Method to treat perioperative neurocognitive disorder

Abstract

The invention relates to a method of treating perioperative neurocognitive disorders (PND) in a patient involving administering to the patient a SAA peptide that decreases serum amyloid A in the patient. In particular, the method involves administering SDKYFHARGNYDAAKR (SEQ ID NO.: 2). Exemplary PNDs include postoperative delirium, delayed neurocognitive recovery, or postoperative neurocognitive disorder.

Description

[0001] METHOD TO TREAT PERIOPERATIVE NEUROCOGNITIVE DISORDER

[0002] SEQUENCE LISTING

[0003] This application contains a Sequence Listing which has been filed electronically in Extensible Markup Language (XML) format and is hereby incorporated by reference in its entirety. Said XML copy, created on December 23, 2024, is named 51807-002W02_Sequence_Listing_12_23_24.XML and is 7,960 bytes in size.

[0004] CROSS-REFERENCE TO RELATED APPLICATIONS

[0005] This application claims benefit of U.S. Provisional Application No. 63 / 613,108, filed on December 21 , 2023, the contents of which are incorporated herein by reference in their entirety.

[0006] STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH

[0007] This invention was made with government support under 2022A006603 awarded by the National Institute on Aging. The government has certain rights in the invention.

[0008] FIELD OF THE INVENTION

[0009] The invention is in the field of treating neurocognitive disorders, specifically perioperative neurocognitive disorder.

[0010] BACKGROUND OF THE INVENTION

[0011] Perioperative neurocognitive disorders (PND) encompass postoperative delirium, delayed neurocognitive recovery (dNCR), and postoperative neurocognitive disorder (PNCD), manifesting within 7 days, 8 to 30 days, and 1 to 12 months post-anesthesia / surgery, respectively. PND not only heightens morbidity, mortality, and care costs but also correlates with the development of Alzheimer’s Disease (AD) and AD- related dementias (AD / ADRD). The etiology of PND, however, remains largely elusive, posing a significant impediment to further research, particularly investigations aimed at targeted interventions for PND prevention or treatment.

[0012] Serum amyloid A (SAA) encompasses a family of proteins encoded by several different genes. In humans, the SAA proteins are encoded by two inducible genes, SAA1 and SAA2, and a constitutively expressed gene, SAA4. In mice, an additional gene, SAA3, encodes an inducible form of SAA with high structural similarities to other SAA proteins. Inducible forms of SAA, are proteins of 103-104 amino acids consisting of four alpha-helices that bundle together to form hexamers. Hepatocytes, macrophages, and colon epithelial cells produce SAA proteins upon stimulation with infectious and inflammatory factors such as LPS, IL-1 p, and IL-6. Secreted SAA proteins function in a paracrine manner in inflammatory tissues and bind to high-density lipoprotein (HDL) in the plasma. In addition to these properties, SAA is a precursor of amyloid A that deposits to major organs and causes secondary amyloidosis. In vitro studies have shown that SAA stimulates a variety of leukocytes to secrete cytokines including IL-1 , IL-6, and TNFa and recently the inducible forms of SAA have been identified as a mediator of local effector Th17 response driven by gut microbiome. The majority of the published reports on the proinflammatory activities of SAA were generated using recombinant human SAA that is a hybrid of the SAA1 and SAA2 isoforms expressed in Escherichia coli (Cheng et al. Serum amyloid A promotes LPS clearance and suppresses LPS-induced inflammation and tissue injury. EMBO Rep. Oct 2018;19(10)).

[0013] To date, there have been no targeted drugs to treat PND. Accordingly, such drugs are needed in the art.

[0014] SUMMARY OF THE INVENTION

[0015] Methods of treating perioperative neurocognitive disorders (PND) in a patient are provided. In one method, a peptide that decreases the level of serum amyloid A (SAA) (e.g., human SAA) is administered. In this method, the peptide is selected from the group consisting of:

[0016] RSFFSFLGEAFDGARDMWRAYSDMREA (SEQ IN NO.: 1 ),

[0017] SDKYFHARGNYDAAKR (SEQ ID NO.: 2),

[0018] SDKYFNARGNYDAAKR (SEQ ID NO.: 3),

[0019] GGVWAAEAISDARENIQRFF (SEQ ID NO.: 4), AEDSLADQAANEWGRS (SEQ ID NO.: 5), and GKDPNHFRPAGLPEKY (SEQ ID NO: 6).

