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Original Investigation
January 14, 2019

Utility of Neuronal-Derived Exosomes to Examine Molecular Mechanisms That Affect Motor Function in Patients With Parkinson Disease: A Secondary Analysis of the Exenatide-PD Trial

Author Affiliations
  • 1Department of Clinical and Movement Neurosciences, University College London Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
  • 2Laboratory of Neurosciences, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
  • 3Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
  • 4University College London Comprehensive Clinical Trials Unit, London, United Kingdom
  • 5School of Biosciences and Medicine, University of Surrey, Kent, United Kingdom
JAMA Neurol. 2019;76(4):420-429. doi:10.1001/jamaneurol.2018.4304
Key Points

Question  How might neuronal-derived exosomes be used to explore the molecular mechanisms by which an experimental intervention exerts clinical effects on motor function?

Findings  In this seconday analysis of a randomized clinical trial, serum samples from 60 participants in the Exenatide-PD trial were used to isolate neuronal-derived exosomes to evaluate levels of the brain insulin-signaling proteins and downstream effectors protein kinase B (Akt) and mechanistic target of rapamycin. After 48 and 60 weeks of subcutaneous drug administration, patients with Parkinson disease treated with exenatide had greater activation of brain insulin signaling proteins and downstream effectors compared with baseline and patients in the placebo group.

Meaning  These results are suggestive of target engagement of brain insulin, protein kinase B, and mechanistic target of rapamycin signaling pathways by exenatide and provide a mechanistic context for the clinical findings of the trial; these techniques could have widespread application across a large number of trials in central nervous system diseases.


Importance  Exenatide, a glucagon-like peptide 1 agonist used in type 2 diabetes, was recently found to have beneficial effects on motor function in a randomized, placebo-controlled trial in Parkinson disease (PD). Accumulating evidence suggests that impaired brain insulin and protein kinase B (Akt) signaling play a role in PD pathogenesis; however, exploring the extent to which drugs engage with putative mechnisms in vivo remains a challenge.

Objective  To assess whether participants in the Exenatide-PD trial have augmented activity in brain insulin and Akt signaling pathways.

Design, Setting, and Participants  Serum samples were collected from 60 participants in the single-center Exenatide-PD trial (June 18, 2014, to June 16, 2016), which compared patients with moderate PD randomized to 2 mg of exenatide once weekly or placebo for 48 weeks followed by a 12-week washout period. Serum extracellular vesicles, including exosomes, were extracted, precipitated, and enriched for neuronal source by anti–L1 cell adhesion molecule antibody absorption, and proteins of interest were evaluated using electrochemiluminescence assays. Statistical analysis was performed from May 1, 2017, to August 31, 2017.

Main Outcomes and Measures  The main outcome was augmented brain insulin signaling that manifested as a change in tyrosine phosphorylated insulin receptor substrate 1 within neuronal extracellular vesicles at the end of 48 weeks of exenatide treatment. Additional outcome measures were changes in other insulin receptor substrate proteins and effects on protein expression in the Akt and mitogen-activated protein kinase pathways.

Results  Sixty patients (mean [SD] age, 59.9 [8.4] years; 43 [72%] male) participated in the study: 31 in the exenatide group and 29 in the placebo group (data from 1 patient in the exenatide group were excluded). Patients treated with exenatide had augmented tyrosine phosphorylation of insulin receptor substrate 1 at 48 weeks (0.27 absorbance units [AU]; 95% CI, 0.09-0.44 AU; P = .003) and 60 weeks (0.23 AU; 95% CI, 0.05-0.41 AU; P = .01) compared with patients receiving placebo. Exenatide-treated patients had elevated expression of downstream substrates, including total Akt (0.35 U/mL; 95% CI, 0.16-0.53 U/mL; P < .001) and phosphorylated mechanistic target of rapamycin (mTOR) (0.22 AU; 95% CI, 0.04-0.40 AU; P = .02). Improvements in Movement Disorders Society Unified Parkinson’s Disease Rating Scale part 3 off-medication scores were associated with levels of total mTOR (F4,50 = 5.343, P = .001) and phosphorylated mTOR (F4,50 = 4.384, P = .04).

Conclusions and Relevance  The results of this study are consistent with target engagement of brain insulin, Akt, and mTOR signaling pathways by exenatide and provide a mechanistic context for the clinical findings of the Exenatide-PD trial. This study suggests the potential of using exosome-based biomarkers as objective measures of target engagement in clinical trials using drugs that target neuronal pathways.