Acta Pharmaceutica Sinica B 2024;14(7):2795e2814

Chinese Pharmaceutical Association

Institute of Materia Medica, Chinese Academy of Medical Sciences

Acta Pharmaceutica Sinica B

w w w. e l s ev i e r. c o m / l o c a t e / a p s b
w w w. s c i e n c e d i r e c t . c o m

REVIEW

Monoclonal antibodies and aptamers: The

future therapeutics for Alzheimer’s disease
Alvaro Barrera-Ocampo*

Facultad de Ingenierı´a, Diseño y Ciencias Aplicadas, Departamento de Ciencias Farmace´uticas y Quı´micas, Grupo
Natura, Universidad Icesi, Cali 760031, Colombia

Received 6 February 2024; received in revised form 6 March 2024; accepted 14 March 2024

KEY WORDS Abstract Alzheimer’s disease (AD) is considered the most common and prevalent form of dementia of
adult-onset with characteristic progressive impairment in cognition and memory. The cure for AD has not
Ab;
been found yet and the treatments available until recently were only symptomatic. Regardless of multi-
Monoclonal antibody;
DNA aptamers;
disciplinary approaches and efforts made by pharmaceutical companies, it was only in the past two years
Cognitive impairment; that new drugs were approved for the treatment of the disease. Amyloid beta (Ab) immunotherapy is at
Alzheimer’s disease; the core of this therapy, which is one of the most innovative approaches looking to change the course of
Clinical trials; AD. This technology is based on synthetic peptides or monoclonal antibodies (mAb) to reduce Ab levels
Immunotherapy; in the brain and slow down the advance of neurodegeneration. Hence, this article reviews the state of the
Machine learning art about AD neuropathogenesis, the traditional pharmacologic treatment, as well as the modern active
and passive immunization describing approved drugs, and drug prototypes currently under investigation
in different clinical trials. In addition, future perspectives on immunotherapeutic strategies for AD and the
rise of the aptamer technology as a non-immunogenic alternative to curb the disease progression are
discussed.

ª 2024 The Author. Published by Elsevier B.V. on behalf of Chinese Pharmaceutical Association and
Institute of Materia Medica, Chinese Academy of Medical Sciences. This is an open access article under
the CC BY license (http://creativecommons.org/licenses/by/4.0/).

*Corresponding author.
E-mail address: aabarrera@icesi.edu.co (Alvaro Barrera-Ocampo).
Peer review under the responsibility of Chinese Pharmaceutical Association and Institute of Materia Medica, Chinese Academy of Medical Sciences.