[0020] In particular, the peptide for administration is SDKYFHARGNYDAAKR (SEQ ID NO.: 2). The disclosed peptides are administered to a human for treating or preventing a PCD as described herein.

[0021] In another aspect, the invention features a method of treating or preventing PND in a patient undergoing anesthesia comprising administering thermotherapy to the patient following the anesthesia. In some embodiments, the method involves elevating the body temperature of the patient from 37 °C to 38.5 °C for 1 hour, repeated four times with 30 minutes break in between following the anesthesia.

[0022] In any of the aforementioned aspects, the PND is selected from postoperative delirium, delayed neurocognitive recovery (dNCR), and postoperative neurocognitive disorder (PNCD).

[0023] In another aspect, the invention features, a peptide including a modified human serum amyloid A (MKLLTGLVFCSLVLGVSSRSFFSFLGEAFDGARDMWRAYSDMREANYIGSDKYFHARGNYDAAKRGPG GVWAAEAISDAR ENIQRFFGHGAEDSLADQAANEWGRSGKDPNHFRPAGLPEKY, SEQ ID NO. 7) or a fragment thereof. In some embodiments, the fragment is ANYIGSDKYFHARGNYDAAKRGPGGV (SEQ ID NO: 8). In some embodiments, the fragment is SEQ ID NO.: 2. In still other embodiments, the peptide is PEGylated.

[0024] In another aspect, the invention features a peptide consisting essentially of SEQ ID NO: 8 or a fragment thereof. In some embodiments, the fragment is SEQ ID NO: 2. In still other embodiments, the peptide is modified.

[0025] In still another aspect, the invention features composition including any of the above peptides or fragments thereof.

[0026] In yet another aspect, the invention features a method of treating a patient having PND, the method administering any of the above-described peptides. In preferred embodiments, the peptide is SEQ ID NO:2). In some embodiments, the PND is postoperative delirium, delayed neurocog nitive recovery (dNCR), or postoperative neurocognitive disorder (PNCD).

[0027] In any of the aforementioned methods, the patient is a human

[0028] Other features and advantages of the invention will be apparent from the following detailed description and figures, and from the claims.

[0029] Definitions

[0030] The terms “treating” or “treatment,” when used herein in reference to a patient, are used to mean ameliorating at least one symptom of a condition or disease in a subject having the condition or disease, e.g., a perioperative neurocognitive disorder (PND) such as postoperative delirium, dNCR, or PNCD, as compared with an equivalent untreated control. In some embodiments, delirium symptoms are decreased in patients receiving treatment as well as symptoms such as agitation, confusion, difficulty communicating, memory loss, mood or behavioral changes, as well as impairment of learning and memory. In other embodiments, a patient receiving treatment demonstrates a reduction in symptoms (e.g., a decrease in serum amyloid A levels is at least 50% (e.g., at least 50%, 60%, 80%, 90%, 95%, or 100%), as measured in accordance with methods recognized in the art as suitable for assessing the symptom (e.g., serum amyloid A levels).

[0031] Modifications

[0032] Peptides described herein may be modified (e.g., at the N-terminus or the C-terminus). The accordingly may include amino acids with side chains amenable to modification, for example, through ester or thioester formation (e.g., Ser, Thr, Tyr, Glu, and Asp), amide formation (e.g., Lys, Glu, and Asp), ether formation (e.g., Ser, Thr, Cys), or amine formation (e.g., Lys). For example, the polypeptides of the invention can be modified to include polyethylene glycol (PEG).

[0033] In some embodiments, the peptide may be PEGylated, wherein one or more polyethylene glycol (PEG) polymers are covalently attached to the peptide. PEG polymers of different sizes (e.g., from about 500 D to about 300,000 D) and shapes (e.g., linear or branched) have been known and widely used in the field. The polymers useful for the present invention may be obtained commercially (e.g., from Nippon Oil and Fats; Nektar Therapeutics; Creative PEGWorks) or prepared from commercially-available starting materials using conventional chemical procedures.

