disease
Allam A. Rao a, Gumpeny R. Sridhar b, Undurti N. Das c,*

a
Department of Computer Sciences and Systems Engineering, Andhra University,
Visakhapatnam 530 003, India
b
Endocrine and Diabetes Centre, 15-12-16 Krishnanagar, Visakhapatnam 530 002, India
c
UND Life Sciences, 13800 Fairhill Road, #321, Shaker Heights, OH 44120, USA

Received 1 March 2007; accepted 6 March 2007

Summary Plasma levels of C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-a (TNF-a), and lipid
peroxides are elevated and concentrations of endothelial nitric oxide (eNO) decreased in type 2 diabetes mellitus and
Alzheimer’s disease. This suggests that both these diseases are low-grade systemic inflammatory conditions and are
closely associated with each other. Recent studies revealed that plasma and tissue concentrations of enzymes
butyrylcholinesterase and acetylcholinesterase are elevated in type 2 diabetes and Alzheimer’s disease. Acetylcholine
has anti-inflammatory actions. Hence, elevated butyrylcholinesterase and acetylcholinesterase concentrations will
lead to a decrease in the levels of acetylcholine that could trigger the onset of low-grade systemic inflammation seen
in type 2 diabetes and Alzheimer’s disease. In view of this, we propose that butyrylcholinesterase and acetylcho-
linesterase will not only serve as therapeutic targets but also may serve as markers to predict the development of type
2 diabetes mellitus and Alzheimer’s disease.
c 2007 Elsevier Ltd. All rights reserved.

Introduction concentrations of endothelial nitric oxide (eNO)

Both type 2 diabetes mellitus and Alzheimer’s
disease are low-grade systemic inflammatory con-
ditions since, plasma levels of C-reactive protein
(CRP), interleukin-6 (IL-6), tumor necrosis factor-
a (TNF-a), and lipid peroxides are elevated and
* Corresponding author. Tel.: +1 216 231 5548; fax: +1 928 833
0316.
E-mail address: undurti@hotmail.com (U.N. Das).
decreased in them [1–6]. Alterations in the levels
of same inflammatory markers in both type 2 dia-
betes mellitus and Alzheimer’s disease suggest
that a close connection exists between these
two diseases. Recent studies suggest that in-
crease in the plasma and tissue levels of butyryl-
cholinesterase could be the common link
between type 2 diabetes mellitus and Alzheimer’s
disease.