https://doi.org/10.1016/j.apsb.2024.03.034
2211-3835 ª 2024 The Author. Published by Elsevier B.V. on behalf of Chinese Pharmaceutical Association and Institute of Materia Medica, Chinese
Academy of Medical Sciences. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
2796
1. Introduction
The approval of new anti-Ab monoclonal antibodies by the FDA
(Food and Drug Administration, USA) for the treatment of AD has
reignited the interest in immunotherapeutic strategies for this and
other neurodegenerative diseases caused mainly by protein mis-
folding and aggregation. Some years ago, it was reported the
failure of many clinical trials involving mAb that showed no
cognitive improvement of AD patients despite the observed
reduced load of Ab peptides and the excellent preclinical results1.
The acceptance by the FDA of aducanumab and lecanemab has
been highly controversial among the AD field, but it has opened a
window of opportunity for many other antibodies and immune
therapies that were stuck in the pipeline for years2,3.
1.1. Behavioural and psychological symptoms of AD
Neuroepidemiology studies have established that AD is the most
prevalent neurodegenerative illness of adult-onset, with extended
prodromal phases characterized by progressive cognitive decline
and memory loss. It is also the most common type of dementia
accounting for 60%e80% of the cases4. It is estimated that the
average time course of the disease is 7e10 years, but changes in
the brain probably start many years before any clinical symptoms
and signs appear. Most of these changes are caused by the death of
neurons in regions of the brain responsible for memory processing
and other higher cognitive functions.
The entorhinal cortex is one of the first brain regions affected.
This structure is connected with the hippocampus and plays a key
role in learning and the formation of long-term memories. The
neuronal death and decrease in size of these brain areas explain
the symptoms observed at the early stages of AD, such as
forgetfulness, changes in attention and ability to solve problems.
The progression of the disease is characterized by memory
decline, language alteration, visuospatial difficulty, loss of
awareness and changes in personality, among others. At this stage,
the clinical diagnosis is usually made, but further structural
damage can be observed in areas of the cerebral cortex responsible
for the control of language, conscious thought, reasoning and
sensory processing. Changes in the neuronal communication in
the cortex can cause delusions, paranoia, hallucinations, anger
outbursts and inability to carry out routine tasks (e.g., eating,
bathing, dressing and others). At the end, extensive neuronal
damage causes serious atrophy of the cerebral cortex and the
enlargement of the ventricles. The patient becomes incapable to
recognize its relatives, and cannot control the bladder or bowel
function, swallow, walk and sleep5.
1.2. Risk factors associated with AD
A number of risk factors have been related with the onset of AD.
The greatest risk factor for AD is the advanced age, since most of
the patients are aged 65 or older6. Other risk factors include family
history, mild cognitive impairment (MCI), being an apolipoprotein
E-ε4 (APOE-ε4) allele carrier7, which associated with the pres-
ence of susceptibility genes, such as ABCA7, TREM2 and SORL18,
may be useful for predicting dementia linked to AD. Additional
risk factors include potentially modifiable conditions occurring in
midlife, in particular metabolic factors (e.g., type 2 diabetes, high
blood pressure, high cholesterol, obesity, smoking, etc.), and
traumatic brain injury9e13. In fact, there is increasing evidence
Alvaro Barrera-Ocampo
that suggests that environmental risk factors, such as exposure to
poor quality air, occupational-related exposures and toxic heavy
metals, may also contribute to the development of AD14.
Increasing amount of evidence has led to the hypothesis that
central nervous system infections caused by viruses, bacteria,
fungi and parasites may represent an important risk factor because
these microorganisms may be able to drive the pathogenesis of
AD by inducing neuroinflammation or compromising the integrity
of the braineblood barrier15,16. In this regard, recent multi-omic
analysis identified 22 key genes regulated by herpes virus in-
fections, which were associated with the occurrence and devel-
opment AD17. Additional studies have also related infections
caused by some bacterial species (e.g., Chlamydia pneumonia,
Porphyromonas gingivalis, Borrelia burgdorferi) with the neuro-
pathogenesis of AD18e20. However, despite the correlational data
presented by these and other studies, a direct relation between the
neurodegeneration and the microbial infection is hard to establish
because the mechanism underlying the infection and the changes
at the cellular and molecular level that could explain the devel-
opment of AD are largely unknown.
1.3. Biomarkers and early diagnosis of AD
The discovery of biomarkers associated with risk factors is an
essential step in the early diagnosis, monitoring the onset and the
progression of the disease. It is clear that a simple cause of AD is
improbable and multiple factors are involved in its progression. In
2018, the NIA-AAA work group proposed that AD could be part
of a syndrome formed by multiple diseases characterised by signs
and symptoms. However, this definition only makes sense if the
person can be accurately diagnosed by its neurocognitive and
neuropathologic changes and the use of biomarkers that can
support the differential diagnoses to rule out non-AD patients. For
this, the NIA-AAA work group outlined an unbiased descriptive
classification scheme for biomarkers used in brain aging and AD
intended initially for research (interventional trials and observa-
tional cohort studies)5. They called this classification “AT(N)
biomarker grouping”, where A corresponds to aggregated Ab or
associated pathologic state (Cerebrospinal fluid (CSF) Ab42, or
Ab42/Ab40 ratio or amyloid PET); T relates to aggregated tau
(neurofibrillary tangles-NFTs) or associated pathologic state (CSF
phosphorylated tau or tau PET); and N comprehends neuro-
degeneration or neuronal injury (anatomic MRI, fluorodeox-
yglucose PET or CSF total tau)21e23. It is important to clarify that
the biomarkers in the N group are related to neurodegeneration
and brain injury as a result of different causes and are not specific
for AD. The AT(N) biomarker scheme can incorporate new bio-
molecules such as TDP43 and a-synuclein, and alterations like
hippocampal sclerosis, argyrophilic grains and microinfarcts,
which can occur alone, or more frequently, along with AD path-
ologic changes24,25. Thus, the appearance of new therapeutic al-
ternatives makes early and accurate diagnosis essential to increase
the likelihood of success in delaying the onset or progress of the
disease, which must be reflected in a stabilization of the cognitive
decline and an improvement in the quality of life of patients and
relatives.
There is no cure for AD and the treatments available until 2021
were only symptomatic. However, the recent approval of a series
of mAbs capable of reducing Ab load in the brain has put the
immune therapy at the centre of the stage not only for the treat-
ment of AD, but for other types of dementias. Therefore, this
Monoclonal antibodies, aptamers and Alzheimer’s disease
review will discuss the relationship between AD, passive and
active immunization with emphasis on the monoclonal antibodies
currently available in the pharmacotherapy of the disease and
some new molecules that are currently under development and
under clinical evaluation.
2. Protein aggregation and alternative hypotheses about the
pathogenesis of Alzheimer’s disease
2.1. Neuropathogenesis of Alzheimer’s disease
The amyloid cascade hypothesis that embodies the primacy of the
biology of amyloid and tau proteins around which much of the
drug discovery efforts have been focused in the past 20 years, fails
to acknowledge many other covert mechanisms that have been
suggested as relevant to elucidate the causes of AD. Under-
standing the cellular events that lead to neuronal and synaptic loss,
which are the likely causes of cognitive impairment in AD, has
been a matter of intense research, but many aspects of it remain
unknown. In this review, the biology of Ab is prominently
featured as is the base of many mAbs approved or in development
as treatment for AD. Nonetheless, it is important to emphasize that
there is growing evidence that many other changes occur at the
cellular and biochemical level before the appearance of Ab and
tau aggregates26e28, which has been used for years as markers of
AD.
From a neuropathological point of view Ab and tau aggregates
in the form of senile plaques and NFTs are the main hallmarks of
AD29. The amyloid cascade hypothesis is based in genetic, path-
ologic, and biochemical evidence that implicate the aggregation of
Ab as a critical trigger in the series of events related to the
abnormal deposition in the brain of the hyperphosphorylated tau
protein (also known as tauopathy), neuronal dysfunction, death,
and dementia30. However, the deposition of tau protein correlates
with the cognitive decline observed in AD patients31, questioning
the role of Ab aggregation as the cause for tau pathogenesis.
Analyses of post-mortem human brains revealed a characteristic
progression of Ab deposits and a regular pattern of appearance of
NFTs. The progression of Ab plaques appearance is associated
anatomically and functionally with affected brain areas32,33.
Extracellular neuritic plaques containing Ab are found widely
distributed throughout the cerebral cortex including the subcortex,
allocortex and neocortex while tau-containing NFTs arise first in
the medial temporal lobe (entorhinal cortex/limbic brain areas and
locus coeruleus), then spread to isocortical regions of the tem-
poral, parietal, and frontal lobes5,34e36.
The occurrence of plaques and tangles correlates positively in
AD where Ab deposition occurs in a group of areas known as the
default mode network (DMN)37, which is distributed in the
frontal, temporal and parietal cortex, and the posterior cingulate
gyrus. Brain imaging has evidenced that the activity of these
regions increases during processes like memory or abstract
thought, but decreases during tasks that require attention. There-
fore, the DMN is active when the individual is not focused on the
external environment38,39. In contrast, tauopathy seems to affect
networks that support more specific cognitive domains and are
impaired in symptomatic AD, as shown by functional MRI and
fluorodeoxyglucose PET40e42. Recent advances in the elucidation
of the brain connectome, which try to determine how billions of
neurons are interconnected to form neuronal networks that support
cognition and behaviour43, have allowed to show that the
2797
functional activity in specific brain regions could selectively
modify synaptic homeostasis, thus offering an explanation to the
convergence of Ab and tau pathology in AD43e45. In this regard, it
has been suggested that the loss of synaptic homeostasis in areas
of high neuronal activity in the DMN could give rise to a
cascading network failure affecting the balance in remote but
connected brain regions that depend on the DMN for proper
functioning46. The posterior cingulate cortex is one of these
regions highly connected to the medial temporal lobe47, therefore,
the synaptic stress caused by Ab accumulation in the posterior
cingulate could explain the propensity of the medial temporal
lobes to accumulate tau when it loses functional support from the
DMN48. Thus, during the lifetime of a person prone to developing
AD, synaptic dysfunction that leads to Ab accumulation in the
DMN could accelerate tauopathy in strongly linked brain regions
and the spreading of tau from the medial temporal lobe to iso-
cortical regions could account for the transition from no symptoms
to dementia in AD. However, despite the advances in under-
standing of the interaction between Ab and tau, it is still unknown
how this interplay affects the organization of the connectome
in AD.
2.2. Ab peptides and aggregates
2.2.1. Formation of Ab
The most abundant species of Ab are 27e43 amino acids in length
and are derived from the scission of the amyloid precursor protein
(APP), a single transmembrane protein that is enriched in neuronal
synapses49. APP is produced in neurons and metabolized
rapidly50. Following the sorting in the endoplasmic reticulum
(ER) and Golgi network, APP is translocated to the axon and
synaptic terminals. APP processing is made in the trans-Golgi
network (TGN) and from there; the protein can be transported
to the cell surface or to endosomal compartments through clathrin-
associated vesicles. To generate Ab, APP is endocytosed in
clathrin-coated pits into endosomal compartments containing
b-secretase enzymes. BACE1 is the b-secretase enzyme that
cleaves the extracellular juxtamembrane region of APP (b-cleav-
age) (Fig. 1). The cleavage of APP by b-secretase releases the
soluble N-terminus of APP (sAPPb) while the C-terminal frag-
ment (CTF-b or C99) remains bound to the membrane51 (Fig. 1).
This fragment is subsequently cleaved by g-secretase, which is an
aspartyl-type protease membrane protein complex and consists of
different several components (Fig. 1). The catalytic elements of
the membrane-embedded tetrameric g-secretase complex are
represented by presenilin-1 and presenilin-2, which generate the
Ab carboxyl terminus from APP52,53. Nicastrin (NCT), anterior
pharynx defective 1 (APH-1) and presenilin enhancer 2 (PEN-2)
are additional proteins involved in the g-secretase complex. NCT
and APH-1 seem to stabilize the formation of high-molecular-
mass protein complex needed for the catalytic activity54,55,
whilst PEN-2 is thought to modulate the endoproteolysis of pre-
senilin by forming a stable complex with NCT/APH156. The
g-secretase complex interacts with APP in its transmembrane
region to create Ab40/Ab42 peptides and the AICD50 fragment57,58
(Fig. 1). Once Ab peptides are produced, they can be released to
the extracellular space or degraded in lysosomes. This process is
known as the Amyloidogenic pathway59e61 (Fig. 1).
2.2.2. Aggregation of Ab
Ab peptides are found in human brains, both healthy and AD, at
subnanomolar concentrations. In the brain tissue various isoforms
2798
Figure 1 Processing of APP and production of Ab. APP is initially cleaved by a-secretase (ADAM-10) in the Non-amyloidogenic pathway,
yielding two fragments: sAPPa and C83. The late is cleaved by the g-secretase complex, creating the p3 and AICD peptides. In the Amyloi-
dogenic pathway, b-secretase (BACE1) cleaves APP to produce the sAPPb and C99 fragments, which are then processed by the g-secretase
complex to produce the Ab and AICD peptides.
of Ab can be found. They differ in the number of amino acid
residues at the C-terminal region of the peptide. The most abun-
dant Ab species in the brain of AD patients is the isoform Ab40,
which has 40 residues62,63. Another Ab species also related to the
disease is the isoform Ab42, which is less soluble than Ab40 and it
aggregates faster64. The structure of Ab peptides have a charac-
teristic type of b-sheet arrangement that favours the
aggregation, which leads to the formation of oligomeric species
that diffuse through the interstitial fluids. Ab monomers aggregate
and polymerize to form high molecular weight species such as
oligomers, protofibrils and fibrils65,66 (Fig. 1). In vitro experiments
have shown that the aggregation of Ab starts with a nucleation
step, which leads to the formation of disordered oligomers con-
verted afterwards into nuclei that elongate into fibrillar assemblies
creating a secondary nucleation process responsible for the pro-
liferation of the aggregates67,68.
2.2.3. Impact of Ab aggregates on the neuronal function
