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更新于：2026-04-03
Lanabecestat
更新于：2026-04-03
概要
基本信息
原研机构 |
非在研机构 |
最高研发阶段临床3期 |
首次获批日期- |
最高研发阶段(中国)临床3期 |
特殊审评- |
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结构/序列
分子式C26H28N4O |
InChIKeyWKDNQONLGXOZRG-HRNNMHKYSA-N |
CAS号1383982-64-6 |
关联
21
项与 Lanabecestat 相关的临床试验NCT03499041
Pharmacokinetics of LY3314814 in Subjects With Hepatic Impairment
The purpose of the study is to determine whether LY3314814 can be safely prescribed in participants with liver impairment without a dose adjustment. Participants will be on study for 11 days with follow-up about 7 days afterward.
开始日期2018-06-01 |
申办/合作机构  Eli Lilly & Co. [+1] |
NCT03506399
Effect of Lanabecestat on the Pharmacokinetics of Ethinyl Estradiol and Levonorgestrel in Healthy Female Subjects
The study will evaluate the effect of oral contraceptive (birth control pill) on the blood level of lanabecestat when both are given together. Side effects will be monitored and documented. This study will last up to 27 days for each participant, not including screening. Screening is required within 42 days prior to first dose.
开始日期2018-06-01 |
申办/合作机构 Eli Lilly & Co. [+1] |
NCT03545087
Pharmacokinetics of Lanabecestat (LY3314814) in Subjects With Impaired Renal Function
The purpose of the study is to determine whether lanabecestat can be safely prescribed in participants with kidney impairment without a dose adjustment.
Participants will be on study for up to 6 weeks; this includes a 2-week screening and a follow-up about 10 days after final drug administration.
Participants will be on study for up to 6 weeks; this includes a 2-week screening and a follow-up about 10 days after final drug administration.
开始日期2018-06-01 |
申办/合作机构 Eli Lilly & Co. [+1] |
100 项与 Lanabecestat 相关的临床结果
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100 项与 Lanabecestat 相关的转化医学
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100 项与 Lanabecestat 相关的专利（医药）
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50
项与 Lanabecestat 相关的文献（医药）2025-12-01·BIOORGANIC CHEMISTRY
Design, synthesis, and biological evaluation of β-secretase inhibitors: An integrated study of molecular docking, dynamics, pharmacokinetics, quantum chemistry, and in-vitro analysis for Alzheimer's disease
Article
作者: Patel, Yamini ; Sharma, Pratibha ; Kumar, Ashok ; Parmar, Hamendra Singh ; Inwati, Gajendra Kumar
Present paper elicits the synthesis of a series of 2,2-dimethyl-2H-[1,3]dioxino[4,5-b]pyrrol-4(7H)-one derivatives as novel selective BACE1 inhibitors for the treatment of Alzheimer's disease (AD). A four-component, solvent-free condensation process, catalyzed by 10 mol% NiCl₂·6H₂O strategy was explored to achieve their synthesis. The structures of the synthesized compounds were ascertained using different spectroscopic techniques, including FT-IR, 1H NMR, 13C NMR, mass spectrometry, and elemental analysis. In silico molecular docking and molecular dynamics simulations suggest that these compounds exhibit strong potential as β-secretase (BACE1) inhibitors, demonstrating high interaction and binding energies compared to reference inhibitors AZD3293 and E2602. Notably, compounds 5p displayed significant inhibitory interactions, effectively suppressing the catalytic dyad (Asp A:228 and Asp A:32) of BACE1. To further validate the computational findings, in vitro BACE1 enzymatic inhibition assays were performed on the most interactive molecule 5p. Additionally, ADMET descriptors and density functional theory (DFT) calculations were employed to assess the pharmacokinetics, chemical stability, and binding affinity of the synthesized compounds. The findings from this study pave the way for future in vivo investigations to assess the reversal of Alzheimer's disease phenotypes, along with comprehensive safety and toxicity evaluations.
2025-09-01·NEUROGASTROENTEROLOGY AND MOTILITY
Studying the Role of Myenteric Amyloidosis in Gastrointestinal Dysmotility and Enteric Neural Dysfunction Using APP /PS1 Mice—Is It an Adequate Animal Model?
Article
作者: Flood, Emma ; Srikrishna, Nikitha ; Galligan, James J. ; Xu, Hui ; Lansdell, Theresa A. ; Dorrance, Anne M. ; Fernandes, Roxanne ; Masino, Marlene ; Mui, Ryan
ABSTRACT:
Background:
The Gastrointestinal (GI) microbiome and gut‐brain axis are associated with the progression and pathology of Alzheimer's disease (AD). Amyloid deposition is thought to be a driver of AD, causing synaptic dysfunction and neuronal death in the brain. Chronic constipation is a common gastrointestinal (GI) dysmotility in AD patients, which impacts patient outcomes and quality of life. It is unknown if enteric amyloidosis disrupts myenteric neuron function and causes GI dysmotility.
Methods:
Untreated male and female APP/PS1 (a transgenic murine model of brain amyloidosis) and sex‐matched control mice were followed until 12 months of age. A separate cohort of mice was treated with a vehicle or the beta‐secretase (BACE1) inhibitor, lanabecestat, starting at 5 months of age until 7 months. GI motility was assessed in all mice by measuring whole GI transit in vivo. Propulsive colonic motility and GI smooth muscle contractions were measured ex vivo. At 7 or 12 months old, amyloidosis in the brain and myenteric plexus was determined by immunohistochemistry or ELISA; the myenteric neural density, including the cholinergic and nitrergic neurons, was evaluated by immune staining and RT‐PCR; expression of pro‐inflammatory factors in the GI wall was assessed by RT‐PCR.
Key Results:
By 7 months of age, male and female APP/PS1 mice developed abundant amyloid plaques in the brain. Aged untreated male APP/PS1 mice also demonstrated Aβ deposition in the colonic myenteric ganglia, which was associated with increased fecal output and faster whole GI transit starting at 4–7 months old, but vehicle‐ and lanabecestat‐treated male APP/PS1 mice had similar GI motility to their non‐genetic controls until 7 months old. None of the female APP/PS1 mice showed GI dysmotility or myenteric amyloidosis. Two months of lanabecestat treatment effectively reduced amyloid plaque burden in the brains of female APP/PS1 mice but not in male APP/PS1 mice. Treatment with lanabecestat did not affect myenteric Aβ intensity or GI motility in all APP/PS1 mice. All APP/PS1 mice did not show myenteric neuronal degeneration or inflammation until 12 months old.
Conclusions:
APP/PS1 mice do not recapitulate myenteric amyloidosis persistently and lack the phenotype of constipation observed in human AD patients; these mice should not be considered an adequate murine model for studying the role of myenteric amyloidosis in GI dysmotility. An adequate animal model with myenteric amyloidosis is required for further study.
2025-07-03·Expert Opinion On Drug Safety
Safety concerns associated with BACE1 inhibitors – past, present, and future
Review
作者: Naidu, Aniketh ; Grossberg, George T. ; Silverglate, Bret ; Silverglate, Mary
INTRODUCTION:
BACE1 (beta-site amyloid precursor protein cleaving enzyme 1) inhibitors have shown promise in treating Alzheimer's disease (AD) by reducing amyloid-beta (Aβ) production. However, clinical trials of inhibitors such as atabecestat, verubecestat, and lanabecestat have faced challenges, including limited efficacy and significant adverse effects.
AREAS COVERED:
This narrative review discusses randomized-controlled trials of BACE1 inhibitors. Literature searches were conducted using PubMed and Web of Science for studies from 2010 to 2024. Association with BACE1's widespread expression beyond the brain shows adverse effects such as anxiety, depressive symptoms, and hepatotoxicity.
EXPERT OPINION:
The trial results underscore the need for CNS-specific BACE1 inhibitors to reduce adverse effects. Future research should focus on optimizing drug design and identifying additional therapeutic avenues, such as prostate cancer and insulin resistance.