0306-9877/$ - see front matter c 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.mehy.2007.03.032
Elevated butyrylcholinesterase and acetylcholinesterase
Low-grade systemic inflammation in
Alzheimer’s disease
Plasma and cerebrospinal fluid levels of pro-
inflammatory cytokines: IL-1 and TNF-a are in-
creased in Alzheimer’s disease [5,6]. The
increase in the levels of TGF-b noted in Alzhei-
mer’s disease was considered to be a protective
host response to immunologically mediated neu-
ronal injury induced by IL-1 and TNF-a [7]. Sys-
temic injection of IL-1 decreased extracellular
acetylcholine in the hippocampus suggesting that
increased concentrations of IL-1 in Alzheimer’s
disease could be responsible for lowered cerebral
acetylcholine levels seen. In addition, IL-1 stimu-
lates the beta-amyloid precursor protein pro-
moter that is processed out of the larger
amyloid precursor protein (APP), which is found
in the form of amyloid plaques in the brains of
Alzheimer’s diseased patients. Receptors of IL-1
are present on APP mRNA positive cells and its
ability to promote APP gene expression suggests
that IL-1 plays an important role in Alzheimer’s
disease [8,9]. Furthermore, the observation that
inhibition or neutralizing the actions of TNF-a
could be of benefit to these patients [10] sug-
gests that Alzheimer’s disease is a low-grade sys-
temic inflammatory condition.
Acetylcholine suppresses inflammation
Acetylcholine (ACh) is the principal vagus neuro-
transmitter and the receptors that recognize
ACh are acetylcholine receptors or AChRs. The
two major AChRs in the body are nicotinic
(nAChRs) and muscarinic receptors. The acetyl-
choline receptor modulates interactions between
the nervous system and the immune system. For
instance, AChR agonist, nicotine, dampens
inflammation.
The cholinergic anti-inflammatory pathway sig-
nals through the efferent vagus nerve and is
mediated primarily by nicotinic acetylcholine
receptors on tissue macrophages [11]. This ‘‘cholin-
ergic anti-inflammatory pathway’’ mediated by ACh
acts by inhibiting the production of TNF, IL-1, MIF,
and HMGB1 and suppresses the activation of NF-jB
expression, and enhances eNO production [11].
ACh is a neurotransmitter and has regulatory role
on serotonin, dopamine and other neuropeptides
[12], suggesting that a close interaction exists be-
tween immune response and neurotransmission.
1273
Acetylcholinesterase and
butyrylcholinesterase
Acetylcholinesterase is a specific choline
esterase, hydrolyzing predominantly choline es-
ters, and characterized by high concentrations
in brain, nerve and red blood cells (RBCs). The
other type, called butyrylcholinesterase, is a non-
specific choline esterase (also called as ‘‘pseu-
do’’ choline esterase) hydrolyzing other esters
as well as choline esters, and found in blood ser-
um, pancreas, liver, and central nervous system
[13]. Activity of acetylcholine in the brain is
terminated by the hydrolytic action of cholines-
terases. Inhibitors of these enzymes (cholinester-
ases) enhance the activity of cholinergic neurons
in the brain and thus, may suppress inflamma-
tion. Such an effort is useful especially in pa-
tients with Alzheimer’s disease, who have
decreased forebrain cholinergic neurons and a
progressive decline in acetylcholine [14]. All
cholinesterase inhibitors currently licensed for
Alzheimer’s disease inhibit acetylcholinesterase
and to a varying degree, butyrylcholinesterase,
which is a second cholinesterase in the brain
[15].
In healthy human brain, acetylcholinesterase
predominates over butyrylcholinesterase, but the
latter likely has been previously underestimated
[16]. Acetylcholinesterase is localized mainly to
neurons; butyrylcholinesterase is associated pri-
marily with glial cells, as well as to endothelial
cells and neurons [17]. Butyrylcholinesterase and
acetylcholinesterase differ in their kinetic re-
sponse to concentrations of acetylcholine. Butyr-
ylcholinesterase is less efficient in acetylcholine
hydrolysis at low concentrations but highly
efficient at high ones, at which acetylcholinester-
ase becomes substrate inhibited [18]. Under
conditions of high brain activity, local synaptic
acetylcholine can reach micromolar levels that
approach inhibitory levels for acetylcholinesterase
activity. The close spatial relationship of glial
butyrylcholinesterase would allow synergistic
butyrylcholinesterase-mediated hydrolysis to as-
sist in the regulation of local acetylcholine
levels to permit the maintenance of normal
cholinergic function. The survival of acetyl-
cholinesterase knockout mice [16] with normal
levels and localization of butyrylcholinesterase
[19] supports the concept that butyrylcholin-
esterase has a key role that can partly
compensate for the action of acetylcholin-
esterase.
1274
Acetylcholinesterase and
butyrylcholinesterase in Alzheimer’s
disease
Alteration in the levels of butyrylcholinesterase
in situations wherein there is a deficiency or absence
of acetylcholinesterase assumes significance in
Alzheimer’s disease in which acetylcholinesterase
is lost up to 85% in specific brain regions, whereas
butyrylcholinesterase levels rise with disease
progression [20,21]. The ratio of butyrylcholinester-
ase to acetylcholinesterase changes dramatically in
cortical regions affected by Alzheimer’ disease from
0.2 up to as much as 11 [22]. This altered ratio of
butyrylcholinesterase to acetylcholinesterase in
Alzheimer’s disease brain will modify the normally
supportive role of butyrylcholinesterase in hydrolyz-
ing excess acetylcholine only. Selective butyrylcho-
linesterase inhibition may therefore be useful in
ameliorating a cholinergic deficit, which likely
worsens in Alzheimer’s disease due to increased
activity of butyrylcholinesterase.
In the Alzheimer’s disease, increasing levels of
butyrylcholinesterase correlate significantly and