It is clear now that not only Ab peptides (Ab40 and Ab42) cause
neuronal dysfunction; especially oligomeric forms of the protein
seem to be more detrimental to brain functions than the Ab
aggregates such as senile plaques49,69. In this regard, a mixture of
dimers and dodecamers was observed in soluble Ab oligomers
derived from human brains70; whereas the treatment of primary
cultures of hippocampal neurons with Ab oligomers induced a
rapid decrease in membrane expression of memory-related
Alvaro Barrera-Ocampo
receptors, followed by changes in the morphology of dendritic
spines, reduction in spine density, and synaptic deterioration71.
Moreover, results suggest that soluble Ab oligomeric species can
inhibit electrophysiological activity of hippocampal neurons that
may be important for the formation and storage of memory; so, as
a consequence, this inhibition seems critical for the development
of AD72. Another interesting finding suggests that Ab oligomers
also bind to different types of membrane proteins including the
N-methyl-D-aspartate (NMDA) receptor subunits. The interaction
of the oligomers with this receptor inhibits synaptic plasticity and
disturbs calcium homeostasis73,74, causing neuronal death. For this
reason, targeting Ab forms can slow the aggregation process and
attenuate the cognitive dysfunction that is the main symptom of
AD.
2.3. Alternative hypotheses about the neuropathogenesis of AD
For more than two decades, hypotheses regarding the amyloid
cascade and tau aggregation have dominated the research scene
and the development of treatments for AD75. This is probably
because Ab and tau are the main histopathological markers of the
disease widely found in the diseased population. However, other
points of view have emerged in light of new evidence that
maintains that the origin of AD is multifactorial. Different studies
have shown that a large number of changes occur at the molecular,
cellular, and biochemical levels before Ab and tau aggregates are
Monoclonal antibodies, aptamers and Alzheimer’s disease
evident. Thus far, more than 10 hypotheses relating to the path-
ogenesis of AD have been documented76. Some of the most
notable are described below.
2.3.1. The cholinergic hypothesis
It was one of the first to try to explain the cause of AD77. This
postulates that cholinergic system failure is the cause of AD due to
the decrease in the activity of the enzyme acetylcholinesterase in
regions such as the amygdala, hippocampus, and cortex of AD
brains78. Studies based on this hypothesis led to the development
of the first medications used to treat AD, acetylcholinesterase
enzyme inhibitors (AChEIs)79, which avoid the degradation of
acetylcholine and are useful in the palliative treatment of the
disease that enhance quality of life but have no discernible impact
on the development or course of AD80.
2.3.2. Mitochondrial damage and oxidative stress theories
They suggest that the activity of the mitochondria could affect
APP expression, processing, and accumulation of Ab in AD81.
The concept is composed of three main parts. First, the mito-
chondrial function is determined by the genetic background of the
person. Second, both genetic and environmental factors may affect
the age-related mitochondrial changes. Third, the mitochondrial
activity of an individual varies according to the stage or pro-
gression of AD82e84. It has been found in brain tissue from
deceased AD patients that there is a decreased number of mito-
chondria in neurons while oxidative damage is increased.
Oxidative stress can be caused by an excess of reactive oxygen
species or a weak antioxidant defence85. Thus, the imbalance in
pro-oxidants and antioxidants is associated with the disruption of
redox circuitry and macromolecular damage. In addition, research
has found evidence for a direct relationship between oxidative
stress and neuronal dysfunction in AD. Both in vitro and in vivo
evidence points to a direct link between neuronal dysfunction and
oxidative stress in AD86,87. Ab-dependent endocytosis is associ-
ated with a reduced number of NMDA receptors on the cell sur-
face of neurons. A decreased expression of NMDA receptors can
be attributed to neuronal death caused by excitotoxicity, which can
be triggered by increased calcium influx, impaired energy meta-
bolism, and mitochondrial damage88.
2.3.3. The calcium homeostasis hypothesis
It suggests that Ab can increase intracellular calcium levels,
making neurons more susceptible to environmental stimuli89. This
hypothesis has been linked to AD and is closely related to learning
and memory. A number of studies have demonstrated that Ab
upregulates intracellular calcium in neurons, which disrupts
neuronal metabolism, induces neuronal apoptosis, and contributes
to memory decline90,91. Additional studies found that calcium
overload produce dendrite disintegration, and changes in neuronal
morphology depend on the presence and load of Ab92.
2.3.4. The inflammatory hypothesis
There is mounting evidence about the key role of microglia and
the adaptative immune response in the neuropathogenesis of
AD93,94. Microglial cells are a type of specialized macrophage
present in the brain that have been observed near Ab plaques and
NFTs in AD brains95,96. Interestingly, a team of researchers
recently used cell cultures and a murine model of AD to establish
that the administration of the nanopolyphenol, a-mangostin, was
2799
capable of reinducing the reactive state of microglia and
enhancing the misfolded-protein clearance capacity through
shifting glycolysis to oxidative phosphorylation. This confirms the
importance of microglia within the neurogenerative process in AD
and provides cellular targets for the development of future treat-
ments97. Another group using in vivo experiments have also shown
that glial activation can be induced by inflammatory substances,
such as Ab, which can result in immunological responses and
inflammation. Additional studies have observed increased levels
of inflammatory cytokines, including, IL-1b, IL-12, IL-18, TGF-b
and TNF-a98. These molecules could be related to cellular death,
and to the development of AD.
A recent work evaluated the relationship between the mutation
R136S in the lipid carrier Apolipoprotein E3, denominated
Christchurch (APOE3ch), and Ab-induced tauopathy. For this, the
authors used a humanized APOE3ch knock-in mouse crossed to
an AD mouse model injected with tau protein from AD brains.
Researchers found that the animals had peripheral dyslipidaemia
and a significant decrease in plaque-associated tau pathology. In
addition, an increase in microglial response and a decrease in
amyloid response was observed around Ab plaques. These results
suggest that APOE3ch influences the microglial response to Ab
plaques, and it suppresses tau seeding and spreading induced by
Ab99. The findings are also in accordance with a renowned case
report that identified a person resistant to autosomal dominant AD
caused by a PSEN1-E280A mutation and a homozygous carrier of
the APOE3ch mutation100. These and other works increasingly
emphasize the relationship between lipid metabolism, immune
response, inflammation and the development of AD.
3. Pharmacotherapy of AD: The old and the new
Two variants of AD have been recognized. The sporadic AD
(SAD) variant can be classified as either early- or late-onset (<60
years of age or > 60 years of age) and is characterized by absence
of inheritance pattern. In the familial AD (FAD) variant, the dis-
ease tends to develop before 60 years of age (early-onset) and the
autosomal dominant heritability accounts for w1% of the AD
cases101,102. Genetic mutations in genes coding for the amyloid
precursor protein (APP), presenilin-1 (PS1) or presenilin-2 (PS2)
are the main responsible of the FAD variant103. The study of FAD
cohorts has markedly influenced the understanding of the cellular
mechanisms involved in the pathogenesis of AD. Nevertheless, the
cause of SAD is still unknown and the aetiology seems to be
heterogeneous. The interaction of multiple factors (e.g., genetic,
epigenetic and environment) and the lack of clarity on the mo-
lecular and cellular basis of the disease can explain the complexity
of this variant.
Regarding the pharmacological treatment of AD, many strate-
gies have been tried so far. These range from traditional palliative
approaches to sophisticated disease-modifying strategies such as
gene- and immunotherapy. The standard palliative treatments
include inhibitors of the enzyme acetylcholinesterase, that inhibit
the breakdown of the neurotransmitter acetylcholine (e.g., riva-
stigmine, galantamine and donepezil) and are used in mild to
moderate AD104,105. Initially, these drugs improve cognition,
behavioural symptoms and routine tasks, but they have shown lack
of effectiveness and adverse reactions that compromise their
use106e108. Another drug approved for the palliative treatment of
AD is memantine, an antagonist of the NMDA receptor, indicated
2800
for patients with moderate to severe AD, which presents high drop-
out rates attributed to the numerous associated adverse
events104,105,109. The sparse effectiveness of these drugs and the lack
of success of the therapeutic strategies tried so far may be attributed
to several factors: i) the gap in the knowledge about many other
genomic, metabolic and biochemical changes that occur years
before the onset of the first symptoms of AD110e112, ii) the lack of
biomarkers, accurate and precise tools for the early diagnosis and
the difficulty to assess the disease stages, and iii) the constrains of
the drug discovery process. For years there has been an urgent need
to find disease-modifying agents and this has opened the doors to
new approaches from different areas of biomedicine that seek to
generate a quantum leap in the treatment of AD. In this regard,
immunotherapeutic strategies emerge with great potential.
3.1. Immunotherapy for AD
3.1.1. Active immunotherapy
Accumulation of Ab is one of the main events related to the neu-
rodegeneration process in AD. Therefore, immunotherapy has
become the epicentre of research to avoid Ab aggregation and
promote its clearance from the brain to delay the onset or progress of
the disease. This strategy tries to harness the patient’s immune
system to remove Ab peptides from the brain preventing the for-
mation of amyloid plaques. This process is called Active Ab-im-
munotherapy and it is based on stimulating B cells with synthetic
versions of Ab (fragments of full-length) so that the organism
manufactures its own antibodies, which in turn neutralize the Ab
peptides, thus creating a complex that later is cleared out from the
brain. Relevant information on some of the most notable Ab vac-
cines developed by active immunization is described below.
3.1.1.1. AN1792. The first active vaccine developed for the
treatment of AD (https://clinicaltrials.gov; Identifier: NCT00021723)
was developed in 2001 by ELAN and Wyeth using the full-length
Ab42 peptide (Table 1). The vaccine achieved some positive results
including reduced cognitive decline. However, the clinical trial was
brought to a halt because w6% of the individuals treated with the
vaccine developed meningoencephalitis113e115. Investigations into
the cause of this inflammatory process indicated that one of the
excipients used in the preparation of the vaccine produced the
exposition of the Ab C-terminal region, which seems to activate
the response of T-helper 2 cells115. This information was essential for
the development of the new generation of vaccines that did not
include this region of the peptide.
3.1.1.2. ACI-24. In 2009, AC Immune began a phase I/II trial
of ACI-24 to evaluate safety, immunogenicity, and efficacy. This
vaccine was made using the tetra-palmytoylated Ab1e15 peptide,
which favours the b sheet folding (Table 1). The design induced
the production of antibodies with specificity for the conformation
of the peptide and was formulated as liposomes to elicit the im-
mune response116. The trial finished in 2018 and ultimately
enrolled only 48 patients of which only 36 produced detectable
anti-Ab42 antibodies (https://www.clinicaltrialsregister.eu; Identi-
fier: 2008-006257-40). Then in 2018, a phase II trial started testing
a new formulation. The results indicate that ACI-24 produced IgM
antibody response, but low IgG titers. Levels of Ab40 and Ab42 in
CSF were increased compared to the baseline, suggesting target
engagement, but no change on amyloid-PET was observed. No
Alvaro Barrera-Ocampo
central nervous system inflammation or Amyloid-Related Imaging
Abnormality (ARIA) cases were reported (https://www.
clinicaltrialsregister.eu; Identifier: 2018-000445-39).
3.1.1.3. CAD106. In 2015 Novartis introduced CAD106
(https://clinicaltrials.gov; Identifier: NCT02565511), which
underwent clinical trials until 2020. This contained multiple
copies the Ab1e6 peptide coupled with a carrier with 180 copies of
the bacteriophage QB coat protein for the induction of the immune
response (Table 1). There were no meningoencephalitis cases
reported during the phase I trials. However, during phase IIa trials
one patient developed intracerebral haemorrhage and four
individuals presented imaging alterations related with Ab117,118.
The study was terminated due to unexpected changes in cognitive
function, brain volume loss, and body weight loss.
3.1.1.4. UB-311. In 2015, United Neuroscience Ltd. started a
phase II clinical trial with the vaccine UB-311. The design
concept behind UB-311 consisted in the induction of specific
activation of Th-1 cells by introducing the Ab1e14 peptide in
combination with UBITh helper T-cell epitope (Table 1). Results
of a phase II trial (https://clinicaltrials.gov; Identifier:
NCT02551809) indicated that the vaccine had potential to
improve the cognitive function in early-to-mild AD patients with
100% responder rate and strong on-target immunogenicity119. The
clinical trial did not include a placebo group, but compared the
increase of AD Assessment Scale-Cognitive Section (ADAS-Cog)
scores from baseline in a subgroup of mild AD patients (Mini-
Mental State Examination [MMSE] score 20) with a moderate
AD subgroup. Data show a slower rate of increase in ADAS-Cog
in the subgroup of mild AD patients. In addition, the most com-
mon adverse events observed with UB-311 were injection site
swelling and agitation. The results suggest that UB-311 may have
a potential to improve the cognition of patients with early stage of
AD119. In 2022, the FDA granted UB-311 fast-track designation
for AD, facilitating expedited development and review.
3.1.2. Passive immunotherapy
The passive immunotherapy includes the administration of mAbs
to target a specific antigen. This technology overcomes the
problems of the active immunization taking advantage of three
mechanisms that take place once the antibody has crossed the
bloodebrain barrier120,121. The first mechanism depends on the
interaction AbemAb to decrease the formation of toxic aggre-
gates. The second involves the binding between the Fc-g receptors
present on the microglia and the Fc domain of the mAb to induce
the phagocytosis of the AbemAb complex. In the third mecha-
nism, the formation of the AbemAb complex leads to the acti-
vation of the complement-dependent cytotoxicity effect, which
causes the lysis of the target cell. A fourth additional mechanism
has been described and is based on the interaction of the mAb with
Ab in the peripheral blood to create a concentration gradient that
causes the efflux of Ab from the brain. Next, I present some mAb
against Ab already approved by the FDA or currently on track to
approval, which include aducanumab (Aduhelm ), lecanemab
(Leqembi ), gantenerumab and donanemab.
3.1.2.1. Aducanumab. It is the first mAb approved by the FDA
for the treatment of AD. It was developed by the Swiss
Monoclonal antibodies, aptamers and Alzheimer’s disease 2801