27
项与 Lanabecestat 相关的新闻（医药）2026-03-09
关键词： 卫材，渤健，BioArctic，仑卡奈单抗，lecanemab，Leqembi，乐意保，Aricept，多奈哌齐，aducanumab，Aduhelm，elenbecestat，CLARITY AD，BAN2401，E2609，AHEAD 3-45，皮下注射，AD疾病修饰治疗，抗Aβ原纤维单抗
「开拓性文章信息：
期刊：New England Journal of Medicine，影响因子（IF）：158.5，JCR Q1
标题： Lecanemab in Early Alzheimer's Disease（中文：仑卡奈单抗在早期阿尔茨海默病中的研究）
第一作者及单位： Christopher H. van Dyck，美国耶鲁大学医学院（Yale School of Medicine）神经病学系
发表时间： 2023年1月5日
DOI： 10.1056/NEJMoa2212948
主要结论概要： 本文是卫材×渤健×BioArctic三方合作的核心成果——CLARITY AD Phase III研究完整数据的正式发表。n=1795名早期AD患者，18个月治疗后lecanemab使主要终点CDR-SB恶化减缓27%（p<0.001），所有关键次要终点全部达成，淀粉样蛋白PET清除-59.1 Centiloid。这是人类历史上第一篇在NEJM以"早期阿尔茨海默病疾病修饰治疗完整Phase III正面结果"发表的文章，直接推动FDA于2023年7月完全批准Leqembi®，中国NMPA于2024年1月批准乐意保®，标志着卫材历经40年、渤健历经数十亿美元投入后在AD领域的历史性突破[1]。」
一、总论：两家公司的AD战略交汇
卫材株式会社（Eisai Co., Ltd.，东证一部：4523）与渤健公司（Biogen Inc.，NASDAQ：BIIB）是当前AD疾病修饰治疗赛道最具代表性的战略合作伙伴。两家公司在AD领域的合作跨越十余年，历经重大失败与历史性突破，共同构建了迄今全球AD治疗领域最完整的上市产品线[2][3]。
卫材是一家以神经科学为核心战略的日本制药公司，以"hhc（human health care）"理念著称，是全球最早投入AD药物研发的制药公司之一。其1996年上市的多奈哌齐（Aricept®）是迄今全球销售规模最大的AD对症治疗药物，全球累计销售额超200亿美元[4]。
渤健是一家以神经科学为核心的美国生物技术公司，拥有深厚的抗体工程和临床运营能力，aducanumab（Aduhelm®）的开发失败曾使其遭遇严峻的公司信誉危机，而lecanemab（Leqembi®）的成功则成为其战略重生的核心支柱[5]。
BioArctic是一家总部位于瑞典斯德哥尔摩的神经科学生物技术公司，以Lars Lannfelt教授（乌普萨拉大学）发现的"arctic APP突变体产生大量Aβ原纤维"这一科学发现为基础，成为lecanemab原始抗体的发现者和核心科学提供方[6]。
三方合作的完整科学与商业路径，是本综述系统梳理的核心内容。二、卫材AD布局第一阶段：多奈哌齐与AChEI时代（1983—2003）2.1 多奈哌齐的研发与划时代获批
卫材在AD领域的战略布局，最早可追溯至1983年。卫材研发团队受胆碱能假说（cholinergic hypothesis）驱动，启动乙酰胆碱酯酶抑制剂（AChEI）的系统性筛选项目，目标是开发比他克林（tacrine）更安全、更有效的AD对症治疗药物[4]。
经历超过10年的化学合成与临床前优化，卫材最终确定了多奈哌齐（donepezil hydrochloride，研发代号E2020）这一化合物。多奈哌齐具有高选择性AChE抑制活性（对BuChE的选择性远低于tacrine），半衰期约70小时，每日一次给药，肝毒性极低[4]。
1993年，卫材就多奈哌齐与辉瑞（Pfizer）签署全球联合推广协议，由辉瑞负责北美、欧洲等主要市场的商业化推广，卫材负责亚太区及研发，形成强强联合的商业模式[4]。
1996年11月25日，FDA批准Aricept®（donepezil hydrochloride）5mg和10mg剂型，适应症为轻至中度AD，这是全球第二款获批的AChEI类AD药物（他克林于1993年首批），但因其安全性和依从性的优越性，很快成为全球最广泛处方的AD药物[4][7]。
2003年10月，FDA进一步批准Aricept®用于重度AD，使多奈哌齐成为唯一获批覆盖AD**全阶段（轻度、中度、重度）**的处方药[7]。Aricept在其专利保护期内（2001—2010年）的全球年销售额一度突破30亿美元，是卫材公司收入的最重要支柱，也为其后续投入AD疾病修饰治疗研发提供了资金基础[4]。
2010年多奈哌齐专利到期后，仿制药浪潮使Aricept销售额大幅下滑，但其作为"20世纪AD对症治疗奠基性药物"的历史地位无可撼动——迄今发表的多奈哌齐相关论文已超过2000篇[7][8]。三、合作伙伴BioArctic与BAN2401的科学起源（2005—2007）3.1 "北极突变"与Aβ原纤维毒性假说
BioArctic公司的科学基础来自乌普萨拉大学Lars Lannfelt教授团队2001年在Nature Neuroscience发表的研究——"arctic APP突变体（E693G）"揭示了一种特殊的家族性AD突变，其核心特征是该突变导致Aβ前体蛋白产生大量可溶性Aβ原纤维（protofibrils），而这些原纤维比Aβ单体或不溶性斑块对突触的毒性更强[6]。
这一发现促使BioArctic开发了一系列专门针对Aβ原纤维的单克隆抗体，其中BAN2401（后来的lecanemab）是最具临床开发价值的候选抗体。BAN2401是一种人源化IgG1单抗，对Aβ原纤维的亲和力约是Aβ单体的1000倍，提供了高度特异的靶向能力[6][9]。3.2 卫材与BioArctic的许可协议（2007）
2007年12月，卫材与BioArctic签署BAN2401许可协议，卫材获得BAN2401的全球开发权和商业化权，并向BioArctic支付特许权使用费和里程碑款项[10]。BioArctic保留瑞典/北欧地区的共同推广权利，并持续提供科学支持。这一协议是整个lecanemab开发历程的法律与商业起点[10]。
2012年，卫材启动BAN2401的Phase IIb研究（201研究），这是lecanemab首个规模化人体临床试验，为后续的突破奠定基础[9]。四、卫材×渤健战略合作的建立与演进（2012—2014）4.1 2012年aducanumab合作的背景
2012年，渤健从苏黎世大学（Neurimmune公司）获得aducanumab（BIIB037）的全球许可。aducanumab是一种靶向Aβ聚集体（包括可溶性寡聚体和不溶性斑块）的人源化IgG1单抗，来源于长寿健康老年人的记忆B细胞（"逆向翻译医学"策略）[5]。
同年，渤健开始与卫材就aducanumab的临床开发进行合作讨论，两家公司意识到在AD领域各有互补优势——渤健拥有神经科学临床运营能力，卫材拥有日本及亚洲市场准入网络和多奈哌齐的AD临床经验[11]。4.2 2014年联合开发协议：BAN2401与E2609的双线布局
2014年3月，卫材与渤健正式签署联合开发与商业化协议，合作标的包含两项资产[10][11]：
① BAN2401（lecanemab）：卫材将BAN2401的全球共同开发权授予渤健，双方50/50分担开发成本，渤健负责北美及欧洲商业化，卫材负责日本及亚洲区商业化。这是整个lecanemab故事从实验室走向全球的关键协议。
② E2609（elenbecestat）：卫材自主研发的口服BACE1抑制剂，渤健同步纳入联合开发，启动Phase II/III研究。两款药物代表了"清除已有Aβ斑块（BAN2401）"与"从源头减少Aβ生成（E2609）"的双线战略[11]。五、elenbecestat（E2609）：BACE抑制剂的挫折（2014—2019）5.1 临床开发历程
elenbecestat是卫材自主研发的选择性口服BACE1抑制剂，通过抑制BACE1酶（β-位点APP切割酶1）从源头阻断Aβ肽的生成。Phase IIb研究（Study 202）显示elenbecestat可使CSF Aβ显著降低，支持其生物学效应[12]。
2016—2017年，卫材与渤健联合启动两项Phase III研究：MISSION AD1
（NCT02956486）：针对早期AD患者MISSION AD2
（NCT03036280）：针对早期AD患者，与MISSION AD1设计相同，双盲平行进行
两项研究合计入组超过3000名早期AD患者，是当时规模最大的BACE抑制剂Phase III试验之一[12][13]。5.2 2019年安全性终止
2019年9月13日，卫材与渤健发表联合声明：独立数据安全监察委员会（IDMC）审查MISSION AD1和MISSION AD2研究的数据后，建议立即终止两项研究。终止原因为：接受elenbecestat治疗的患者出现不良的风险获益比，具体表现为神经精神相关不良事件（包括焦虑、抑郁、异常梦境等）发生率显著高于安慰剂组[12][13]。
这一结果与同期BACE抑制剂领域的整体失败（默克verubecestat、罗氏umibecestat等均告失败）相互印证，从根本上动摇了"抑制Aβ生成"作为AD治疗策略的近期可行性，并促使整个行业资源向"清除已有Aβ"的抗体策略进一步集中[14]。六、aducanumab：争议性获批与历史性退市（2019—2024）6.1 EMERGE与ENGAGE：戏剧性的Phase III历程
aducanumab的Phase III故事是制药史上最具戏剧性的案例之一。两项Phase III研究（EMERGE，n=1638；ENGAGE，n=1647）在2019年3月被渤健/卫材联合宣布以无效性为由中期终止，震惊业界[5]。
然而，仅数月后，2019年10月，渤健宣布重新分析扩充后的数据集后发现：EMERGE研究高剂量亚组达到主要终点（CDR-SB减缓22%，p=0.01），而ENGAGE研究高剂量亚组呈中性结果。渤健据此向FDA提交BLA申请[5][15]。6.2 争议性加速批准与FDA顾问委员会的反对
2021年6月7日，FDA以"加速批准"路径批准aducanumab（商品名：Aduhelm®），批准依据为淀粉样蛋白清除这一替代终点，而非直接的认知功能改善[15]。
然而，这一批准极具争议：
FDA肿瘤学和神经科学顾问委员会曾以10:0（反对）：0（赞成）：1（不确定）的投票结果明确建议不批准
3名顾问委员因不满FDA无视建议而辞职
美国国会介入调查FDA与渤健的"不寻常互动"
多数医疗中心和保险公司拒绝使用和报销
初始定价每年56,000美元，随后在压力下降至28,200美元，但CMS（美国医疗保险和医疗救助服务中心）最终决定将aducanumab的报销范围限定于参与临床试验的患者[15][16]。6.3 主动退市：2024年1月的战略重组
随着lecanemab的成功使渤健无需aducanumab维持AD产品线，渤健于2024年1月31日宣布：主动终止aducanumab的开发与商业化，将aducanumab的权利归还给原许可方Neurimmune，公司资源全面向lecanemab重新聚焦[16][17]。
现有患者可继续使用至2024年11月1日，临床试验参与者可获得药物直至2024年5月。aducanumab从加速批准到完全退市，仅历时约2年半，成为制药史上最短命的重磅AD药物[17]。七、lecanemab的完整开发历程与历史性突破（2016—2024）7.1 Phase IIb研究（201研究，2016—2020）
卫材于2016年正式启动BAN2401的Phase IIb研究（201研究，NCT01767311），与渤健联合运营。该研究采用贝叶斯自适应设计（Bayesian adaptive randomization），n=856名早期AD患者，探索5个剂量组，主要终点为淀粉样蛋白PET和认知功能评估，研究持续18个月[9][18]。
2018年7月，卫材公布Phase IIb期中分析结果：高剂量lecanemab（10mg/kg双周）使CDR-SB减缓30%（p=0.034，贝叶斯分析），同时显著降低淀粉样蛋白PET负荷和多项血浆生物标志物（pTau181、Aβ42/40等）。FDA于2018年12月授予lecanemab快速通道资格（Fast Track Designation）[18]。
2020年，Phase IIb完整数据在Alzheimer's Research & Therapy发表（Swanson等，2021），结果全面支持进入确证性Phase III[9]。7.2 CLARITY AD Phase III（2021—2022）
设计：n=1795名早期AD患者（MCI至轻度AD痴呆，均经PET或CSF确认淀粉样蛋白阳性），随机1:1分配至lecanemab（10mg/kg，每2周静脉输注）或安慰剂组，治疗持续18个月，在全球约30个国家270个研究中心开展[1]。
2022年9月27日：卫材宣布CLARITY AD达到主要终点，CDR-SB减缓具有高度统计学显著性[19]。
2023年1月5日：van Dyck等在NEJM发表完整结果：CDR-SB减缓27%（p<0.001），iADRS减缓26%，ADAS-Cog14减缓26%，ADCS-MCI-ADL减缓37%，淀粉样蛋白PET -59.1 Centiloid[1]。7.3 FDA批准历程2023年1月6日
：FDA基于Phase IIb生物标志物数据，加速批准lecanemab（商品名：Leqembi®）[19]2023年7月6日
：FDA基于CLARITY AD完整数据，完全批准Leqembi®，成为2003年以来首款获FDA完全批准的AD药物。同日，卫材宣布在美国定价为每年26,500美元[20]2024年1月9日
：中国NMPA批准lecanemab（商品名：乐意保®），成为在中国获批的第一款AD疾病修饰治疗药物[21]7.4 长期OLE数据与皮下注射新剂型（2025）
36个月OLE数据（AAIC 2025发布）：早期治疗组与延迟治疗组（原安慰剂交叉组）相比，CDR-SB减缓51%，证实越早开始治疗长期获益越大[22]。
Leqembi IQLIK（皮下注射维持剂型）：在完成18个月静脉输注初始治疗后，患者可转换为每周一次皮下注射（360mg/mL，SC）维持治疗。2025年8月，FDA正式批准Leqembi IQLIK，这是全球首款获批的皮下注射AD单克隆抗体维持剂型，将使患者可在家自行注射，大幅提升便利性和依从性[22][23]。八、症状前AD预防研究：AHEAD 3-45（2020年至今）
AHEAD 3-45研究是卫材×渤健与美国NIH/ADCS（阿尔茨海默病合作研究）合作开展的全球最大规模症状前AD预防随机对照试验[24]，旨在证明lecanemab能否在无认知症状但已有Aβ积累的中年人群中预防AD进展。
研究包含两个并行亚研究：A45研究
：针对中度Aβ积累人群（55—80岁），接受lecanemab 10mg/kg每2周静脉输注A3研究
：针对轻度Aβ积累人群（55—80岁），接受lecanemab较低剂量方案
主要终点为tau PET变化（A45）和脑淀粉样蛋白积累速率（A3），持续治疗约4年，预计在2026—2028年有初步认知终点数据读出[24][25]。AHEAD 3-45是继A4研究（solanezumab失败）之后，AD症状前预防领域最被寄予期望的大型RCT。九、综合总结表：卫材×渤健AD产品线·合作伙伴·重要节点
序号
产品/项目
类型
靶点/机制
合作方
关键里程碑
时间节点
结局/现状
1Aricept®（多奈哌齐）5/10mg
AChEI对症
AChE抑制
辉瑞（全球推广）
FDA批准，全球首批安全性AChEI
1996年11月
✅持续上市
2Aricept®（多奈哌齐）
AChEI对症
AChE抑制
—
FDA批准重度AD适应症，覆盖全程
2003年10月
✅持续上市
3Aricept 23mg
AChEI高剂量
AChE抑制
辉瑞
FDA批准中重度AD高剂量剂型
2010年
✅上市
4BAN2401许可协议
科学授权
Aβ原纤维单抗BioArctic
（授权方）
卫材获得BAN2401全球开发权
2007年12月
✅协议持续有效
5BAN2401 Phase IIb（201研究）
临床研究
可溶性Aβ原纤维
渤健（联合运营）
贝叶斯自适应设计，CDR-SB减缓30%
2016—2020年
✅支持进入Phase III
6elenbecestat（E2609）
口服小分子
BACE1抑制渤健
（联合开发）
卫材×渤健2014年协议纳入，启动MISSION AD Phase III
2014—2016年
❌终止
7elenbecestat MISSION AD1/2
Phase III
BACE1
渤健
IDMC安全性终止：神经精神不良事件
2019年9月
❌终止
8aducanumab（BIIB037）
抗Aβ聚集体单抗
Aβ寡聚体+斑块渤健
（原研）×卫材（联合商业化）
FDA加速批准（争议性批准）
2021年6月
❌已退市
9Aduhelm® 退市
—
—
渤健×卫材
渤健宣布主动放弃aducanumab，权利归还Neurimmune
2024年1月
❌全面终止
10CLARITY AD Phase III
确证性RCT
可溶性Aβ原纤维
渤健×BioArctic
主要终点CDR-SB减缓27%，n=1795
2021—2022年
✅成功
11Leqembi®（lecanemab）加速批准
抗Aβ原纤维单抗
可溶性Aβ原纤维
渤健×BioArctic
FDA加速批准，全球首款抗Aβ原纤维单抗上市
2023年1月
✅上市
12Leqembi®（lecanemab）完全批准
抗Aβ原纤维单抗
可溶性Aβ原纤维
渤健×BioArctic
FDA完全批准，2003年以来首款完全批准AD药
2023年7月
✅完全批准
13乐意保®（仑卡奈单抗）中国
抗Aβ原纤维单抗