[0034] Fragments

[0035] In some embodiments, the peptide is a fragment of a reference peptide. For example, the peptide may include a contiguous portion of the reference peptide (e.g., 5-10 contiguous amino acids, 10-20 contiguous amino acids, 20-30 contiguous amino acids, 30-40 contiguous amino acids, 40-50 contiguous amino acids, 50-60 contiguous amino acids, 60-70 contiguous amino acids, 70-80 contiguous amino acids, 80-90 contiguous amino acids, 90-100 contiguous amino acids, 100-110 contiguous amino acids, or 110-120 contiguous amino acids of the reference peptide).

[0036] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Methods and materials are described herein for use in the present invention; other, suitable methods and materials known in the art can also be used. The materials, methods, and examples are illustrative only and not intended to be limiting. All publications, patent applications, patents, sequences, database entries, and other references mentioned herein are incorporated by reference in their entirety. In case of conflict, the present specification, including definitions, will control.

[0037] BRIEF DESCRIPTION OF THE DRAWINGS

[0038] The patent or application file contains at least one drawing executed in color. Copies of this patent or patent application with color drawings will be provided by the Office upon request and payment of the necessary fee.

[0039] Figure 1. Anesthesia / surgery increases the levels of SAA in aged mice. a. Heatmaps of the differences in plasma protein levels between sham and A / S condition in aged mice ( n = 4 per group, P<0.05). Protein levels are displayed as colors ranging from green (low level) to red (high level), b. Volcano plot shows the down- and up-regulated levels of proteins in sham versus A / S condition (n = 4 per group). Log2 (FC=1.5) and adjusted P <0.05 were used as cut off values for the significance, c. Plasma levels of SAA were measured by ELISA among different groups. A / S, anesthesia / surgery; SAA, serum amyloid A.

[0040] Figure 2. Thermotherapy rescues the A / S-induced changes in aged mice. Thermotherapy mitigated the A / S-induced delirium-like behaviors, demonstrated as composite Z score, in aged mice (a), increases in the levels of Tau-PT217 in cortex (b) and plasma (c). Thermotherapy also attenuated the A / S-induced increases in SAA levels in liver (d) and cortex (e) of aged mice. A / S, anesthesia / surgery; SAA, serum amyloid A. Figure 3. SAA binds to and interacts with Tau or Tau-PT217. Co-immunoprecipitation showed the binding between SAA and Tau (a) or Tau-PT217 (b) in cortex of aged mice. Nanobeam at single molecular level demonstrated the interaction between SAA and Tau (c) or Tau-PT217 peptide (d). The shifting of spectrum wavelength (AA) indicates the interaction and binding affinity between SAA and Tau or Tau-P217 peptide.

[0041] Figure 4. SAA prevents the entrance of Tau-PT217 into hepatocytes, a. PET scan showed A / S decreased Tau-PT217 levels in liver of aged mice. b. A / S induced time-dependent decreases in Tau-PT217 levels in liver of aged mice. c. Single cell PET scan demonstrated that SAA prevented the entrance of Tau- PT217 into hepatic cells, d. Confocal fluorescent micrographs illustrated that SAA prevented the entrance of Tau-PT217 into hepatic cells.

[0042] Figure. 5. The hypothesized pathway. A / S increased blood Tau-P217 and SAA levels in aged mice. SAA binds to Tau-P217 in the blood that prevents the internalization of Tau-P217 by the liver, resulting in the accumulation of blood and brain Tau-P217 levels, leading to postoperative delirium-like behavior in age mice. Thermotherapy or SAA peptides can release of Tau-PT217 previously bound to SAA, enabling increased entry of Tau-PT217 into hepatic cells for metabolism and degradation. Consequently, this process led to decreased blood and brain levels of Tau-PT217 and the inhibition of delirium-like behavior in the aged mice.