Table 1 Active and passive immunotherapeutic approaches for AD.

Active immunotherapy
Vaccine Company of origin Target Formulation Clinical trial AD patient Result
adjuvant phase status
AN1792 ELAN/Wyeth Ab42 QS-21, polysorbte IIa-finished Mild to No
80 moderate improvement
ACI-24 AC Immune tetra- Liposomes II Mild Decreased Ab
palmytoylated levels
Ab1e15 (b
conformation)
CAD106 Novartis Ab1e6 Bacteriophage Qb III Prodromal NR
protein coat
UB-311 United Neuroscience Ab1e14 CpG/Alum II Mild Decreased Ab
Ltd. levels
Passive immunotherapy
mAb Company of origin Antigen or Binding species Clinical trial AD patient Result
epitope/IgG phase status
Aducamab Biogen NT Ab3-6 (E)/ Oligomers and III Prodromal to Decreased Ab
human IgG1 fibrils mild levels
Lecanemab Biogen/Eisai/ Ab42 AM Protofibrils III Prodromal Decreased Ab
(BAN-2401) BioArctic protofibrils (A)/ levels
hIgG1
Gantenerumab Roche NT Ab1-10 and Monomers, III Prodromal to Decreased Ab
central region oligomers and mild levels
Ab18e27 (E)/ fibrils
human IgG1
Donanemab Eli Lylli pGlu3-Ab/human Core plaques III Prodromal Decreased Ab
IgG1 levels
A: antigen; E: epitope; hIgG: humanized IgG; NT: N-terminal region; CT: C-terminal region; AM: arctic mutation; NR: not reported.
Source: http://www.clinicaltrials.gov.

biotechnology company, Neurimmune, which in 2007 licensed the
development and commercialization to Biogen122,123. This human
IgG1 mAb was developed from a library of B cells created from
healthy aged individuals122. Aducanumab recognizes the Ab
N-terminal region binding to oligomers and fibrils of subjects
with prodromal to mild AD (Table 1)122,124. A linear epitope
formed by the amino acids 2e7 of Ab increases aducanumab’s
affinity towards aggregates of fibrils, as compared to monomers
(Fig. 2)125. The complex between aducanumab and Ab is stabi-
lized by the interaction of an arginine on the antibody and a
phenylalanine on the peptide, which explains the high affinity
binding (Fig. 2)125. A preclinical animal model of AD showed that
aducanumab reduces brain pathology by stimulating microglia and
removing parenchymal, rather than vascular Ab122. In addition, a
proteome analysis of the plaque environment found an elevation in
proteins involved in metabolism, phagocytosis, regeneration of
axons and neurons, as well as reduction in proteins related with
Ab toxicity in a transgenic mouse model of AD treated with
aducanumab126. In 2012, Biogen started a phase Ib clinical trial
(PRIME) (https://clinicaltrials.gov; Identifier: NCT01677572).
The randomized, bouble-blind, placebo-controlled study focused
on the safety and tolerability of aducanumab and the capability to
reduce Ab load. Results revealed an improvement of cognitive
decline in AD patients, but caused ARIA in 41% of the volunteers
with high-dose treatment (10 mg/kg). In 2015, before completing
the phase Ib study, the company began two phase III placebo-
controlled randomized trials (EMERGE and ENGAGE) aiming
to compare the clinical efficacy of low or high doses of the
antibody with placebo. These trials included volunteers (50e85
years of age) with MCI or mild dementia and PET positive evi-
dence of Ab pathology in the brain (https://clinicaltrials.gov;
Identifier: NCT02477800 and NCT02484547)127. Biogen amen-
ded the phase III trial protocol based on results of the phase Ib
study. This time the dose of aducanumab was increased and the
management of the participants who presented mild-to-moderate
ARIA was changed by resuming the treatment at the same
dose128. In 2019, the phase III clinical trials were completed, and
the analysis of the results showed that the studies did not have
statistically or clinically significant effect. However, the company
included additional data and further analyses were made129. Then,
the results of the two trials were published. The EMERGE trial
showed statistically significant effect but clinically doubtful
benefit after 78 weeks of treatment according to the Clinical
Dementia Rating (CDR) Sum of Boxes score in the subgroup
receiving the higher-dose treatment. In contrast, the ENGAGE
trial did not show such benefit. Traditionally drug approval
depended on 2 rigorous trials showing positive results; however,
on June 2021, the FDA gave accelerated approval to aducanumab
for MCI and mild AD dementia based on the drug’s ability to
remove Ab plaques in the brain130. This decision was highly
controversial because it was made against the advice of its own
advisory committee131. Thus far, the relationship between Ab
removal and improvement in clinical outcomes for those with AD
is unclear. The accelerated approval requires conducting post-
marketing studies to confirm the benefits and in this case, Biogen
has 9 years to complete the confirmatory trial, but reliance on
2802 Alvaro Barrera-Ocampo

Figure 2 Region of interaction between aducanumab and Ab. The coecrystal structure reveals the presence of a linear epitope between amino
acids 3 and 7 of Ab. The most essential residues in Ab to form the complex with the antibody are phenylalanine (F4) and histidine (H6), which are
buried inside a hydrophobic pocket formed by the residues tryptophan (W52), tyrosine (Y59), isoleucine (I102), glycine (G103), arginine (R105)
and proline (P108) of the heavy chain, and tyrosine (Y32), tyrosine (Y92) and threonine (T94) of the light chain of aducanumab. Thus, explaining
the high affinity binding (PDB 6CO3, structured epitope amino acids 3e7)125,135.