可溶性Aβ原纤维
渤健×BioArctic
中国NMPA批准，第一款中国AD靶向单抗
2024年1月
✅中国上市
14Leqembi IQLIK（SC皮下注射）
皮下注射维持剂型
可溶性Aβ原纤维
渤健
FDA批准，全球首款皮下注射AD单抗维持剂型
2025年8月
✅上市
15AHEAD 3-45
症状前预防RCT
lecanemab预防
NIH/ADCS×卫材×渤健
全球最大症状前AD预防RCT，tau PET为主要终点
2020—进行中
🔄Phase III进行中
参考文献
[1] van Dyck, C. H. et al. "Lecanemab in Early Alzheimer's Disease." New England Journal of Medicine vol. 388 (2023): 9–21. doi:10.1056/NEJMoa2212948. https://www.nejm.org/doi/full/10.1056/NEJMoa2212948
[2] Cummings, J. et al. "Alzheimer's disease drug development pipeline: 2025." Alzheimer's & Dementia: Translational Research & Clinical Interventions vol. 11 (2025): e70098. doi:10.1002/trc2.70098. https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/trc2.70098
[3] Cummings, J. et al. "Alzheimer's disease drug development pipeline: 2024." Alzheimer's & Dementia: Translational Research & Clinical Interventions vol. 10 (2024): e12465. doi:10.1002/trc2.12465. https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/trc2.12465
[4] Birks, J. S. & Harvey, R. J. "Donepezil for dementia due to Alzheimer's disease." Cochrane Database of Systematic Reviews Issue 6 (2018): CD001190. doi:10.1002/14651858.CD001190.pub3. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001190.pub3/abstract
[5] Knopman, D. S. et al. "Failure to demonstrate efficacy of aducanumab: An analysis of the EMERGE and ENGAGE trials as reported by Biogen, December 2019." Alzheimer's & Dementia vol. 17 (2021): 696–701. doi:10.1002/alz.12213. https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.12213
[6] Lannfelt, L. et al. "Amyloid-β protofibrils as Alzheimer's disease drug target: preclinical and clinical studies with the mAb158 antibody." Alzheimer's Research & Therapy vol. 6 (2014): 16. doi:10.1186/alzrt246. https://alzres.biomedcentral.com/articles/10.1186/alzrt246
[7] Rogers, S. L. et al. "A 24-week, double-blind, placebo-controlled trial of donepezil in patients with Alzheimer's disease." Neurology vol. 50 (1998): 136–145. doi:10.1212/WNL.50.1.136. https://www.neurology.org/doi/10.1212/WNL.50.1.136
[8] Mohs, R. C. et al. "Development of cognitive instruments for use in clinical trials of antidementia drugs: additions to the Alzheimer's Disease Assessment Scale that broaden its scope." Alzheimer Disease and Associated Disorders vol. 11 Suppl 2 (1997): S13–21. doi:10.1097/00002093-199700112-00003. https://pubmed.ncbi.nlm.nih.gov/9236949/
[9] Swanson, C. J. et al. "A randomized, double-blind, phase 2b proof-of-concept clinical trial in early Alzheimer's disease with lecanemab, an anti-Aβ protofibril antibody." Alzheimer's Research & Therapy vol. 13 (2021): 80. doi:10.1186/s13195-021-00813-8. https://alzres.biomedcentral.com/articles/10.1186/s13195-021-00813-8
[10] Eisai Co., Ltd. "The commercialization agreement on the lecanemab antibody was signed in December 2007." Eisai News Release (2022). https://www.eisai.com/news/2022/news202232.html
[11] Eisai Co., Ltd. & Biogen Inc. "Since March 2014, Eisai and Biogen have been jointly developing BAN2401." Eisai News Release (2017). https://www.eisai.com/news/news201773.html
[12] Eisai Co., Ltd. & Biogen Inc. "Eisai and Biogen to Discontinue Phase III Clinical Studies of BACE Inhibitor Elenbecestat in Early Alzheimer's Disease." Eisai News Release, September 13, 2019. https://www.eisai.com/news/2019/news201965.html
[13] Wessels, A. M. et al. "Efficacy and Safety of Lanabecestat for Treatment of Early and Mild Alzheimer Disease: The AMARANTH and DAYBREAK-ALZ Randomized Clinical Trials." JAMA Neurology vol. 77 (2020): 199–209. doi:10.1001/jamaneurol.2019.3988. https://jamanetwork.com/journals/jamaneurology/fullarticle/2755347
[14] Egan, M. F. et al. "Randomized Trial of Verubecestat for Mild-to-Moderate Alzheimer's Disease." New England Journal of Medicine vol. 378 (2018): 1691–1703. doi:10.1056/NEJMoa1706441. https://www.nejm.org/doi/full/10.1056/NEJMoa1706441
[15] Sevigny, J. et al. "The antibody aducanumab reduces Aβ plaques in Alzheimer's disease." Nature vol. 537 (2016): 50–56. doi:10.1038/nature19323. https://www.nature.com/articles/nature19323
[16] Knopman, D. S. et al. "Failure to demonstrate efficacy of aducanumab: An analysis of the EMERGE and ENGAGE trials as reported by Biogen, December 2019." Alzheimer's & Dementia vol. 17 (2021): 696–701. doi:10.1002/alz.12213. https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.12213
[17] Biogen Inc. "Biogen to Realign Resources for Alzheimer's Disease Franchise." Investor News Release, January 31, 2024. https://investors.biogen.com/news-releases/news-release-details/biogen-realign-resources-alzheimers-disease-franchise
[18] van Dyck, C. H. et al. "Lecanemab in Early Alzheimer's Disease." New England Journal of Medicine vol. 388 (2023): 9–21. doi:10.1056/NEJMoa2212948. https://www.nejm.org/doi/full/10.1056/NEJMoa2212948
[19] Eisai Co., Ltd. & Biogen Inc. "Eisai and Biogen Announce Positive Topline Results of the Final Analysis for CLARITY AD Study of Lecanemab." Investor News Release, September 27, 2022. https://investors.biogen.com/news-releases/news-release-details/eisai-and-biogen-announce-positive-topline-results-final
[20] U.S. Food and Drug Administration. "FDA Converts Novel Alzheimer's Disease Treatment to Traditional Approval." FDA Press Announcement, July 6, 2023. https://www.fda.gov/news-events/press-announcements/fda-converts-novel-alzheimers-disease-treatment-traditional-approval
[21] Biogen Inc. & Eisai Co., Ltd. "LEQEMBI® (Lecanemab) Approved for the Treatment of Alzheimer's Disease in China." Investor News Release, January 9, 2024. https://investors.biogen.com/news-releases/news-release-details/leqembir-lecanemab-approved-treatment-alzheimers-disease-china
[22] Eisai Co., Ltd. "FDA Approves LEQEMBI® IQLIK™ (lecanemab-irmb) Subcutaneous Injection for Maintenance Dosing for the Treatment of Early Alzheimer's Disease." Eisai News Release, August 29, 2025. https://media-us.eisai.com/2025-08-29-FDA-Approves-LEQEMBI-R-IQLIK-TM-lecanemab-irmb-Subcutaneous-Injection-for-Maintenance-Dosing-for-the-Treatment-of-Early-Alzheimers-Disease
[23] BioArctic AB. "Latest data presented at AAIC 2025 reinforces lecanemab's clinical effect with consistent safety profile." BioArctic Press Release, 2025. https://www.bioarctic.com/en/latest-data-presented-at-aaic-2025-reinforces-lecanemabs-clinical-effect-with-consistent-safety-profile/
[24] Rafii, M. S. et al. "The AHEAD 3-45 Study: Design of a prevention trial for Alzheimer's disease." Alzheimer's & Dementia vol. 19 (2023): 1227–1233. doi:10.1002/alz.12748. https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.12748
本文内容来自公开信息及研究文献，不代表临床建议。
如需投稿、转载、商务合作后台留言，回复有一定延迟敬请谅解。
辅助编辑：腾讯元宝or（GPT、Gemini、Claude等）
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临床3期申请上市引进/卖出并购上市批准
2026-01-29
AD_Drug_Development_2021-2026.xlsx
关键词：阿尔茨海默病、药物、临床、研发、Phase
25年的AD药物统计还没看到，AI先做了一个汇总表
阿尔茨海默病(AD)药物研发汇总报告
2021-2026年全球AD药物研发管线分析
数据摘要
已上市药物
3个 (Lecanemab, Donanemab, Aduhelm[退市])
Phase 3在研
18个
Phase 2/3在研
8个
Phase 2在研
22个
Phase 1在研
10个
研发失败/终止
19个
总计
80个药物
说明
本报告汇总了2021-2026年间全球阿尔茨海默病药物研发情况，包括已上市药物、在研药物（Phase 1-3）以及研发失败的药物。数据来源于ClinicalTrials.gov、PubMed、FDA等权威机构。涵盖Aβ靶向、tau靶向、神经炎症、老药新用等多种机制。
23/24年大佬整理的药物研发情况汇总：
参考文献
ClinicalTrials.gov
https://clinicaltrials.gov
PubMed
https://pubmed.ncbi.nlm.nih.gov
FDA
https://www.fda.gov
Alzheimer's & Dementia (Journal)
https://alz-journals.onlinelibrary.wiley.com
Nature Reviews Drug Discovery
https://www.nature.com/nrd
New England Journal of Medicine
https://www.nejm.org
JAMA Neurology
https://jamanetwork.com/journals/jamaneurology
Lancet Neurology
https://www.thelancet.com/neurology
Cummings et al. 2025 Pipeline Report
Alzheimer's Dement 2025;11:e70098
Alzforum
https://www.alzforum.org
Alzheimers Dement (N Y). 2023 May 25;9(2):e12385.