[0043] Figure 6. The peptide of SAA1 alleviates the anesthesia / surgery-induced delirium and elevation of Tau-PT217 in aged mice. a. Human SAA1 sequence of amino acid. The amino acid sequence of specific SAA1 peptide is also demonstrated, b. Treatment with SAA1 peptide2-1 mitigates the anesthesia / surgery- induced delirium-like behavior, c. The changes in the individual behavior in the aged mice following anesthesia / surgery and SAA1 administration, d. Immunoblotting analysis demonstrates that SAA1 peptide2-1 mitigates the anesthesia / surgery-induced elevation of Tau-PT217 levels in the cortex of aged mice compared to control condition. The quantification of the Western blot shows that the SAA1 peptide2- 1 decreases the anesthesia / surgery-induce elevation of the ratios of Tau-PT217 to GAPDH (e) and Tau- PT217 to Tau (f). Two-way ANOVA was used to analyze the data in b, e, and f.

[0044] Figure 7. SAA1 peptide2-1 potentiates the entrance of Tau-PT217 into hepatic cell. a. Immunoblotting analysis demonstrates that SAA1 peptide2-1 mitigates the anesthesia / surgery-induced reduction in Tau-PT217 in liver tissues of aged mice compared to scramble peptide, b. Quantification of the Western blot shows that the treatment with SAA1 peptide2-1 mitigates the anesthesia / surgery-induced reduction in the ratio of Tau-PT217 to p-actin compared to scramble peptide. SAA1 peptide2-1 has more robust effects in decreasing the binding between SAA1 and Tau-PT217 compared to other SAA1 peptide (c and d). e. SAA1 inhibits the entrance of Tau-PT217 into hepatic cell (top panel versus middle panel). However, the treatment of SAA1 peptide2-1 mitigates the effects of SAA in inhibiting the entrance of Tau- PT217 into hepatic cells (bottom panel versus middle panel). One-way ANOVA was used to analyze the data in d.

[0045] DETAILED DESCRIPTION OF THE INVENTION

[0046] We have uncovered a connection between elevated blood phosphorylated Tau levels, especially Tau phosphorylated at threonine 217 (Tau-PT217), anesthesia / surgery, and the onset of PND in patients, along with PND-like behavior in rodents. Serum amyloid A (SAA), an acute-phase protein synthesized primarily by the liver, features prominently in our findings. Our investigations indicate that anesthesia / surgery induces an increase in both blood and brain levels of SAA and Tau-PT217, accompanied by PND-like behavior in mice.

[0047] Our data indicates that SAA may bind to Tau-PT217 in the bloodstream, preventing its entry into hepatic cells for metabolism and degradation. Additionally, elevations in body temperature have been associated with reductions in both SAA and Tau-PT217 levels, correlating with the amelioration of PND-like behavior in mice. Consequently, SAA can be targeted for the prevention or treatment of PND by reducing Tau-PT217 levels. Specifically, decreasing SAA levels by either increasing higher body temperature or by administration of specific peptides that decrease SAA levels, or both, will result in the reduction of Tau- PT217 levels and the mitigation of PND.

[0048] It will be appreciated to those skilled in the art that the invention can be performed within a wide range of equivalent parameters of composition, concentration, modes of administration, and conditions without departing from the spirit or scope of the invention or any embodiment thereof. The following examples are meant to illustrate the invention. They are not meant to limit the invention in any way.

[0049] EXAMPLE 1 : PEPTIDE ADMINISTRATION

[0050] The method of treating or preventing PND includes, in this example, administering a peptide that decreases SAA levels in the patient. In a preferred embodiment, the peptide is a truncated SAA peptide selected from:

[0051] RSFFSFLGEAFDGARDMWRAYSDMREA,

[0052] SDKYFHARGNYDAAKR,

[0053] SDKYFNARGNYDAAKR,

[0054] GGVWAAEAISDARENIQRFF,

[0055] AEDSLADQAANEWGRS, and GKDPNHFRPAGLPEKY.

[0056] The peptide can be administered to the patient (e.g., a human) by any available route of administration. See for example, Brown et al, Nature Reviews Materials 5; 127-148 (2020); Brayden et al, Advanced Drug Delivery Reviews 157; 2-16 (2020); Kirkby et al, Pharmaceutical Research 37 (117) (2020); Xie et al, Front. Pharmacol. 11 ; 20 May 2020 and van den Berg et al, Journal of Controlled Release 331 ; 121 -141 (2021 ). For administration, the peptide can be used in the manufacture of a medicament, generally by being formulated in an appropriate carrier or excipient such as, e.g., physiological saline, and administered through an appropriate route of administration (e.g., parenteral (e.g., subcutaneous, intravenous, intramuscular, intraperitoneal), intranasal, transpulmonary, transdermal, transmucosal, or oral administration). An effective amount of the peptide is typically present in the medicament. For example, a typical dosage would be 1 ng to 10 mg of the peptide, e.g., per kg body weight, e.g., per day.