future confirmatory evidence is problematic132. There are serious
concerns about aducanumab’s efficacy and adverse effects, which
include ARIA and the related symptoms (headaches, confusion,
dizziness, nausea, etc.)133. Although these effects are worrisome,
death is the greatest risk as few fatalities potentially related to
aducanumab have been reported134.
3.1.2.2. Lecanemab (BAN2401). It is the second-ever mAb
approved by the FDA for the treatment of AD. It was developed by
BioArtic and then licensed to Eisai in collaboration with Biogen.
This is the humanized version of the murine antibody mAb158,
which was raised against APP bearing the Arctic mutation (mutation
E22G mutation in Ab)136,137. The antibody recognizes Ab proto-
fibrils with much higher affinity than monomers and reduces this
specific conformation of the peptide in the brain and CSF of trans-
genic mice expressing both the Arctic mutation and the “Swedish”
double mutation in APP (K670N/M671L; tgArc-Swe mice)
(Table 1)138. A series of experiments using co-cultures of astrocytes,
neurons, and oligodendrocytes from mouse embryos revealed that
the treatment with mAb158 can protect neurons from Ab42 toxic
concentrations by preventing the accumulation of Ab through
astrocyte-uptake139. In addition, recent preclinical studies have
shown that the mAb rescues neurons from Ab-induced cell death,
which is associated with improvements in brain perfusion and
neuronal viability139,140. In 2010, a phase I clinical trial investigated
the safety and tolerability of the antibody. The study was carried out
with staggered parallel single and multiple ascending doses, from
0.1 mg/kg as a single dose to 10 mg/kg biweekly for four months.
The results proved that the incidence of ARIA-E/H on MRI was
comparable to that of placebo and that the antibody was well-
tolerated across all doses (https://clinicaltrials.gov; Identifier:
NCT01230853)141. In 2012, an 18-month phase II proof-of-
concept, double-blind study evaluated safety, tolerability, and effi-
cacy of lecanemab in individuals with early AD. This clinical trial
assessed three doses across two regimens of lecanemab versus
placebo, and it showed a 64% probability to be better than placebo. It
also determined that the antibody was well tolerated with 9.9%
incidence of ARIA-E at 10 mg/kg biweekly. Even though, the study
did not meet the 12-month primary endpoint, results from pre-
specified 18-month frequentist analyses showed that lecanemab
treatment reduced Ab load and clinical decline by 47% as per
ADAS-Cog in a dose-dependent fashion in volunteers with early
AD142. In addition, the trial established that the optimal dosage for
Ab clearance was 10 mg/kg administered intravenously biweekly,
without titration (https://clinicaltrials.gov; Identifier:
NCT01767311)142. In 2019, it started a phase III study (Clarity AD)
to evaluate the efficacy of lecanemab in participants with early AD.
The aim was to determine the superiority of lecanemab compared
with placebo and to evaluate the long-term safety and tolerability of
this in participants with early AD143. The clinical trial confirmed the
results of the phase II study and met its pre-specified endpoints.
After 18 months, the trial showed that lecanemab reduced the
burden of Ab in the brain versus placebo and slowed the loss of
cognition by 26% according to the ADAS-Cog score. Lecanemab
was generally well-tolerated, with a low incidence of ARIA-E
(12.6%) and demonstrated a significant slowing of decline in clin-
ical outcomes in early AD (https://clinicaltrials.gov; Identifier:
NCT03887455)143.
3.1.2.3. Gantenerumab. It was the first fully human mAb
designed to bind to a conformational epitope on Ab fibrils with
subnanomolar affinity. The antibody was selected from synthetic
Monoclonal antibodies, aptamers and Alzheimer’s disease 2803

human combinatorial antibody libraries created by phage display,
followed by in vitro affinity maturation using cassette exchanges
of complementarity determining regions (CDR)144,145. Experi-
ments of epitope mapping demonstrated that gantenerumab rec-
ognizes two discontinuous regions of Ab (N-terminal and central
region), showing the highest affinity at residues 2e11 and
18e27146. The complex between gantenerumab and Ab is char-
acterized by an extended conformation of the peptide in the
groove. The first four residues are bound to the heavy chain of the
antibody, whereas residues 5 to 11 interact with both heavy and
light chains. Two additional residues interact through hydrogen
bonds with atoms of the main chain146 (Fig. 3). The separate
epitopes provide the antibody with the flexibility to bind several
sequences and facilitate avidity-enhanced binding on the fibril
surface. This flexibility raises the selectivity of the antibody for
various Ab species, and increases the affinity for monomeric,
oligomeric, and fibril forms as evidenced by the dissociation
constants (monomers: 17 nmol/L, oligomers: 1.2 nmol/L, fibrils:
0.6 nmol/L)146. In order to clarify the mechanism throughout
gantenerumab elicits the clearance of Ab from the brain, a
phagocytosis assay was performed using brain slices from
deceased patients with AD. In this experiment, the slices were
treated with the antibody and afterwards they were incubated with
primary human macrophages or primary human microglia.
Immunohistochemical analysis showed a concentration-dependent
decrease of Ab load mediated by phagocytic activity and further
lysosomal degradation146. From 2010 to 2016 four phase I clinical
trials were conducted to test the safety, tolerability, pharmacoki-
netics, and pharmacodynamics of gantenerumab in healthy
individuals and patients with AD (https://clinicaltrials.gov;
Identifier: NCT01224106, NCT01636531, NCT02133937,
NCT02882009). One phase I trial evaluated the effect of the
antibody on cognition and functioning and the safety and phar-
macokinetics in volunteers with prodromal AD (https://
clinicaltrials.gov; Identifier: NCT01224106). The volunteers
received subcutaneous injections of either gantenerumab or pla-
cebo and a subgroup of 16 participants underwent PET scanning
to assess brain amyloid. In the group who received a 60 mg dose,
there was a mean change of 15.6% from the baseline relative to
placebo in the levels of Ab cortical, whereas in the group who
received a 200 mg/kg dose it was 35.7%. Two patients in the last
group showed transient and focal areas of inflammation or vaso-
genic edema on MRI scans at sites with the highest level of am-
yloid reduction147. Through this study it was established that there
was a dose-dependent relationship in the reduction of Ab levels
and it laid the foundation for subsequent efficacy studies, where
105 mg/kg to 225 mg/kg doses were selected if ARIA did not
appear147. The development of a formulation for subcutaneous
administration of gantenerumab was one of the most innovative
aspects achieved by the creators of the antibody, since the drugs
approved for the treatment of AD are administered orally and the
vast majority of mAbs are administered intravenously requiring
specialized personnel in a hospital environment. This imposes an
additional strain on the patient and increases costs to the health-
care system.
In 2010, Hoffmann-La Roche started a multicentre, randomized,
double-blind, placebo-controlled phase II study to determine the
efficacy and safety of 105 and 225 mg/kg doses of subcutaneous
gantenerumab every 4 weeks in participants with prodromal AD
over a 2-year period. This trial included patients with gradual

