April 1997

Effects of Xanomeline, a Selective Muscarinic Receptor Agonist, on Cognitive Function and Behavioral Symptoms in Alzheimer Disease

Author Affiliations

From Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Ind (Drs Bodick, Offen, Shannon, Tollefson, Rasmussen, Potter, and Paul and Mr Bymaster); the Department of Neurology, Emory University, Atlanta, Ga (Dr Levey); California Clinical Trials, Beverly Hills (Dr Cutler); McGill Centre for Studies in Aging, Verdun, Quebec (Dr Gauthier); McLean Hospital, Belmont, Mass (Dr Satlin); and the Department of Psychiatry, Pharmacology, and Toxicology, Indiana University School of Medicine, Indianapolis (Dr Paul). Dr Hurley is in private practice in Beech Grove, Ind.

Arch Neurol. 1997;54(4):465-473. doi:10.1001/archneur.1997.00550160091022

Objective:  To evaluate the therapeutic effects of selective cholinergic replacement with xanomeline tartrate, an ml and m4 selective muscarinic receptor (mAChR) agonist in patients with probable Alzheimer disease (AD).

Design:  A 6-month, randomized, double-blind, placebocontrolled, parallel-group trial followed by a 1-month, single-blind, placebo washout.

Setting:  Outpatients at 17 centers in the United States and Canada.

Participants:  A total of 343 men and women at least 60 years of age with mild to moderate AD.

Interventions:  Patients received 75, 150, or 225 mg (low, medium, and high doses) of xanomeline per day or placebo for 6 months.

Outcome Measures:  Scores on the cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-Cog), the Clinician's Interview-Based Impression of Change (CIBIC+), the Alzheimer's Disease Symptomatology Scale (ADSS), and the Nurses' Observational Scale for Geriatric Patients (NOSGER).

Results:  A significant treatment effect existed for ADAS-Cog (high dose vs placebo; P≤.05), and CIBIC+ (high dose vs placebo; P≤.02). Treatment Emergent Signs and Symptoms analysis of the ADSS, which assesses behavioral symptoms in patients with AD, disclosed significant (P≤.002) dose-dependent reductions in vocal Out-bursts, bursts, suspiciousness, delusions, agitation, and hallucinations. On end-point analysis, NOSGER, which assesses memory, instrumental activities of daily living, self-care, mood, social behavior, and disturbing behavior in the elderly, also showed a significant dose-response relationship (P≤.02). In the high-dose arm, 52% of patients discontinued treatment because of adverse events; dose-dependent adverse events were predominantly gastrointestinal in nature. Syncope, defined as loss of consciousness and muscle tone, occurred in 12.6% of patients in the high-dose group.

Conclusions:  The observed improvements in ADAS-Cog and CIBIC+ following treatment with xanomeline provide the first evidence, from a large-scale, placebo-controlled clinical trial, that a direct-acting muscarinic receptor agonist can improve cognitive function in patients with AD. Furthermore, the dramatic and favorable effects on disturbing behaviors in AD suggest a novel approach for treatment of noncognitive symptoms.