positively with the development of hallmark corti-
cal and neocortical amyloid-rich neuritic plaques
and neurofibrillary tangles [14,23]. Greig et al.
[24] reported that in rat brain slices selective
butyrylcholinesterase inhibition augmented long-
term potentiation, improved the cognitive perfor-
mance of aged rats, and reduced intra- and
extracellular b-amyloid precursor protein, and the
secreted b-amyloid peptide levels. Thus, activities
of acetylcholinesterase and butyrylcholinesterase
are closely associated with the disease activity it-
self [14,23,24]. Hence, estimation of acetylcholin-
esterase and butyrylcholinesterase could serve as
markers of Alzheimer’s disease and also in assess-
ing the severity of the disease and its prognosis.
Acetylcholinesterase and
butyrylcholinesterase in diabetes
mellitus
Acetylcholinesterase activity was found to be high-
er in islets of Langerhans than in the exocrine tis-
sue in rat pancreas, and in rats made diabetic with
streptozotocin compared to controls [25]. Activity
of serum butyrylcholinesterase was significantly
elevated in both type 1 and type 2 diabetes com-
pared with the control subjects [26]. Serum butyr-
ylcholinesterase activity correlated with serum
fasting triacylglycerol concentration and insulin
sensitivity in patients with type 1 and type 2 dia-
Rao et al.
betes. On the other hand, in non-diabetic subjects
with butyrylcholinesterase deficiency serum
triacylglycerol levels were in the normal range,
suggesting that butyrylcholinesterase might have
a role in the altered lipoprotein metabolism in
hypertriglyceridaemia associated with insulin
insensitivity or insulin deficiency in diabetes melli-
tus [26].
Butyrylcholinesterase K variant allele was more
common among type 2 diabetic subjects than
non-diabetic subjects suggesting the close associ-
ation of the butyrylcholinesterase gene (3q26)
with type 2 diabetes that could be related to an
identified susceptibility locus on chromosome
3q27 but independent of islet function [27]. Fur-
thermore, correlation analysis showed that butyr-
ylcholinesterase activity was positively correlated
with risk factors for coronary heart disease such
as Apo B, triglycerides, and diabetes. It was re-
ported that butyrylcholinesterase activity is asso-
ciated with lipoprotein synthesis, hypertension,
and diabetes [28] and a close association between
butyrylcholinesterase activity and serum choles-
terol, triglycerides, and albumin was also noted.
Paradoxically, individuals in the lowest quintile
of butyrylcholinesterase activity had significantly
higher mortality than those in the highest quin-
tile: all-cause mortality and cardiovascular
deaths, indicating that low butyrylcholinesterase
activity could a nonspecific risk factor for mortal-
ity in the elderly [29]. Thus, in the initial stages
of Alzheimer’s disease and diabetes mellitus,
the activity of butyrylcholinesterase is increased
whereas in the terminal stages of the disease
and when these diseases are advanced butyrylch-
olinesterase activity is low. These results imply
that activity of butyrylcholinesterase could be
used to predict prognosis in Alzheimer’s disease
and type 2 diabetes mellitus.
Acetylcholinesterase and
butyrylcholinesterase in inflammation
Both Alzheimer’ disease and type 2 diabetes
mellitus are low-grade systemic inflammatory con-
ditions in which plasma concentrations of acetyl-
cholinesterase and butyrylcholinesterase enzyme
are increased [30], whereas ACh is an anti-inflam-
matory molecule. Hence, when the concentrations
of acetylcholinesterase and butyrylcholinesterase
are increased it will lead to reduced levels of
acetylcholine that could result in increase in the
levels of IL-1 and TNF-a due to the absence of
the negative feed back control exerted by ACh.
Elevated butyrylcholinesterase and acetylcholinesterase
Butyrylcholinesterase
Acetylcholinesterase
Acetylcholine NF-κB
Acetate
Choline
IL-6, TNF-α
Nitric Oxide
Neurotransmission Inflammation
Alzheimer’s disease
Type 2 Diabetes mellitus
Figure 1 Scheme showing relationship between
cholinesterases, inflammation, pro-inflammatory cyto-
kines, and Alzheimer’s disease and type 2 diabetes
mellitus.
Thus, increased plasma, CSF, and RBC concentra-
tions of acetylcholinesterase and butyrylcholinest-
erase indirectly reflect reduced concentrations of
ACh that, in turn, will enhance local and systemic
inflammatory events. These results imply that ace-
tylcholinesterase and butyrylcholinesterase could
serve as markers of low-grade systemic inflamma-
tion (Fig. 1).
Conclusion
Although many studies showed enhanced plasma
levels of CRP, IL-6, TNF-a, and lipid peroxides
and low levels of NO in the plasma of patients with
type 2 diabetes mellitus and Alzheimer’s disease
[1–6], some studies did not confirm these observa-
tions [1]. This suggests that more reliable markers
of low-grade systemic inflammation need to be
identified. ACh has anti-inflammatory actions and
is an important neurotransmitter. Hence, measure-
ment of the activities of acetylcholinesterase and
butyrylcholinesterase enzymes may mirror the con-
centrations of ACh in the brain, especially in Alz-
heimer’s disease. The observation that activities
of acetylcholinesterase and butyrylcholinesterase
are enhanced in the plasma and RBCs of patients
with type 2 diabetes mellitus and Alzheimer’s dis-
ease suggests that they could be used as markers
of low-grade systemic inflammation. Based on
these evidences, we propose that estimation of
acetylcholinesterase and butyrylcholinesterase en-
zymes are useful to predict prognosis and response
to treatment in type 2 diabetes and Alzheimer’s
1275
disease. In addition, we suggest that plasma and
tissue levels of acetylcholinesterase and butyrylch-
olinesterase enzymes may serve as reliable markers
of low-grade systemic inflammation.
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