Figure 3 Region of interaction between gantenerumab and Ab. The co-crystal structure of the antibody and Ab (PDB 5CSZ) shows a linearized
conformation formed by amino acids 1e10 of Ab. Gantenerumab exhibits nanomolar binding affinity to Ab40 as revealed by the dissociation
constants for Ab40 fibrils, oligomers, and monomers: 0.6, 1.2, and 17 nmol/L, respectively146,148. X-ray crystallography of gantenerumab Fab with
Ab1-10 monomer reveals that the peptide contacts extensively with histidine (H1), histidine (H2), histidine (H3), and leucine (L1) in the CDR.
However, the complex formed with neutral histidine is energetically unstable and the protonation of histidine (H6) seems to control the interaction
between the antibody and Ab148.
2804
decline in memory function, impaired episodic memory on testing, a
CDR scale global score of 0.5, a memory score of 0.5 or 1 in the same
rating test, and biomarker evidence of AD pathology. Then, in 2012
the study was expanded to a phase II/III trial called SCarlet RoAD,
which was looking to establish the effect on cognition and function
of patients with prodromal AD under treatment for two years with
the option of a two-year extension (https://clinicaltrials.gov; Iden-
tifier: NCT01224106). The primary endpoint was the change from
baseline to week 104 in CDR Sum of Boxes scores and the change in
brain amyloid levels as measured by PET. However, the study was
halted early based on an interim futility analysis; dosing was dis-
continued; and the study was unblinded. No differences were
observed between groups in the CDR Sum of Boxes from baseline,
and for placebo and gantenerumab (105 and 225 mg/kg doses). The
incidence of asymptomatic ARIA increased in a dose- and APOEε4
genotype-dependent manner149. Despite stopping the study, it was
possible to establish dose-dependent effects based on clinical and
biomarker endpoints, thus suggesting that higher dosing with the
antibody was necessary to achieve clinical efficacy. Given the out-
comes of the phase I gantenerumab PET substudy showing the safe
Ab removal from the brain, a second phase III study in mild AD
dementia was initiated. The Marguerite RoAD was a multicenter,
randomized, double-blind, placebo-controlled, parallel-group trial
evaluating the efficacy and safety of subcutaneous gantenerumab
(105 or 225 mg/kg every 4 weeks) in volunteers with mild AD
dementia for 2-years (https://clinicaltrials.gov; Identifier:
NCT02051608). However, the interruption of the SCarlet RoAD
study because the results of the futility analysis, led to a halt in the
recruitment of volunteers for the Marguerite RoAD trial, which
together with the SCarlet RoAD study were switched to open-label
extension studies, with participants titrated up to 1200 mg/kg gan-
tenerumab. These extension studies lowered brain amyloid by an
average of 59 centiloid on florbetapir PET, with half of the 28 par-
ticipants who reached this timepoint falling below the threshold for
Ab positivity, and the rest on trajectory to do so. About one-third of
participants in the extension studies developed ARIA-E and 65% of
these cases were asymptomatic150,151.
In 2012, gantenerumab was evaluated in parallel with sol-
anezumab in a phase II/III trial called Dominantly Inherited
Alzheimer Network Trials Unit (DIAN-TU). This aimed at pre-
venting dementia in people with an inherited autosomal-dominant
mutation in APP, PS1, or PS2 (https://clinicaltrials.gov; Identifier:
NCT01760005). Unfortunately, the DIAN-TU study did not meet
its primary endpoint because none of the antibodies demonstrated
a positive effect on cognition when compared to placebo, and the
cognitive change in the clinically normal group was negligible.
However, a significant reduction on Ab plaques was observed
using the Pittsburgh Compound B PET compared with placebo at
2 and 4 years. Furthermore, the antibody seemed to normalize AD
biomarkers152.
Later in 2018, the phase III GRADUATE 1 and 2 trials began
(https://clinicaltrials.gov; Identifier: NCT03443973). During these
studies, participants with prodromal or mild AD received up to
1020 mg subcutaneous gantenerumab, given as 510 mg/kg every
two weeks for two years. The GRADUATE trials take into
consideration Ab positivity confirmed by CSF or PET; a gradual
and universal dose-titration regimen regardless of APOEε4 status
aiming to reduce Ab plaque levels while minimizing ARIA-E
events153. Then, in 2021 the study was expanded expecting
to reclute 2032 participants until 2024. The volunteers would
receive 510 mg/kg of gantenerumab every two weeks. However,
on November 2022, Roche (a member of the Genentech
Alvaro Barrera-Ocampo
Group since 2009) announced that gantenerumab failed to
slow cognitive decline on the CDR Sum of Boxes in the
GRADUATE trials and informed that it had stopped all gante-
nerumab studies including recently started phase III SKYLINE
trial (https://clinicaltrials.gov; Identifier: NCT05256134). The
latter aimed to evaluate gantenerumab in cognitively unimpaired
people with CSF or PET evidence of brain amyloid154. In spite of
that, Roche has already developed a new formulation of gante-
nerumab based on the “brain shuttle” technology to increase the
antibody’s ability to enter the brain155. This time under the name
of Trontinemab (RO7126209), the brain shuttle gantenerumab
(RG6102)156 is being tested in a phase Ib/IIa trial. This random-
ized, double blind, placebo-controlled, parallel-group study is
aiming to evaluate the safety, tolerability, immunogenicity, phar-
macokinetics, and pharmacodynamics of multiple-ascending
intravenous doses of the new antibody in volunteers with pro-
dromal or mild to moderate AD with confirmed Ab plagued based
on PET scan (https://clinicaltrials.gov; Identifier: NCT04639050).
3.1.2.4. Donanemab. It is a humanized IgG1 mAb directed
against the N-truncated pyroglutamate Ab peptide at position 3
(pGlu3-Ab, AbpE3). This antibody reduces pGlu3-Ab by inhib-
iting the enzyme glutamyl cyclase (QC), thus averting pGlu3-Ab
formation and aggregation in plaques157e160. Pyroglutamate is a
cyclic amino acid found at the N-terminal region of some proteins
and peptides. pGlu3-Ab is formed by the cyclisation of either
glutamine or glutamate by the enzyme GC at amino acid positions
3 or 11 of Ab, following truncation by N-terminal proteases161.
The N-terminal pyroglutamate structure is resistant to degradation
by peptidases, thus increasing peptide stability. In addition,
pGlu3-Ab has been found in the hippocampi and cortices of
patients with AD in greater concentrations than full-length Ab,
suggesting that it is involved in the early neurodegeneration pro-
cess162. Preclinical data has shown that donanemab binds against
either soluble or aggregated conformations of pGlu3-Ab and it has
strong reaction with amyloid plaques, specifically with cored
plaques without causing microhemorrhages in mice160. Histolog-
ical analysis using postmortem brain tissue from Down’s syn-
drome or AD patients demonstrated that this antibody is able to
recognize a subset of about one-third of Ab plaques, and strongly
reacts with Ab plaque core. It also binds to vascular Ab and is able
to detect intraneuronal Ab in a mouse model of AD163.
In 2013, Eli Lilly started a phase I study including 100 people
Ab positive (PET scan) with mild cognitive impairment due to
AD, or mild AD. The aim was to establish the safety, pharma-
cokinetics, and pharmacodynamics of five intravenous doses from
0.1 to 10 mg/kg, infused monthly up to four times, and a single
subcutaneous injection against placebo (https://clinicaltrials.gov;
Identifier: NCT01837641). Only the six participants who received
the highest dose showed an Ab plaque load reduction in the brain
of 40%; in this group, no ARIA-E was found, but two asymp-
tomatic cases of ARIA-H were identified. Worryingly, the anti-
body turned out to be strongly immunogenic causing infusion
reaction with flushing, rash, chills, dizziness, and fever, and anti-
drug antibodies were found in plasma164. Then, in 2015, the
company began a second phase 1 study in people with prodromal
to moderate AD (https://clinicaltrials.gov; Identifier: NCT02
624778). The main outcome was to measure the effect of dona-
nemab on Ab load by using florbetapir PET. In addition, the study
was set to determine blood pharmacokinetics of donanemab, and
auto-antibodies raised against the molecule. For this, 61 partici-
pants were randomized 3:1 to drug or placebo and three dosing
Monoclonal antibodies, aptamers and Alzheimer’s disease
regimens were tested, the first consisting of a single dose of 10,
20, or 40 mg/kg, the second of 10 mg/kg every other week for 24
weeks, and the third of 10 or 20 mg/kg every month for 16
months. Results indicate that the antibody reduced Ab load by an
average of 90e100 centiloids after monthly doses of 10 or
20 mg/kg for 16 months. However, about 25% of the participants
developed ARIA-E, of which only two cases presented symptoms
that resolved when dosing was discontinued165.
Based on the encouraging results from previous studies, Elli
Lilly started in 2017 a series of phase II and III trials called
TRAILBLAZER-ALZ. The first of them was a phase II study aimed
to evaluate safety, tolerability, and efficacy of an 18-month course of
donanemab alone and in combination with the BACE inhibitor
LY3202626 produced by the same company (https://clinicaltrials.
gov; Identifier: NCT03367403). This enrolled participants who
had memory deficits for at least six months and had positive flor-
taucipir PET scans. In this case, donanemab was dosed at 700 mg/kg
monthly for the first three months, then 1400 mg/kg for up to 18
months. The main result was to look for changes in the cognitive
performance of the participants according to different rating scales
(e.g., Integrated AD Rating Scale - iADRS, ADAS-Cog13, CDR
Sum of Boxes, MMSE, ADCS-iADL), as well as Ab and tau PET
and volumetric MRI. In 2018, the administration of the BACE
inhibitor was stopped and early in 2021, the company announced
that donanemab was able to slow the cognitive decline on the iADRS
by 32% compared to placebo at 18 months. The treatment with the
antibody produced an average reduction in Ab plaque by 84 centi-
loids, from 108 at baseline and 66% of the participants who received
the antibody were Ab negative by the end of the trial. Additional
results showed that the treatment decreased the aggregation rate of
NFT in the frontal cortex and other brain areas166. Regarding the
adverse events, at the end from the 272 participants enrolled in the
study, 27% developed ARIA-E, with 6% becoming symptomatic.
Treated participants also had more ARIA-H, small brain bleeds, and
nausea. The results also indicate that 90% of the patients developed
anti-drug antibodies and loss of brain volume measured by MRI
probably because of inflammation166. By the end of 2020, Eli Lilly
began recruiting for TRAILBLAZER-ALZ 2, a phase II study
focused on volunteers who had shown progressive and gradual
memory decline for at least six months (MMSE with scores from 20
to 28) with Ab and tau PET scans (https://clinicaltrials.gov; Iden-
tifier: NCT04437511). The main objective of the trial was to
determine the change in CDR Sum of Boxes after 18 months, whilst
the secondary outcomes included cognitive deficit scores (e.g.,
MMSE, ADAS-Cog13, iADRS, and ADCS-iADL), disease bio-
markers (Ab and tau by PET), volumetric MRI, as well as phar-
macokinetics and anti-donanemab antibodies evaluation. Initially,
the study was set to be developed during early 2024, but the com-
pany decided to extend the study to a phase III trial with 1800
participants. In this case, the main outcome will be to establish
changes in the iADRS based on a disease-progression model.
In August 2021, the phase III TRAILBLAZER-ALZ 3 study
started enrolling cognitively normal volunteers aged 50 to 55 with