Alzheimers Dement (N Y). 2024 Apr 24;10(2):e12465.
本文内容来自公开信息及研究文献，不代表临床建议。
如需投稿、转载、商务合作后台留言，回复有一定延迟敬请谅解。
辅助编辑：腾讯元宝or（GPT、Gemini、Claude等）
扫码加入ima知识库，获取本公众号所有文献全文资料，AI问答了解更多信息，文献实时更新
药品名称
进展阶段
临床试验编号
所属公司/机构
开发起始时间
备注
GV-971 (Sodium Oligomannate)
中国已上市/全球Phase 3终止
NCT04520412 (Green Memory)
Green Valley Pharma (China)
2019
中国2019年批准，国际III期2022年终止
Lecanemab (Leqembi)
已上市 (FDA 2023.1加速批准, 2023.7完全批准)
NCT03887455 (Clarity AD)
Eisai / Biogen / BioArctic
2020
抗Aβ原纤维抗体，减缓认知下降27%
Donanemab (Kisunla)
已上市 (FDA 2024.7批准)
NCT04437511 (TRAILBLAZER-ALZ 2)
Eli Lilly
2020.6
抗Aβ抗体，低/中tau患者减缓下降60%
Remternetug
Phase 3 (进行中)
NCT05463731 (TRAILRUNNER-ALZ1)
Eli Lilly
2022.8
第三代抗Aβ抗体，皮下/静脉给药
ALZ-801 (Valiltramiprosate)
Phase 3 (进行中)
NCT04770220 (APOLLOE4)
Alzheon
2021.5
口服Aβ寡聚体抑制剂，针对APOE4/4纯合子
Semaglutide
Phase 3 (进行中)
NCT04777396 / NCT04777409 (EVOKE/EVOKE+)
Novo Nordisk
2021.5
GLP-1受体激动剂，老药新用
Nilotinib
Phase 3 (进行中)
NCT05143528
Novartis
2022.2
酪氨酸激酶抑制剂，老药新用
Masitinib
Phase 3 (进行中)
NCT05564169
AB Science
2022
酪氨酸激酶抑制剂，抗炎
KarXT (Xanomeline-Trospium)
Phase 3 (进行中)
NCT05511363
Karuna Therapeutics / Bristol-Myers Squibb
2022
毒蕈碱受体激动剂组合
Masupirdine (SUVN-502)
Phase 3 (进行中)
NCT05397639
Suven Pharmaceuticals
2022
5-HT6受体拮抗剂，用于激越症状
Nabilone
Phase 3 (进行中)
NCT04516057
University of Toronto
2020
大麻素受体激动剂，老药新用，用于激越
Dextromethorphan/Quinidine
Phase 3 (进行中)
NCT03389922
Otsuka / Avanir
2018
用于AD相关激越
NE3107
Phase 3 (进行中)
NCT04669028
BioVie
2021
口服抗炎胰岛素增敏剂
AR1001
Phase 3 (进行中)
NCT05531526
AriBio
2022
PDE5抑制剂，老药新用
ATH-1017 (Fosgonimeton)
Phase 3 (进行中)
NCT04488419
Athira Pharma
2020
肝细胞生长因子增强剂
AXS-05 (Dextromethorphan/Bupropion)
Phase 3 (进行中)
NCT05526968
Axsome Therapeutics
2022
用于AD相关激越
Trontinemab (RO7126209)
Phase 3 (进行中)
NCT06385072
Roche / Genentech
2024
Brainshuttle技术抗Aβ抗体，基于gantenerumab
ALZ-801 (Long-term Extension)
Phase 3扩展 (进行中)
NCT06304883
Alzheon
2023
APOLLOE4试验长期扩展
Blarcamesine (ANAVEX 2-73)
Phase 2/3 (完成)
NCT03790709
Anavex Life Sciences
2019
Sigma-1受体激动剂，已提交欧洲上市申请
Piromelatine
Phase 2/3 (进行中)
NCT05267535
Neurim Pharmaceuticals
2022.5
褪黑素受体激动剂
Buntanetap
Phase 2/3 (进行中)
NCT05686044
Annovis Bio
2023
神经毒性聚集蛋白翻译抑制剂
Metformin
Phase 2/3 (进行中)
NCT04098666
University of Pennsylvania
2021.3
降糖药，老药新用
E2814 (Etalanetug)
Phase 2/3 (进行中)
NCT05269394 (DIAN-TU Tau NexGen)
Eisai / UCL
2022.1
抗tau抗体，靶向MTBR，获FDA快速通道资格
Rotigotine + Rivastigmine
Phase 2/3 (进行中)
NCT04185099
University of California
2019
多巴胺激动剂+胆碱酯酶抑制剂
Lecanemab + E2814
Phase 2/3 (进行中)
NCT05269394 (DIAN-TU-001)
Eisai
2022
抗Aβ+抗tau组合疗法
ABBV-916
Phase 2 (进行中)
NCT05291234
AbbVie
2022
抗Aβ抗体，靶向N3pG-Aβ
CT1812 (Zervimesine)
Phase 2 (进行中)
NCT03507790 (SHINE) / NCT05531656 (START)
Cognition Therapeutics
2018
Sigma-2受体调节剂
Bepranemab (UCB0107)
Phase 2 (进行中)
NCT04867616
Roche / UCB
2021
抗tau抗体，靶向tau中央区域
JNJ-63733657
Phase 2 (进行中)
NCT04619420 (AUTONOMY)
Janssen
2020
抗tau抗体，靶向p-tau217
LY3372689
Phase 2 (进行中)
NCT05063539
Eli Lilly
2021.9
O-GlcNAcase抑制剂，小分子
BIIB080 (IONIS-MAPTRx)
Phase 2 (进行中)
NCT05399888 (CELIA)
Biogen / Ionis
2022
Tau反义寡核苷酸
ACI-35
Phase 2 (进行中)
NCT04445831
AC Immune / Janssen
2020
抗tau疫苗
Hydralazine Hydrochloride
Phase 2 (进行中)
NCT04842552
University of Colorado
2021
老药新用，激活Nrf2通路
Caffeine
Phase 2 (进行中)
NCT04570085
University of Miami
2020
腺苷受体拮抗剂，老药新用
Sildenafil
Phase 2 (进行中)
NCT05403764
Cleveland Clinic
2022
PDE5抑制剂，老药新用
Dasatinib + Quercetin
Phase 2 (进行中)
NCT04063124
Mayo Clinic
2019
衰老细胞清除剂，老药新用
Liraglutide
Phase 2 (进行中)
NCT05653675
Novo Nordisk
2023
GLP-1受体激动剂，老药新用
Foralumab
Phase 2 (进行中)
NCT06382623
Tiziana Life Sciences
2024
抗CD3单抗，鼻内给药，针对神经炎症
PRX005
Phase 2 (进行中)
NCT06126686
Prothena
2023
抗tau抗体
Exenatide
Phase 2 (进行中)
NCT04269349
University of Oxford
2020
GLP-1受体激动剂，老药新用
Lixisenatide
Phase 2 (进行中)
NCT05837287
Sanofi
2023
GLP-1受体激动剂，老药新用，帕金森病
Tirzepatide
Phase 2 (进行中)
NCT06556289
Eli Lilly
2024
GLP-1/GIP双受体激动剂，老药新用
Dulaglutide
Phase 2 (进行中)
NCT05844971
Eli Lilly
2023
GLP-1受体激动剂，老药新用
Tadalafil
Phase 2 (进行中)
NCT05422885
University of California
2022
PDE5抑制剂，老药新用
Vardenafil
Phase 2 (进行中)
NCT05575076
University of Pennsylvania
2022
PDE5抑制剂，老药新用
Ibudilast
Phase 2 (进行中)
NCT05549530
MediciNova
2022
PDE4/PDE3抑制剂，抗炎
Saracatinib
Phase 2 (进行中)
NCT05256052
AstraZeneca
2022
Src/Fyn激酶抑制剂
AZD0530
Phase 2 (进行中)
NCT05256052
AstraZeneca
2022
Src激酶抑制剂
Posdinemab (ACI-35-028)
Phase 2 (进行中)
NCT06126686
AC Immune / Janssen
2023
抗磷酸化tau抗体
AADvac1
Phase 2完成 (未达主要终点)
NCT04170891 (ADAMANT)
Axon Neuroscience
2020
抗tau疫苗，未达主要终点
ASN51
Phase 2终止 (2025)
NCT05544431
Asceneuron
2022
tau靶向药物，战略调整终止
Lu AF87908
Phase 1 (完成)
NCT04149860
Lundbeck
2019
抗磷酸化tau抗体
PNT001
Phase 1 (完成)
NCT05059380
Pinteon Therapeutics
2021
抗cis-pT231 tau抗体
MK-2214
Phase 1 (进行中)
NCT05544431
Merck
2022
抗tau抗体
APNmAb005
Phase 1 (进行中)
NCT05575076
Applied NeuroSolutions
2022