[0057] In another aspect the invention encompasses a method of treating or preventing PND in a patient undergoing anesthesia comprising administering thermotherapy to the patient following the anesthesia. In this method the thermotherapy includes elevating the body temperature of the patient from 37 °C to 38.5 °C for 1 hour, repeated four times with 30 minutes break in between following the anesthesia.

[0058] The PND being treated in either method is postoperative delirium, delayed neurocognitive recovery (dNCR), or postoperative neurocognitive disorder (PNCD).

[0059] EXAMPLE 2: THERMOTHERAPY

[0060] We used aged (18-months-old) wild-type (WT) C57BL / 6J female mice obtained from the National Institute on Aging (Bethesda, MD). Mice in the anesthesia / surgery group underwent a simple laparotomy under isoflurane anesthesia, as per established methods with a modification involving the use of 40% oxygen (Lu et al. Blood tau-PT217 contributes to the anesthesia / surgery-induced delirium-like behavior in aged mice. Alzheimers Dement. May 30, 2023). The assessment of POD-like behavior was conducted using the Confusion Assessment Method (CAM) in mice (Peng et al. Battery of behavioral tests in mice to study postoperative delirium. Scientific reports. 2016;6:29874).

[0061] Our investigation into the effects of anesthesia / surgery on blood proteins in aged mice utilized proteomics. Thermotherapy was administered by elevating the body temperature of aged mice from 37 °C to 38.5 °C for 1 hour, repeated four times with 30 minutes break in between following the anesthesia / surgery. Subsequently, we evaluated the effects of thermotherapy on blood Tau-PT217 levels by using nanoneedle (Lu et al. Blood tau-PT217 contributes to the anesthesia / surgery-induced delirium-like behavior in aged mice. Alzheimers Dement. May 30, 2023). To decipher the underlying mechanisms, we employed various techniques, including whole body and single-cell PET imaging, nanobeam technology, coimmunoprecipitation, hepatic cellular Tau trafficking assay, and others. These methodologies elucidated how thermotherapy effectively reduced blood Tau-PT217 levels and mitigated POD-like behavior in the aged mice.

[0062] Results: In our proteomics study, we observed a significant rise in blood levels of serum amyloid A (SAA), an acute-phase inflammation-related protein primarily synthesized by the liver, following anesthesia / surgery. This increase was corroborated through enzyme-linked immunosorbent assay (Figure 1). Subsequently, the thermotherapy intervention demonstrated its efficacy in mitigating the anesthesia / surgery-induced elevations in both SAA and Tau-PT217 levels in the blood of aged mice. Furthermore, the thermotherapy intervention proved effective in alleviating the POD-like behavior induced by anesthesia / surgery in the aged mice (Figure 2). Mechanistically, the data revealed that SAA interacted with Tau-PT217, as evidenced by co-immunoprecipitation at the protein level and nanobeam analysis at the single molecular level (Figure 3). Moreover, the investigation showed that SAA prevents the entry of Tau-PT217 into hepatic cells, as determined by PET imaging and a single cellular model (Figure 4). These mechanistic insights provide a foundation for understanding how thermotherapy can modulate the levels of Tau-PT217 and SAA, ultimately mitigating the POD-like behavior induced by anesthesia / surgery in aged mice. SAA1 peptide2-1 (SDKYFHARGNYDAAKR; SEQ ID NO:2) of SAA1 (SEQ ID NO.: 7) was found to alleviate anesthesia / surgery-induced delirium and elevation of Tau-PT217 in aged mice (Figure 6). Furthermore, the SAA1 peptide2-1 (SEQ ID NO.: 2) potentiated the entrance of Tau-PT217 into hepatic cell (Figure 7).