increased levels of phosphorylated tau (ptau217). The main goal
of this study is to evaluate the safety and efficacy of donanemab in
participants with preclinical AD. Nine monthly infusions of the
antibody or placebo will be administered, and the individuals will
be monitored every six months. The main goal is to determine the
clinical progression based on a score above zero on the CDR for
two consecutive evaluations. The trial, set to run until 2027, also
2805
aims to establish the steady-state concentration in plasma of the
antibody, the incidence of anti-donanemab antibodies, and a
number of cognitive tests. It is worth mentioning that the assess-
ments and monitoring of the participants are done remotely using
phone or video calls. Drug administration, blood draws
and complementary tests will be done in specialized centres
(https://clinicaltrials.gov; Identifier: NCT05026866). At the end of
2021, Eli Lilly began TRAILBLAZER-ALZ 4, a phase III study
looking to compare donanemab to aducanumab on Ab plaque
clearance in participants with early symptomatic AD. This is an
open-label, parallel-group, 2-arm trial aimed to determine the
number of participants who reach complete plaque clearance after
treatment during every four weeks for 18 months according to
florbetapir PET. Preliminary results indicate that in the first six
months of treatment donanemab eliminated four times more Ab
plaques than aducanumab, whilst adverse events such as ARIA-E
were similar in both groups (https://clinicaltrials.gov; Identifier:
NCT05108922). Another phase III study called TRAILBLAZER-
ALZ 5, started at the end of 2022. The volunteers will receive
monthly infusions of donanemab or placebo, and the change on
the iADRS at 18 months will be the primary outcome expected to
be reached before 2027 (https://clinicaltrials.gov; Identifier:
NCT05508789). Recently, Eli Lilly started the TRAILBLAZER-
ALZ 6 trial, which will investigate different donanemab dosing
regimens and their effect on the frequency and severity of ARIA-E
in adults with early symptomatic AD and explore participant
characteristics that might predict risk of ARIA. The study is
focused on volunteers aged 60 to 85 with gradual and progressive
change in memory function for six months with a MMSE score of
20e28 and Ab PET scan results consistent with the presence of
amyloid pathology (https://clinicaltrials.gov; Identifier:
NCT05738486). Based on the results and the evidence collected in
previous studies, the company is planning to apply for FDA
approval in the next months, this after the application for dona-
nemab’s accelerated approval was rejected at the beginning of
2023 citing insufficient safety data at the moment of the sub-
mission in 2021. Eli Lilly’s antibody slows AD and data suggests
that donanemab may work better than similar drugs already in the
market. However, there is serious concern about the safety of the
patients since the company acknowledges deaths and serious brain
side effects.
The TRAILBLAZER-ALZ clinical trials represent a magnifi-
cent opportunity to advance knowledge about AD, even if the
results are not positive in the end. Donanemab is presented as a
therapeutic alternative with high potential to modify the progres-
sion of AD and, in an ideal scenario, offers patients and their
families the possibility of improving the quality of life by pre-
serving cognitive function and reducing the burden of symptoms
associated with the disease, which would have a positive impact
on the autonomy and well-being of patients. However, the adverse
effects reported by the participants evidence a significant risk that
must be considered, taking into account fundamental ethical
principles such as respect for autonomy and equity in the distri-
bution of risks and benefits. The presence of ARIA-H, small brain
bleeds, and decreased brain volume can have disastrous conse-
quences for the health of the patients, potentially exacerbating the
symptoms of the disease or favoring the appearance of new
complications. Likewise, the formation of anti-donanemab anti-
bodies could affect the efficacy of the treatment and trigger serious
immunological reactions for the individual. Even mild adverse
2806
effects such as nausea should be weighed, as they can affect the
treatment adherence and quality of life of the patient.
3.2. DNA aptamers: An alternative to the immunotherapy for
AD
Nucleic acids can assume complex structures to act as scaffolds of
molecular interaction and create complexes with a great variety of
molecules. This principle was the fundamental basis for the
development of aptamers more than 20 years ago167,168. Aptamers
are single-stranded oligonucleotides (DNA or RNA), with a length
less than 100 base pairs, which have the ability to bind to other
molecules with high affinity and specificity. Currently, a large
number of aptamers can bind several targets, ranging from inor-
ganic molecules to large protein complexes, and whole cells.
Aptamers can be considered nucleotide analogues of antibodies,
but with very low immunogenicity and toxicity. In addition, its
generation is significantly easier and cheaper than the production
of antibodies169.
The discovery of the aptamers is carried out through an iter-
ative selection process called SELEX (Systematic Evolution of
Ligands by EXponential enrichment), in which libraries contain-
ing about 1  1015 oligonucleotides of random sequence are
incubated with the target of interest. The molecules that bind to
the target are separated from those that do not bind. Subsequently,
those oligonucleotides that recognize the target are amplified to
increase the population of interacting molecules. This process is
repeated several times until a group of sequences with high
affinity for the target of interest is obtained170.
These oligonucleotides are a very powerful tool that has
multiple advantages because they can be produced in greater
quantity than the antibodies while preserving the sequence that
encodes them; this translates into a high level of reproducibility at
the time of manufacturing them. Because the generation process is
chemical and not biological, the risk of contamination with bac-
teria and viruses that can occur in the production of antibodies
disappears, reducing the downstream processing costs171. Its small
molecular size (<30 kDa) facilitates access to regions that cannot
be reached by antibodies172. In addition, aptamers can be func-
tionalized and integrated with other technologies to increase their
plasma half-life, promote passage through biological barriers or
interact with a specific cell type169. Advances in aptamer engi-
neering have made it possible that many of the limitations pre-
sented by these molecules have been overcome. Some of the
improvement strategies include modification and optimization to
improve the pharmacokinetic properties and make them resistant
to degradation by nucleases, among others173.
The therapeutic potential of aptamers to treat neurodegenera-
tive diseases such as AD has begun to be explored. Currently,
multiple aptamers have been generated against molecular targets
of this disease. In the case of AD, there are aptamers with high
affinity for the b-secretase enzyme, BACE1; which is involved in
the initial step of Ab production. In this regard, Liang et al.174
discovered the A1 aptamer, which inhibits the activity of
BACE1 with high specificity and reduces the production of Ab.
Other approaches to this disease are focused on inhibiting the
aggregation of Ab and the high toxicity shown by its oligomers. In
2018, Chakravarthy et al.175 by using SELEX developed a number
of DNA aptamers with affinity against Ab40. The authors used the
ELONA-binding assay and Western blot to establish that the
aptamer RNV95 conformed by 39 nucleotides had the capability
to bind to tetrameric and/or pentameric Ab peptide aggregates in
Alvaro Barrera-Ocampo
neuropathologically confirmed AD brain tissue (Fig. 4a). Then, in
2020, Zheng et al.176 generated the Ab7-92-1H1 aptamer aimed to
inhibit the aggregation of both Ab42 monomers and oligomers as
demonstrated by atomic force microscopy and surface plasmon
resonance analysis. This 44-nucleotide aptamer with a Kd of
63.4 nmol/L, effectively avoided the formation of amyloid
aggregates (Fig. 4b). Altogether, these results show that aptamers
have the potential to modify the course of AD by binding with
high affinity and selectivity to Ab species in order to inhibit its
aggregation and thus alter/delay the neurodegenerative process of
this disease. In addition, these proof-of-concept studies in aptamer
technology continue to reveal their promising functionality and
immense therapeutic potential. This unique class of biomolecules
not only possesses the flexibility of small molecules, but also has
the high specificity of antibodies, allowing targeted disease ther-
apy that cannot be achieved with small drug molecules. The
particular advantages of aptamers, specially the next-generation
aptamer-based therapeutics with superior biological functions
and pharmacokinetic profiles are highly anticipated and could fill
an important niche market. Furthermore, the technological
advancements in synthesis and formulation, and the inclusion of
artificial intelligence (AI) and machine learning (ML) in the
SELEX process, provide a strong impetus for the development of
this promising class of therapeutics.
3.2.1. DNA aptamers: Clinical implications, ethical
considerations, and comparison with traditional immunotherapy
DNA aptamers show significant promise in the treatment of
neurodegenerative diseases such as AD, but the clinical implica-
tions, ethical considerations, and comparative advantages with
traditional immunotherapy need to be considered. As this tech-
nology evolves, it is essential to ethically and equitably address
the challenges and opportunities it presents to ensure its respon-
sible and beneficial use in the clinical setting.
When analysing the clinical implications of aptamers, it is
important to take into account aspects such as specificity and
selectivity, versatility in design and accelerated development, and
lower immunogenic capacity. DNA aptamers can be designed to be
highly specific and selective toward their therapeutic targets. This
could lead to more precise treatments by avoiding unwanted side
effects and minimizing interference with other cellular functions.
Likewise, the ability to design specific aptamers for a wide range of
targets makes them versatile in the treatment of various neurode-
generative diseases, including AD. This could allow the develop-
ment of personalized therapies adapted to the individual needs of
patients. Aptamer technology enables rapid design and efficient
production of therapeutic agents, which could accelerate the
development of new treatments and reduce the time to market.
Additionally, compared to some traditional treatments, DNA
aptamers may have fewer adverse immunological reactions, which
could improve the tolerability and safety of the treatment. However,
it is essential to carry out exhaustive preclinical studies in order to
understand in depth the behaviour and effect of aptamers on the cells
and tissues to which they are directed. This is in order to guarantee
their safety once they are used on human beings.
Regarding the ethical considerations of using DNA aptamers
for the treatment of AD, it is crucial to ensure that patients are
fully informed about the nature of aptamers, their potential ben-
efits, and their risks before participating in clinical trials. Trans-
parency in communication and informed consent are fundamental
ethical principles. Since aptamers are an emerging technology,
patient safety must be prioritized. Continuous monitoring during
Monoclonal antibodies, aptamers and Alzheimer’s disease 2807