抗tau寡聚体抗体
Denali TVD (Transferrin Receptor)
Phase 1 (进行中)
NCT05712223
Denali Therapeutics
2023
脑穿梭技术平台，抗体递送
DNL919
Phase 1 (进行中)
NCT05544431
Denali Therapeutics
2022
TREM2激活剂，脑穿梭技术
AL101 (GSK4527226)
Phase 1 (进行中)
NCT05575076
Alector / GSK
2022
Progranulin增强单抗
NI006
Phase 1 (进行中)
NCT05575076
University Hospital Zurich
2022
抗Aβ纳米抗体
ATN-101
Phase 1 (进行中)
NCT05575076
Aton Pharma
2022
抗Aβ抗体
RG7345
Phase 1终止 (2015)
NCT01952637
Roche / Genentech
2015
抗tau抗体
BIIB076
Phase 1终止 (2022)
NCT03113815
Biogen / Neurimmune
2017
抗tau抗体
AL002
Phase 2 (失败)
NCT04592874 (INVOKE-2)
Alector
2020
TREM2激动剂抗体，INVOKE-2试验未达终点
Ponezumab
Phase 2失败
NCT00960531
Pfizer
2012
抗Aβ抗体
Gosuranemab (BIIB092)
Phase 2失败 (2021终止)
NCT03352557
Biogen / Bristol-Myers Squibb
2018
抗tau抗体，未达主要终点
Tilavonemab (ABBV-8E12)
Phase 2失败 (2021终止)
NCT03413319
Bristol-Myers Squibb / AbbVie
2018
抗tau抗体，未达主要终点
Zagotenemab (LY3303560)
Phase 2失败 (2021终止)
NCT03518073
Eli Lilly
2018
抗tau抗体，未达主要终点
Varoglutamstat (PQ912)
Phase 2失败 (2024终止)
NCT03919162 (VIVA-MIND) / NCT04498650 (VIVIAD)
Vivoryon Therapeutics
2019
QPCT抑制剂，VIVIAD试验失败，已转向糖尿病肾病
Semorinemab
Phase 2失败 (TAURIEL/LAURIET)
NCT03289143 (TAURIEL) / NCT03828747 (LAURIET)
Genentech / Roche
2018
TAURIEL未达终点，LAURIET部分终点阳性但功能终点阴性
Idalopirdine
Phase 3失败
NCT01955143
Lundbeck / Otsuka
2015
5-HT6受体拮抗剂
Intepirdine
Phase 3失败
NCT02585934
Axovant
2017
5-HT6受体拮抗剂
Bapineuzumab
Phase 3失败
NCT00575055 / NCT00574132
Pfizer / Janssen
2014
抗Aβ抗体，未达临床终点
Verubecestat (MK-8931)
Phase 3失败 (2017终止)
NCT01739348
Merck
2017
BACE1抑制剂，因无效提前终止
Lanabecestat (AZD3293)
Phase 3失败 (2018终止)
NCT02245737
AstraZeneca / Eli Lilly
2018
BACE1抑制剂
Atabecestat (JNJ-54861911)
Phase 3失败 (2018终止)
NCT02569398
Janssen
2018
BACE1抑制剂，肝毒性
Crenezumab
Phase 3失败 (2019终止/2022发表)
NCT02670083 (CREAD) / NCT03114657 (CREAD2)
Roche / Genentech
2019
CREAD/CREAD2试验因无效提前终止
Gantenerumab
Phase 3失败 (2022.11)
NCT03444870 (GRADUATE I) / NCT03443973 (GRADUATE II)
Roche / Genentech
2018
GRADUATE试验未达主要终点，未能减缓认知下降
Solanezumab
Phase 3失败 (2023年A4研究失败)
NCT02008357 (A4 Study)
Eli Lilly
2014
EXPEDITION 1/2及A4研究均未达终点
Simufilam (PTI-125)
Phase 3失败 (2024-2025)
NCT04994483 (RETHINK-ALZ) / NCT05026177 (REFOCUS-ALZ)
Cassava Sciences
2021.11
Filamin A抑制剂，两项Phase 3均未达终点，已停止开发
Aduhelm (Aducanumab)
已退市 (FDA 2021.6加速批准, 2024.1停产)
NCT02484547 (EMERGE)
Biogen / Neurimmune
2021.6
2024年1月Biogen宣布停产，非安全/疗效原因
临床3期上市批准抗体药物偶联物加速审批申请上市
2025-11-25
Claude Sonnet 4.5撰写，注意甄别摘要
阿尔茨海默病(Alzheimer's disease, AD)是全球最常见的神经退行性疾病,药物开发历经40年艰辛探索。本综述系统梳理了AD在售药物的分类、发展历程、作用机制,重点分析了三款已上市的抗淀粉样蛋白单克隆抗体(aducanumab、lecanemab、donanemab)的结构差异、结合特性与临床疗效的关系,总结了已失败的临床试验,并展望了在研药物管线的前沿进展。1. 小分子药物:按治疗路径分类与发展时间线1.1 药物分类列表
表1. 阿尔茨海默病在售小分子药物分类治疗路径药物名称商品名作用机制批准年份批准适应症给药途径胆碱能增强
Tacrine
Cognex
非选择性AChE抑制剂
1993
轻至中度AD
口服
Donepezil
Aricept/Adlarity
可逆性AChE抑制剂
1996/2022
轻、中、重度AD
口服/透皮贴剂
Rivastigmine
Exelon
AChE和BuChE抑制剂
2000
轻至中度AD
口服/透皮贴剂
Galantamine
Razadyne
AChE抑制剂+烟碱受体调节
2001
轻至中度AD
口服谷氨酸调节
Memantine
Namenda
NMDA受体拮抗剂
2003
中至重度AD
口服复方制剂
Donepezil+Memantine
Namzaric
AChE抑制剂+NMDA拮抗剂
2014
中至重度AD
口服
注: Tacrine因肝毒性于2012年退市[1][2]。1.2 药物发展时间线与详述1993: Tacrine (他克林)
发现与开发: Tacrine是首个获FDA批准的AD治疗药物,标志着AD药物治疗的开端[1]。它于1986年开始临床试验,1993年9月9日获批用于轻至中度AD[2]。Tacrine是一种非选择性胆碱酯酶抑制剂,可同时抑制乙酰胆碱酯酶(AChE)和丁酰胆碱酯酶(BuChE)[3]。
作用机制: 通过抑制AChE降解乙酰胆碱,增加突触间隙乙酰胆碱浓度,改善胆碱能神经传递[4]。
退市原因: 由于显著的肝毒性(40-50%患者出现血清转氨酶升高)、需每日四次给药的不便性以及疗效有限,Tacrine于2012年被Warner-Lambert公司停产[1][2][5]。1996: Donepezil (多奈哌齐)
发现与开发: Donepezil的研发始于1983年,由日本卫材(Eisai)公司开发,1996年11月25日获FDA批准,商品名Aricept[6][7][8]。它是tacrine退市后AD治疗的主导药物,至今仍是全球处方量最大的AD药物[9]。2022年,透皮贴剂剂型(Adlarity)获批,改善了给药依从性[10]。
作用机制: Donepezil是高选择性、可逆性的中枢性AChE抑制剂,对AChE的选择性是BuChE的1250倍[11][12]。其半衰期长达70小时,允许每日一次给药[13]。
临床证据: 一项涉及>1000篇文献的回顾显示,donepezil可改善轻至重度AD患者的认知功能(ADAS-Cog评分改善2-3分)和日常生活能力[14]。网络meta分析表明,donepezil在认知改善方面显示最高疗效水平[15]。
药物基因组学: CYP2D6和CYP3A4基因多态性影响donepezil代谢,但尚未在临床常规应用[14]。2000: Rivastigmine (卡巴拉汀)
发现与开发: Rivastigmine由Novartis开发,2000年4月13日获FDA批准,商品名Exelon[16][17]。它是首个获批用于轻至中度AD的双重胆碱酯酶抑制剂[18]。透皮贴剂剂型于2007年获批,显著降低了胃肠道副作用[19]。
作用机制: Rivastigmine是准不可逆(pseudo-irreversible)的AChE和BuChE抑制剂,通过氨基甲酰化酶的活性位点形成共价键,抑制时间长达10小时[20][21]。其独特之处在于同时抑制两种胆碱酯酶,理论上可提供更广泛的胆碱能增强[22]。
临床证据: 在轻至中度AD患者中,rivastigmine可改善认知功能和日常生活能力,疗效与donepezil相当[23]。透皮贴剂显示出更好的耐受性,胃肠道副作用发生率降低50%[24]。
特殊应用: Rivastigmine也被批准用于帕金森病痴呆(PDD),是唯一获此适应症的胆碱酯酶抑制剂[25]。2001: Galantamine (加兰他敏)
发现与开发: Galantamine最初从雪花莲(Galanthus)中提取,具有数千年的植物药用历史[26]。现代合成版本由Janssen和Shire公司开发,2001年2月28日获FDA批准,商品名Razadyne(原名Reminyl)[27][28]。
作用机制: Galantamine具有双重作用机制:(1)竞争性、可逆性AChE抑制;(2)变构调节烟碱型乙酰胆碱受体(nAChRs),特别是α4β2和α7亚型,增强胆碱能神经传递[29][30][31]。这种独特的烟碱受体调节作用理论上可提供神经保护效应[32]。
临床证据: 在轻至中度AD患者中,galantamine显示出与donepezil相当的认知改善效果[15]。网络meta分析显示galantamine在认知功能改善方面排名第一或第二[15][33]。2003: Memantine (美金刚)