[0063] Conclusions: The therapeutic impact of thermotherapy on POD-like behavior in aged mice was attributed to the reduction in blood levels of serum amyloid A (SAA). This reduction facilitated the release of Tau- PT217 previously bound to SAA, enabling increased entry of Tau-PT217 into hepatic cells for metabolism and degradation. Consequently, this process led to decreased blood levels of Tau-PT217 and the inhibition of POD-like behavior in the aged mice (Figure 5). Thus, thermotherapy can prevent and / or treat postoperative delirium by specifically targeting the interaction between Tau-PT217 and SAA in the bloodstream. Finally, the SAA peptide (SDKYFHARGNYDAAKR) has been shown to mitigate the postoperative delirium-like behavior in mice and the anesthesia / surgery-induced increase in the levels of Tau-PT217 in cortex of mice (Figure 6). Mechanistically, the SAA peptide promote the entrance of Tau- PT217 into hepatic cells (Figure 7).

[0064] OTHER EMBODIMENTS

[0065] While the invention has been described in connection with specific embodiments thereof, it will be understood that it is capable of further modifications and this application is intended to cover any variations, uses, or adaptations of the invention following, in general, the principles of the invention and including such departures from the present disclosure come within known or customary practice within the art to which the invention pertains and may be applied to the essential features hereinbefore set forth.

[0066] All publications, patents, and patent applications are herein incorporated by reference in their entirety to the same extent as if each individual publication, patent, or patent application was specifically and individually indicated to be incorporated by reference in its entirety.

[0067] Other embodiments are within the following claims.

[0068] What is claimed is:

Claims

CLAIMS1 . A method of treating a perioperative neurocognitive disorder (PND) in a patient comprising administering to the patient a SAA peptide that decreases serum amyloid A in the patient.

2. The method of claim 1 , wherein the peptide is SDKYFHARGNYDAAKR (SEQ ID NO.: 2).

3. The method of claim 1 wherein the peptide is selected from the group consisting of:RSFFSFLGEAFDGARDMWRAYSDMREA (SEQ ID NO.:1 ), SDKYFHARGNYDAAKR (SEQ ID NO.: 2), SDKYFNARGNYDAAKR (SEQ ID NO.:3), GGVWAAEAISDARENIQRFF (SEQ ID NO.: 4), AEDSLADQAANEWGRS (SEQ ID NO.: 5), and GKDPNHFRPAGLPEKY (SEQ ID NO.: 6).

4. A method of treating or preventing PND in a patient undergoing anesthesia comprising administering thermotherapy to the patient following the anesthesia.

5. The method of claim 4, wherein the method comprises elevating the body temperature of the patient from 37 °C to 38.5 °C for 1 hour, repeated four times with 30 minutes break in between following the anesthesia.

6. The method of any of claims 1 -4, wherein the PND is selected from postoperative delirium, delayed neurocognitive recovery (dNCR), and postoperative neurocognitive disorder (PNCD).

7. A peptide comprising a modified human Serum amyloid A (MKLLTGLVFCSLVLGVSSRSFFSFLGEAFDGARDMWRAYSDMREANYIGSDKYFHARGNYDAAKRGPG GVWAAEAISDAR ENIQRFFGHGAEDSLADQAANEWGRSGKDPNHFRPAGLPEKY, SEQ ID NO. 7) or a fragment thereof.

8. The peptide of claim 7, wherein the fragment is ANYIGSDKYFHARGNYDAAKRGPGGV (SEQ ID NO: 8).

9. The peptide of claim 7, wherein the fragment is SEQ ID NO.: 2.

10. The peptide of claim 7, wherein the peptide is PEGylated.1 1 . A peptide consisting of SEQ ID NO: 8 or a fragment thereof.

12. The peptide of claim 1 1 , wherein the fragment is SEQ ID NO: 2.

13. The peptide of claim 11 or 12, wherein the peptide is modified.

14. A composition comprising the peptide of any one of claims 7-13.

15. A method of treating a patient having PND, the method comprising administering the peptide of any one of claims 7-13.

16. The method of claim 15, wherein the PND is selected from postoperative delirium, delayed neurocognitive recovery (dNCR), and postoperative neurocognitive disorder (PNCD).

Images