Figure 4 Interaction of the aptamers RNV95 and Ab7-92-1H1 with Ab. a) Molecular docking analysis showing the interaction between the
Ab40 peptide (light blue) and the RNV95 aptamer (ocher and orange) published by Chakravarthy et al.175. In the analysis, it is observed that the
most notable interactions between both molecules occur due to the formation of hydrophobic interactions (black dotted lines), salt bridges (yellow
dotted lines) and hydrogen bonds (blue lines). b) Molecular docking analysis showing the interaction between the Ab42 peptide (light blue) and the
Ab7-92-1H1 aptamer (ocher and orange) published by Zheng et al.176. The analysis reveals that bindings that contribute the most to the interaction
between both biomolecules include pi-stacking interactions (green lines), salt bridges (yellow dotted lines) and hydrogen bonds (blue lines).
Molecular docking analyses were made using the following software and web platforms: Mfold, RNAfold, RNAComposer, VMD, Chimera X,
Yasara, HADDOCK, PLIP, and PDBePISA177e185.

clinical trials and long-term data collection are essential to eval-
uate and mitigate any unexpected adverse effects. The issue of
equity in access to aptamer-based treatments also needs to be
addressed, especially given that scientific advances often face
challenges in global distribution and accessibility for different
communities.
When comparing traditional immune therapy and aptamers, it
is necessary to analyse in detail critical aspects of each technol-
ogy, such as specificity and selectivity, structural complexity and
development, production and costs, pharmaceutical forms and
routes of administration, and immunogenicity (Fig. 5). Regarding
specificity and selectivity, both approaches, aptamers and anti-
bodies, can be designed to be highly specific. However, the
versatility of aptamers in terms of structural design may allow for
greater selectivity for specific targets. On the other hand, the
structural complexity of antibodies can be an advantage or
disadvantage, depending on the context. While the fixed structure
of antibodies can confer stability, the structural flexibility of
aptamers allows for more specific and rapid design.
Aptamer production can be more cost-effective and faster
compared to antibody production, which often involves the use of
live cells in culture. This could influence the accessibility and cost
of treatments. Likewise, aptamers can be designed to be admin-
istered by various routes, including oral and topical, which could
facilitate administration compared to some antibodies that are
often administered intravenously. Furthermore, while some anti-
bodies can induce immune responses, aptamers tend to be less
immunogenic. This could reduce the risk of adverse reactions
from the immune system, thus being safer for patients.
3.2.2. The impact of AI and ML on the development DNA
aptamers
The combination of AI and machine learning ML has the potential
to transform the development of DNA aptamers for the treatment
of neurodegenerative diseases such as AD. These technologies can
accelerate the process of aptamer design, optimization, formula-
tion, delivery, and customization, leading to more effective and
precise therapeutic approaches to address the complexity of these
diseases. In recent years there has been a resurgence in the number
of publications related to the application of AI and ML to the
discovery of aptamers for various applications, thus demonstrating
the enormous potential that exists when combining these
technologies.
In 2021, a methodology using ML-guided Particle Display was
published. This was used to develop, validate and improve exist-
ing experimental candidates, discover new aptamers, and improve
therapeutic characteristics. The authors were able to evaluate more
than 187.000 aptamers and automatically identify candidates with
2808
Figure 5 Advantages, disadvantages and similarities between Aptamers and mAbs technology. Each type of technology has advantages, and
many of these are similar between the two. However, it is important to highlight that there are also fundamental differences between aptamers and
mAbs in terms of structure, production method, and some characteristic properties that may represent a disadvantage when selecting between
these types of biomolecules.
minimal length and high affinity for the target186. More recently,
Perez et al.187 published a ML algorithm capable of predicting
aptamers from conserved primary and secondary structures, taking
into account parameters such as sequence abundance, stability,
and structure. This algorithm represents an alternative way to
select aptamers from extensive libraries bases on patterns, and it
could help shorten the discovery of new molecules. However,
despite these advances, to date, no work has yet been published
that applies AI and ML to the discovery of aptamers directed
against Ab, tau, or other proteins related to neurodegenerative
diseases.
The identification and design of specific aptamers for AD-
associated proteins such as Ab and tau can greatly benefit from the
power of ML algorithms. AI models can analyse large molecular
data sets to predict and optimize aptamer sequences that have
improved affinity and specificity for desired therapeutic targets. In
this way, the discovery of aptamers can be accelerated, reducing
time and cost. Currently, obtaining aptamers using the SELEX
method takes around 3 months and has an approximate cost of
USD 8000. It is possible that in the short term, through the use of
AI and ML, the aptamer selection process could be reduced to
weeks or days, and the cost of obtaining them could be less than
USD 1000. In this context, it is possible to imagine a scenario
where the crystalline structure of monomeric or oligomeric Ab is
presented to the machine. This, in turn, will iterate through
thousands of random DNA sequences and the target protein. The
result will be candidates with a high probability of success that
can subsequently be used to generate aptamers with optimized
physicochemical properties. Thus, minimizing the number of
experimental trials required for their validation.
The implementation of AI and ML in the discovery of DNA
aptamers can also revolutionise the formulation process and the
Alvaro Barrera-Ocampo
design of pharmaceutical forms of administration. In this case,
the algorithms will analyse, for example, the compatibility and
stability of the formulation components with the aptamers.
Additionally, generative AI could be used to engineer nanometric
dosing systems (e.g., liposomes, dendrimers, polymeric nano-
particles, polymeric micelles, and virus-based nanoparticles) to
target the release of the aptamers in tissues or cells of interest. In
this way, it would be possible to reduce potential adverse effects in
other organs and help establish appropriate doses based on critical
pharmacokinetic parameters such as the distribution, metabolism,
and elimination of the biomolecule and the selected pharmaceu-
tical form.
In the future, AI and ML could also help personalise patient
treatment by analysing clinical, genetic, and molecular data from
patients with AD and other neurodegenerative diseases. This
would allow aptamers to be tailored to address the unique char-
acteristics of the disease in each individual, improving efficacy
and reducing side effects.
4. Concluding remarks and future perspectives
Current drug therapy has limited effects on disease progression
and often has side effects such as nausea, diarrhoea or dizziness
that are bothersome to patients. AD is a complex entity in which a
large number of genomic, epigenetic, biochemical and cellular
events converge. Therefore, it is unlikely that monotherapy offers
any option for a cure, other than slowing the degree and rate of
deterioration of brains with the disease.
The era of vaccines and mAbs for the treatment of AD and
other neurodegenerative diseases is here to stay, and similar bio-
molecules are expected to be approved in the coming years, with
notable improvements in their pharmacodynamic and
Monoclonal antibodies, aptamers and Alzheimer’s disease
pharmacokinetic characteristics. It is very likely that in the next
few years we will see mAbs conjugated with other drugs in the
market as warheads capable of attacking several targets simulta-
neously. Nonetheless, despite all the advances made and the new
molecules discovered with this technology, the risk of excessive
autoimmune or inflammatory reactions, and the interindividual
variability in this response could negatively affect patient’s health,
even causing death. Therefore, to enhance the safety of new
therapies, it is paramount to fully understand AD at its core and
discover early diagnostic biomarkers that allow targeted and
personalized therapy.
Nucleic acid-based compounds such as aptamers offer a viable
and interesting alternative to mAbs due to their easy production.
Although aptamers exhibit high specificity, their long-term sta-
bility and efficacy in a complex biological environment have yet
to be fully validated. Furthermore, it is necessary to comprehen-
sively evaluate the risks of this technology, such as the possibility
of triggering adverse immunological responses. Likewise, it is
essential to address these risks through rigorous preclinical and
clinical studies, as well as continuous safety monitoring in the
implementation of aptamer-based treatments. This in order to
achieve a careful balance between therapeutic efficacy and the
management of possible risks to ensure the safety and well-being
of patients.
Aptamers offer significant promise in the treatment of neuro-
degenerative diseases. On the one hand, they present advantages
over other technologies thanks to flexibility and optimization in
their design and the possibility of producing fewer adverse effects
due to their selectivity and specificity. On the other hand, their
successful implementation will require carefully addressing
challenges such as stability and pharmacokinetic behaviour, the
complexity of the biological environment that can expose them to
degradation or favour the appearance of adverse immunological
reactions, large-scale production, and the clinical validation
necessary to demonstrate their safety and efficacy in patients
under real disease conditions. Aptamers still have a long way to go
in terms of preclinical and clinical studies, but it is possible that in
the future these biomolecules will complement the therapeutic
arsenal for the treatment of AD and other neurodegenerative
diseases.
The future panorama of AD is marked by the combination of
advances in early diagnosis, molecular therapies, immunotherapy,
and emerging technologies such as AI that are transforming the
paradigm of how this disease is addressed. It is necessary to
explore the disease in a more effective way through multimodal
approaches that generate therapies that not only focus on a single
cellular target but on multiple aspects of the pathological process.
In this way, more solid and lasting results could be offered.
Likewise, the application of AI and Big Data analysis will revo-
lutionize the understanding of the cellular and molecular phe-
nomena that occur in neurodegenerative diseases. Advanced
algorithms will be able to analyse large data sets obtained in
preclinical and clinical studies and identify complex patterns to
assist in early diagnosis, prediction of disease progression, and the
development of more effective and safer treatments. This
convergence of emerging technologies has the potential to accel-
erate discoveries and improve our understanding of the mecha-
nisms underlying AD. However, although the future of
understanding and treating AD is promising, it is not without
challenges. The complexity of the human brain and the variability
between individuals pose significant obstacles. Additionally, the
need to address ethical issues related to data privacy, informed
2809
consent, and equity in access to innovative treatments will become
more pressing.
Acknowledgments
AB-O was funded by Ministerio de Ciencia, Tecnologı́a e Inno-
vación de Colombia (Grants No. CT 775-2018, CT 80740-460-
2021 and CT 86980-460-2021, Colombia) and Universidad
Icesi e Convocatoria Interna (Grant No. CA041370, Colombia).
The author thanks Mateo Fotich (Department of Pharmaceutical
and Chemical Sciences, School of Engineering, Design and
Applied Sciences, ICESI University. Cali, Colombia) and Victoria
Robles (Department of Pharmaceutical and Chemical Sciences,
School of Engineering, Design and Applied Sciences, ICESI
University, Cali, Colombia) for preparing the figures on the mo-
lecular docking of the aptamers.
Author contributions
Alvaro Barrera-Ocampo carried out the bibliographic review,
analysis and interpretation of results necessary for the preparation
of the manuscript. Additionally, he wrote the entire document. The
author has approved the final article should be true and included in
the disclosure.
Conflicts of interest
The author declares no commercial interest that could represent a
conflict of interest.
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