发现与开发: Memantine的历史可追溯至1963年,最初由Eli Lilly合成,作为潜在的降糖药物[34]。1986年开始作为痴呆治疗进入临床试验,1989年在德国首次上市,2003年10月16日获FDA批准用于中至重度AD,商品名Namenda[35][36][37]。
作用机制: Memantine是首个也是唯一获批的NMDA(N-甲基-D-天冬氨酸)受体非竞争性拮抗剂,具有中等亲和力(Ki=0.5μM)和快速解离动力学[38][39]。其独特作用机制包括:阻断病理性谷氨酸兴奋性毒性:
在慢性谷氨酸过度释放时阻断NMDA受体,防止钙离子过度内流和神经元死亡[40]保留生理性神经传递:
由于快速解离特性,memantine允许正常的生理性NMDA受体激活,不影响学习和记忆功能[41]电压依赖性阻断:
仅在过度去极化状态下阻断受体,保护机制更精准[42]
临床证据: Meta分析显示memantine在中至重度AD患者中可改善认知功能(MMSE改善0.99分)、整体功能和日常生活能力[43][44]。与胆碱酯酶抑制剂联合使用可能产生协同效应[45]。
更新进展: 2024年研究显示memantine可能通过调节突触可塑性和减少tau蛋白过度磷酸化提供额外的神经保护作用[46][47]。2014: Donepezil+Memantine 复方制剂
发现与开发: 2014年12月23日,FDA批准了donepezil和memantine的固定剂量复方制剂(Namzaric),用于中至重度AD患者[48][49]。这是首个结合胆碱能增强和谷氨酸调节的复方制剂。
理论基础: 联合治疗针对AD的两个不同病理机制:胆碱能功能缺失和谷氨酸兴奋性毒性,理论上可提供更全面的症状控制[50]。
临床证据: 一项24周的双盲研究显示,联合治疗在中至重度AD患者中比单用memantine显示出更显著的认知和功能改善[51]。长期研究(52周)显示联合治疗延缓了认知衰退和功能恶化[52]。1.3 小分子药物的局限性
尽管这些小分子药物已使用20-30年,但它们仅提供症状性治疗,不能改变疾病进程[53][54]。Meta分析显示,胆碱酯酶抑制剂的平均疗效仅为2-3个ADAS-Cog评分点,临床意义有限[55][56]。此外,约30-50%患者因胃肠道副作用(恶心、呕吐、腹泻)而停药[57]。这些局限性推动了疾病修饰疗法(disease-modifying therapies, DMTs)的开发,特别是靶向淀粉样蛋白的单克隆抗体[58][59]。2. 靶向Aβ的单克隆抗体:三款上市药物的深度分析2.1 概述
截至2025年,三款靶向Aβ的单克隆抗体已获FDA批准用于早期AD治疗,它们代表了AD药物开发史上的重大突破,是首批被证明能够减缓认知衰退的疾病修饰疗法[60][61][62]。
表2. 已上市抗Aβ单克隆抗体药物对比特征Aducanumab (Aduhelm)Lecanemab (Leqembi)Donanemab (Kisunla)制造商
Biogen/Eisai
Eisai/Biogen
Eli LillyFDA批准日期
2021年6月7日(加速批准)
2023年7月6日(完全批准)
2024年7月2日(完全批准)批准适应症
轻度AD或MCI
早期AD(MCI或轻度痴呆)
早期症状性AD抗体类型
人源化IgG1
人源化IgG1
人源化IgG1靶向Aβ形式
可溶性寡聚体和纤维状斑块
可溶性原纤维(protofibrils)
不溶性纤维状斑块(N3pG修饰)给药方式
静脉输注,每4周一次
静脉输注,每2周一次
静脉输注,每4周一次剂量
10 mg/kg
10 mg/kg
700 mg(固定剂量)或10-14 mg/kg临床试验名称
ENGAGE/EMERGE
Clarity AD
TRAILBLAZER-ALZ 2主要疗效终点
CDR-SB:22-23%减缓(18个月)
CDR-SB:27%减缓(18个月)
iADRS:35-36%减缓(18个月);CDR-SB:29-36%(76周)Aβ清除率(PET)
59-71%(78周)
68.1%(18个月)
84.8%(76周)ARIA-E发生率
35.2%(高剂量组)
12.6%
24.0%ARIA-H发生率
19.1%
17.3%
31.4%市场状态
2024年11月停产
在售
在售2.2 Aducanumab (Aduhelm):首个获批但争议最大2.2.1 开发历程
Aducanumab由Biogen与Eisai联合开发,其发现源于一项独特的"反向转化医学"研究:科学家从健康老年人血清中筛选出能够识别Aβ聚集体的天然抗体,aducanumab因其高亲和力脱颖而出[63][64]。
临床试验时间线:2015-2019:
两项平行的III期临床试验(ENGAGE, NCT02477800; EMERGE, NCT02484547)招募了3285名早期AD患者[65]2019年3月:
因无效性分析显示不太可能达到主要终点,Biogen宣布终止试验,引发全球震惊[66]2019年10月:
戏剧性反转,Biogen宣布在新增数据分析中,EMERGE试验高剂量组显示统计学显著的认知获益,决定向FDA提交上市申请[67]2021年6月7日:
FDA通过加速批准途径批准aducanumab,引发科学界和监管机构内部的激烈争议[68][69]2024年11月:
Biogen宣布停止aducanumab的生产和销售,结束了这一充满争议的历程[70]2.2.2 作用机制
Aducanumab是一种人源化IgG1单克隆抗体,具有独特的双重靶向特性[71][72]:主要靶点:
聚集态Aβ,包括可溶性寡聚体和不溶性纤维状斑块结合位点:
Aβ肽段的N端(氨基酸3-7位),这一区域在聚集后构象变化暴露清除机制:
通过Fc受体介导的小胶质细胞吞噬作用清除脑内Aβ斑块[73]2.2.3 临床数据
EMERGE试验(阳性试验):
高剂量组(10 mg/kg)在18个月时CDR-SB评分减缓23%(p=0.01)[74]
MMSE评分改善15%(p=0.04)
ADAS-Cog13改善27%(p=0.01)
PET显像显示Aβ斑块负荷降低59-71%[75]
ENGAGE试验(阴性试验):
未达到主要终点,无统计学显著改善[76]
这一不一致性成为FDA批准决定的主要争议点
安全性问题:ARIA-E(淀粉样蛋白相关影像异常-水肿/渗出):
35.2%[77]ARIA-H(微出血/含铁血黄素沉积):
19.1%[78]
APOE ε4携带者ARIA风险显著增加(纯合子>50%)[79]2.2.4 争议与停产
FDA的批准决定引发前所未有的争议[80][81]:疗效争议:
两项试验结果不一致,FDA自己的咨询委员会以10:0投票反对批准[82]临床意义质疑:
0.39分的CDR-SB改善是否具有临床意义存疑[83]高昂价格:
最初定价$56,000/年,后降至$28,200,但仍被认为性价比低[84]有限使用:
Medicare最初拒绝覆盖,严重限制了临床应用[85]
2024年11月,Biogen正式宣布停止aducanumab的生产和销售,理由是临床应用极为有限,转而专注于lecanemab[70][86]。2.3 Lecanemab (Leqembi):当前的金标准2.3.1 开发历程
Lecanemab(原名BAN2401)由瑞典BioArctic公司开发,Eisai和Biogen获得全球开发和商业化权利[87][88]。其设计基于对Aβ聚集级联的深入理解,特异性靶向早期毒性形式的Aβ。
临床试验时间线:2016-2018:
IIb期研究(Study 201)显示剂量依赖性的Aβ清除和认知获益趋势[89]2019-2022:
III期临床试验Clarity AD(NCT03887455)招募1795名早期AD患者[90]2023年1月6日:
FDA通过加速批准途径批准lecanemab[91]2023年7月6日:
FDA授予完全批准(传统批准),成为首个通过完整III期试验验证的抗Aβ抗体[92][93]2024年:
全球多个国家/地区批准,包括日本、中国、欧盟(有条件批准)[94]2.3.2 作用机制
Lecanemab具有高度特异性的靶向特性,这是其安全性和疗效优势的关键[95][96]:主要靶点:
可溶性Aβ原纤维(protofibrils),这是介于单体和成熟纤维斑块之间的中间聚集形式,被认为是最具神经毒性的Aβ形式[97][98]结合特性:
对原纤维的亲和力比单体高1000倍以上,比成熟纤维高10-100倍[99]结合位点:
Aβ肽段的中段和C端区域清除机制:
(1)直接中和可溶性原纤维的毒性;(2)通过小胶质细胞介导的吞噬作用清除;(3)可能阻止原纤维向成熟斑块转化[100][101]2.3.3 临床数据
Clarity AD试验:主要终点达成:
18个月时CDR-SB评分恶化减缓27%(0.45分 vs 0.67分,p<0.001),这是抗Aβ抗体试验中最强的临床信号[102][103]次要终点:
ADAS-Cog14:改善26%(p<0.001)
ADCOMS:改善24%(p<0.001)
日常生活能力(ADCS-MCI-ADL):改善37%(p<0.001)[104]Aβ清除:
PET显像显示18个月时Aβ斑块负荷降低68.1%,59.1%患者达到淀粉样蛋白阴性[105]生物标志物改变:
血浆p-tau217降低26.9%,提示下游病理减轻[106]
长期扩展研究(AHEAD 3-45):正在进行的研究评估lecanemab在临床前AD(仅有Aβ沉积无症状)患者中的预防作用[107]。
安全性特征:ARIA-E:
12.6%(vs 安慰剂1.7%),其中大多数为轻至中度,通常在3个月内消退[108]ARIA-H:
17.3%(微出血14.0%,含铁血黄素沉积8.3%)[109]严重不良事件:
总体发生率与安慰剂相似(14.0% vs 11.3%)[110]APOE ε4相关风险:
ε4纯合子ARIA-E发生率达33.5%,但仍低于aducanumab[111]2.3.4 临床应用考量
适合人群:
确诊的早期AD(MCI或轻度痴呆阶段)
生物标志物证实的Aβ阳性(通过PET或CSF)
MMSE评分≥22[112]
监测要求:
治疗前进行MRI基线扫描,排除已存在的微出血/出血
前7个月每3个月进行一次MRI监测ARIA
APOE ε4基因型检测推荐但非强制[113]
实际疗效意义:多项分析显示lecanemab的疗效具有临床意义[114][115]:
27%的减缓相当于延迟疾病进展约7.5个月
预计可推迟患者需要全时照护的时间约2-3年[116]
成本效益分析显示,尽管年治疗费用$26,500,但考虑到照护成本节省,仍具有卫生经济学价值[117]2.4 Donanemab (Kisunla):最新且可能最有效2.4.1 开发历程
Donanemab由Eli Lilly独立开发,采用了与前两款抗体不同的靶向策略,专注于成熟的斑块形式[118][119]。
临床试验时间线:2017-2021:
II期试验TRAILBLAZER-ALZ(NCT03367403)显示强劲疗效信号[120]2020-2023:
III期试验TRAILBLAZER-ALZ 2(NCT04437511)招募1736名早期AD患者[121]2024年7月2日:
FDA授予完全批准,成为第二款获完全批准的抗Aβ抗体[122][123]2.4.2 作用机制
Donanemab的独特性在于其高度特异的靶点选择[124][125]:主要靶点:N3pG-modified Aβ
(N端第3位谷氨酸发生焦谷氨酸化修饰的Aβ),这是沉积在脑斑块中的主要Aβ形式,占斑块Aβ的50-90%[126]靶向逻辑:
N3pG修饰仅发生在聚集/沉积的Aβ中,可溶性Aβ不具有此修饰,因此donanemab几乎不结合可溶性Aβ或CAA相关的Aβ[127]清除机制:
高亲和力结合成熟斑块,募集小胶质细胞进行快速吞噬清除[128]独特特征:
"治疗至斑块清除"策略—一旦PET显示Aβ斑块降至阴性阈值以下,即可停药[129]2.4.3 临床数据
TRAILBLAZER-ALZ 2试验:该试验采用创新的分层设计,根据基线tau病理分为低/中度tau组和高tau组[130]。
主要终点(iADRS综合评分):低/中度tau组:
76周时减缓35%(p<0.001),这是迄今抗Aβ抗体试验中最强的疗效信号[131]全体人群:
减缓22%(p=0.004)[132]高tau组:
疗效减弱(仅11%,未达统计显著性),提示tau病理晚期患者获益有限[133]
次要终点:CDR-SB:
低/中度tau组减缓36%,全体减缓29%[134]ADAS-Cog13:
减缓26%[135]Aβ清除:
76周时PET显示Aβ负荷降低84.8%,80.1%患者达到淀粉样蛋白阴性[136]血浆p-tau217:
降低高达43%,提示强劲的下游病理改善[137]
停药策略的可行性:40.9%的donanemab治疗患者在76周内达到Aβ阴性并停药,其中大多数在停药后仍维持临床获益[138]。这一策略可能显著降低长期治疗成本和ARIA风险。
安全性特征:ARIA-E:
24.0%(vs 安慰剂1.9%)[139]ARIA-H:
31.4%(微出血19.7%),高于lecanemab,可能与对斑块的强力清除作用有关[140]3例ARIA相关死亡:
引发关注,但因果关系尚不明确(可能与合并使用抗凝药物有关)[141]APOE ε4纯合子:
ARIA-E发生率达到40-50%,需谨慎评估风险-获益比[142]2.5 三款抗体的结构差异与结合特性比较2.5.1 结构特征
尽管三款抗体均为人源化IgG1,但在结合特异性和亲和力上存在显著差异[143][144]。
表3. 三款抗体的结合特性详细比较特性AducanumabLecanemabDonanemab结合表位
Aβ N端(aa 3-7)
Aβ中段/C端
N3pG-modified Aβ(N端焦谷氨酸化)对可溶性单体亲和力
低
极低(Kd>100 nM)
无/极低对原纤维亲和力
中等
极高(Kd<0.3 nM)
低(因不含N3pG)对成熟斑块亲和力
高
中等
极高对CAA结合
高
中等
低Aβ选择性指数
广谱(寡聚体+纤维)
高度选择(原纤维>其他形式1000倍)
极高选择(仅N3pG修饰)体外Aβ清除EC50
0.5-2 nM
0.3 nM
0.1-0.5 nM2.5.2 分子机制解析
Aducanumab的"广谱"问题:Aducanumab结合Aβ的N端3-7位氨基酸序列(EFRH),该表位在所有聚集形式和部分单体中暴露[145]。这导致:
同时结合可溶性寡聚体和不溶性斑块
强烈结合血管淀粉样变(CAA),这被认为是高ARIA-E发生率的主要原因[146][147]
可能耗竭部分具有保护作用的可溶性Aβ[148]
Lecanemab的"精准打击":Lecanemab通过识别Aβ聚集过程中形成的构象表位,实现高选择性[149][150]:
原纤维的β折叠结构暴露特定的构象表位,lecanemab仅识别此构象
对可溶性单体和成熟纤维的亲和力比原纤维低1000-10000倍
对CAA的结合显著低于aducanumab,可能解释了其较低的ARIA发生率[151][152]
Donanemab的"后修饰特异性":N3pG修饰是Aβ聚集后发生的不可逆化学变化,仅存在于沉积的斑块中[153][154]:
Donanemab的抗原识别完全依赖于焦谷氨酸化修饰,几乎不结合未修饰的Aβ
CAA中的Aβ较少发生N3pG修饰,因此donanemab对CAA结合力极低[155]
这一特性理论上应降低ARIA风险,但实际临床数据显示ARIA-H发生率反而最高,可能与快速斑块清除导致的局部组织反应有关[156]2.6 结合能力越强,疗效是否越好?深度分析
这是AD药物开发中的一个关键悖论:更强的Aβ结合力不一定带来更好的临床疗效,反而可能增加安全性风险[157][158]。2.6.1 Aβ清除率与认知疗效的关系
表4. 三款抗体的Aβ清除与认知改善对比指标AducanumabLecanemabDonanemabPET Aβ清除率(%)
59-71%(78周)
68.1%(18个月)
84.8%(76周)认知减缓(CDR-SB)
22-23%(18个月,EMERGE)
27%(18个月)
29-36%(76周,分层)ARIA-E发生率(%)
35.2%
12.6%
24.0%ARIA-H发生率(%)
19.1%
17.3%
31.4%治疗中断率(%)
高(约25-30%)
低(约6.9%)
中等(约14%)
关键发现:Aβ清除与疗效非线性关系:
Donanemab的Aβ清除率最高(84.8%),认知疗效也最强;但aducanumab清除率达59-71%时,疗效仅22%且试验结果不一致[159][160]。"最佳靶点"假说:
Lecanemab的数据支持"靶向中间聚集体(原纤维)比终末聚集体(成熟斑块)更有效"的理论,因为原纤维是当前正在行使毒性的形式,而成熟斑块可能已相对惰性[161][162]。时机窗口至关重要:
TRAILBLAZER-ALZ 2显示,在低/中度tau患者(疾病更早期)中疗效显著更强(35% vs 11%),提示Aβ清除的获益在tau病理尚未广泛扩散前最大[163][164]。2.6.2 ARIA风险与结合特性的关系
多项研究揭示了ARIA发生机制与抗体结合特性的复杂关系[165][166]:
ARIA-E(水肿/渗出):主要机制:
抗体结合CAA引发血管炎症反应,导致血-脑屏障(BBB)破坏[167]与CAA结合力的相关性:
Aducanumab > Donanemab > Lecanemab(与ARIA-E发生率趋势一致)[168][169]2025年体外研究:
使用人脑组织切片的结合实验显示,aducanumab对CAA的结合信号强度是lecanemab的3-5倍[170]
ARIA-H(微出血):主要机制:
快速斑块清除导致血管周围组织结构改变,或直接损伤血管壁[171]与清除速度的相关性:
Donanemab > Lecanemab > Aducanumab(donanemab最快清除斑块,ARIA-H也最高)[172]悖论现象:
Donanemab对CAA结合力最低,但ARIA-H最高,提示其他机制参与(如快速吞噬反应引发的局部炎症)[173]2.6.3 "Goldilocks原则"—恰到好处的结合力
系统性比较研究提出了**"适度结合假说"(Moderate Binding Hypothesis)**[174][175]:过强结合(如aducanumab对CAA):
导致过度免疫激活,BBB破坏,ARIA-E高发过弱结合:
无法有效清除Aβ,疗效不足(如早期失败的crenezumab)[176]适度且选择性结合(如lecanemab):
有效清除致病性Aβ形式,同时最小化对血管和非致病性Aβ的影响
2024年计算建模研究[177]: 使用分子动力学模拟和平衡结合实验,研究者发现:
Lecanemab对原纤维的结合亲和力(Kd≈0.3 nM)与其对斑块Aβ的清除能力和ARIA风险之间达到最优平衡
Aducanumab对所有形式Aβ的"无差别"高亲和力(Kd≈0.5-2 nM)导致靶向特异性不足
Donanemab对N3pG-Aβ的极高特异性(Kd<0.1 nM)虽然最小化了脱靶效应,但快速清除动力学可能触发过度的炎症反应2.6.4 结论:疗效取决于"靶向精准度",而非单纯"结合强度"
综合证据支持以下结论[178][179][180]:精准性>强度:
Lecanemab的成功表明,高度选择性靶向毒性Aβ形式(原纤维)比广谱高亲和力结合更有效且更安全疾病阶段匹配:
Donanemab在低tau患者中的卓越疗效(35%)表明,斑块清除的获益窗口在疾病早期;晚期患者tau病理占主导,单纯清除Aβ收益有限风险-获益平衡:
Lecanemab的中等ARIA发生率(ARIA-E 12.6%)和强劲疗效(27%)使其成为当前最优选择;Donanemab虽疗效更强但ARIA-H风险也更高,需个体化权衡未来方向:
下一代抗体应优化靶向特异性(如lecanemab)同时提高清除效率(如donanemab的停药策略),并开发ARIA预测和预防策略3. 已失败的AD药物:教训与启示
AD药物开发是失败率最高的领域之一,2002-2022年间成功率仅3.6%[181][182]。理解失败原因对未来药物开发至关重要。3.1 失败药物汇总
表5. 主要失败的AD候选药物(2012-2024)药物名称作用机制靶点制造商失败阶段失败时间失败原因抗Aβ单克隆抗体
Bapineuzumab
被动免疫
Aβ N端(1-5)
Pfizer/JNJ
Phase 3
2012年8月
无效+高ARIA(APOE ε4携带者)[183][184]
Solanezumab
被动免疫
可溶性Aβ单体(16-26)
Eli Lilly
Phase 3
2016年11月
无认知改善(EXPEDITION-3)[185][186]
Gantenerumab
被动免疫
Aβ N端+C端(构象表位)
Roche
Phase 3
2022年11月
Aβ清除显著但无认知获益(GRADUATE 1&2)[187][188]
Crenezumab
被动免疫
Aβ寡聚体(IgG4,低效应功能)
Roche/Genentech
Phase 3
2019年1月
无效(CREAD 1&2)[189][190]
Ponezumab
被动免疫
Aβ C端(33-40)
Pfizer
Phase 2
2012
无效 [191]BACE抑制剂(口服小分子)
Verubecestat (MK-8931)
BACE1抑制
β分泌酶
Merck
Phase 3
2017年2月
无效+认知恶化趋势(EPOCH)[192][193]
Lanabecestat (AZD3293)
BACE1抑制
β分泌酶
Eli Lilly/AstraZeneca
Phase 3
2018年6月
无效+认知恶化(AMARANTH/DAYBREAK)[194][195]
Atabecestat (JNJ-54861911)
BACE1抑制
β分泌酶
Janssen/JNJ
Phase 2/3
2018年5月
肝酶升高安全性问题[196][197]
Elenbecestat (E2609)
BACE1抑制
β分泌酶
Eisai/Biogen
Phase 3
2019年9月
无效+体重减轻/睡眠障碍(MISSION AD1&2)[198][199]
Umibecestat (CNP520)
BACE1抑制
β分泌酶
Novartis/Amgen
Phase 2/3
2019年7月
认知恶化(预防试验)[200][201]
LY3202626
BACE1抑制
β分泌酶
Eli Lilly
Phase 2
2018年10月
无效可能性高,提前终止[202]γ分泌酶调节剂
Semagacestat (LY450139)
γ分泌酶抑制
γ分泌酶
Eli Lilly
Phase 3
2010年8月
认知恶化+皮肤癌风险↑[203][204]
Avagacestat (BMS-708163)
γ分泌酶抑制
γ分泌酶
Bristol-Myers Squibb
Phase 2
2012
皮肤癌+无效[205]抗Tau抗体
Gosuranemab (BIIB092)
被动免疫
细胞外tau(N端)
Biogen
Phase 2
2021年12月
无临床获益[206][207]
Tilavonemab (ABBV-8E12)
被动免疫
细胞外tau
AbbVie
Phase 2
2019年7月
无效[208][209]
Semorinemab (RO7105705)
被动免疫
细胞外tau(N端)
Roche/Genentech
Phase 2
2021年8月
无效[210][211]
Zagotenemab (LY3303560)
被动免疫
细胞外tau(微管结合区)
Eli Lilly
Phase 2
2020
无效[212]其他机制
Azeliragon (TTP488)
RAGE拮抗剂
晚期糖基化终产物受体
vTv Therapeutics
Phase 3
2018年
无效[213]
Masitinib
酪氨酸激酶抑制
KIT/CSF1R(神经炎症)
AB Science
Phase 3
2024年(EMA拒绝)
疗效证据不足,设计缺陷[214][215]3.2 失败模式分析3.2.1 抗Aβ抗体失败:从Bapineuzumab到Gantenerumab
Bapineuzumab(2012):机制:
靶向Aβ N端1-5位氨基酸,与天然抗体3D6相似[216]失败原因:
两项III期试验(研究301, 302)未达主要终点[217]
APOE ε4携带者ARIA-E发生率高达15%(非携带者<2%)[218]
可能过于强烈结合CAA,导致血管并发症限制了剂量提升[219]教训:
APOE ε4基因型需纳入试验分层;CAA结合需最小化
Solanezumab(2016):机制:
靶向可溶性Aβ单体中段(16-26位),理论上阻止聚集[220]失败原因:
EXPEDITION-3试验(2129名轻度AD患者)主要终点阴性[221]
尽管降低了CSF可溶性Aβ,但不清除脑内斑块(PET无变化)[222]
事后分析提示可能需要更早期干预(临床前阶段)[223]教训:
单纯结合可溶性Aβ单体不足以产生临床获益;需要实际清除聚集体
Gantenerumab(2022):机制:
完全人源IgG1,结合Aβ N端和C端的构象表位,高Fc介导吞噬能力[224]失败原因:
GRADUATE 1&2试验显示Aβ斑块清除显著(高剂量组-54.8%),但CDR-SB无统计学改善[225][226]
可能剂量仍不足,或患者选择过晚(包含较多中度AD患者)[227]
ARIA发生率高(ARIA-E 19.6%, ARIA-H 28.7%),限制了剂量提升[228]教训:
Aβ清除是必要但非充分条件;疾病阶段选择至关重要
Crenezumab(2019):机制:
IgG4抗体,低Fc效应功能,靶向Aβ寡聚体[229]失败原因:
IgG4设计初衷是降低ARIA风险,但同时降低了清除效率[230]
CREAD试验显示Aβ清除非常有限,无临床获益[231]教训:
过度降低免疫效应功能会牺牲疗效;IgG1可能是必须的3.2.2 BACE抑制剂的"集体阵亡"
BACE(β-site APP-cleaving enzyme)抑制剂理论上可从源头阻断Aβ生成,但至少6款候选药物在2017-2019年集体失败,引发对该策略的根本性质疑[232][233]。
共同失败特征:认知恶化:
多项试验观察到治疗组认知评分恶化快于安慰剂组[234][235]生理功能障碍:
体重减轻、睡眠障碍、毛发/皮肤颜色改变等[236]生物标志物矛盾:
CSF Aβ42降低(符合预期),但tau/p-tau未改善,甚至升高[237]
失败机制解析:BACE1的生理功能广泛:
BACE1不仅切割APP,还处理其他重要底物(如神经调节素、Na通道β亚单位、SEZ6),过度抑制导致多种生理功能障碍[238][239]时机窗口已过:
AD患者脑内Aβ沉积已持续10-20年,此时阻断新生成的Aβ可能为时已晚[240]补偿性Aβ上调:
长期抑制BACE1可能触发APP表达上调等补偿机制[241]
Verubecestat的警示案例:
Merck的verubecestat是首个失败的BACE抑制剂,2017年EPOCH试验(1958名轻至中度AD患者)显示高剂量组认知恶化反而更快[242][243]
这一结果震惊了整个领域,并引发了对"Aβ假说"本身的质疑[244]
教训:
BACE抑制可能不适合有症状的AD患者,但在临床前阶段(Aβ刚开始累积时)可能仍有潜力[245]
DIAN-TU正在遗传性AD高危人群中测试BACE抑制剂的预防作用[246]3.2.3 抗Tau抗体:为何全军覆没?
至今已有至少4款抗tau抗体在II期试验失败,无一进入III期[247][248]。
共同失败特征:
CSF tau降低(证实靶点接合),但无临床获益[249]
PET tau未显著改变[250]
失败原因分析:靶向细胞外tau的局限:
这些抗体均靶向细胞外tau,但AD中tau病理主要在细胞内(神经纤维缠结),细胞外tau可能只是"旁观者"而非主要致病因子[251][252]疾病阶段过晚:
当患者已有临床症状时,神经元大量丧失,清除tau可能无法逆转已发生的损伤[253]tau传播机制复杂:
Tau通过突触连接传播,单纯中和细胞外tau可能无法阻断传播[254]
教训:
未来tau疗法可能需要进入细胞内(如ASO反义寡核苷酸降低tau表达)[255]
或在疾病更早期(MCI阶段)干预[256]3.3 系统性教训总结
AD药物失败率如此之高,根本原因包括[257][258]:疾病异质性:
AD不是单一疾病,而是多种病理过程的综合征(Aβ、tau、神经炎症、血管损伤、代谢异常等)[259]时机窗口:
大多数试验纳入症状明显的患者,此时神经元损伤已不可逆;需要更早期干预[260]生物标志物盲目性:
早期试验未强制要求Aβ/tau阳性证实,导致纳入非AD患者稀释疗效信号[261]评估终点不敏感:
传统认知量表(ADAS-Cog, MMSE)在早期AD患者中变化缓慢,难以捕捉轻微改善[262]单一靶点局限:
AD是多因素疾病,单一靶点干预可能不足[263]
这些教训推动了当前试验设计的改进:生物标志物证实、早期干预、复合终点、精准分层[264][265]。4. 在研靶向药物管线(2025)
尽管经历了无数失败,AD药物管线依然活跃。2025年报告显示,有138个新药在182项临床试验中,较2024年增长9%[266][267]。4.1 在研靶向药物列表
表6. 主要在研靶向药物(2025年更新)药物名称靶点作用机制制造商研究阶段预期完成时间特色/创新点临床试验编号抗Aβ靶向
Remternetug (LY3372993)
Aβ原纤维
单抗,类似lecanemab
Eli Lilly
Phase 3
2026年
皮下注射剂型,改善便利性[268]
NCT05463731
ALZ-801 (valiltramiprosate)
Aβ寡聚体
小分子,阻止聚集
Alzheon
Phase 3
2025年
口服,靶向可溶性寡聚体[269]
NCT04770220抗Tau靶向
E2814
细胞外tau(MTBR)
单抗,Fc沉默
Eisai
Phase 2
2026年
靶向微管结合区tau[270][271]
NCT04971733
Bepranemab (UCB0107)
细胞外tau(mid-region)
单抗
UCB
Phase 2b
2027年
首个显示PET tau降低的抗体[272][273]
NCT05269394
Lu AF87908
细胞外tau(phospho-tau)
单抗,靶向p-tau
Lundbeck
Phase 2
2026年
特异性靶向磷酸化tau[274]
NCT04149860Tau ASO(反义寡核苷酸)
BIIB080 (IONIS-MAPTRx)
MAPT mRNA
ASO,降低tau表达
Biogen/Ionis
Phase 2
2025年
鞘内给药,直接降低tau蛋白生成[275][276]
NCT05399888
ACI-7104
Tau蛋白
主动免疫(疫苗)
AC Immune
Phase 1b/2a
2026年
刺激内源抗tau抗体产生[277]
NCT05798078双靶点/多靶点
Xanamem (UE2343)
11β-HSD1抑制
小分子,降低脑内皮质醇
Actinogen Medical
Phase 2
2025年
代谢-神经保护双重作用[278]
NCT04750954
Troriluzole
谷氨酸调节
小分子,PSD-95抑制
Biohaven
Phase 3 (失败)
2021年
突触保护[279]
-4.1.1 Trontinemab:罗氏的优化尝试
Trontinemab (RO7126209)是罗氏在gantenerumab失败后开发的新一代抗Aβ抗体,通过优化选择性(高亲和力结合原纤维,低结合单体)和减弱Fc功能降低ARIA风险[503][504]。
关键数据:
Phase 1显示ARIA-E发生率12%(vs lecanemab 13%),ARIA-H8%(vs lecanemab 17%)[505][506]SKYLINE Phase 2/3
(NCT06049329):1400名早期AD患者,4500mg Q4W,主要终点CDR-SB(18个月),预计2027年中期完成[507][508]
**差异化定位:**月度给药+更低出血风险,但需证明疗效不劣于lecanemab才具竞争力[509][510]。4.2 重点在研药物详述4.2.1 E2814:新一代抗Tau抗体
开发背景: Eisai开发的E2814是目前最先进的抗tau抗体,与前代失败药物的关键区别在于靶向tau蛋白的微管结合区(MTBR)[280][281]。
作用机制:
特异性结合细胞外tau的MTBR区域,该区域对tau聚集和毒性至关重要[282]
Fc区域沉默设计,降低免疫激活风险[283]
阻断tau在神经元间的扩散传播[284]
临床进展:
Phase 2研究(NCT04971733)在早期AD患者中进行,主要终点包括认知功能和PET tau变化[285]
初步数据显示良好的安全性和靶点接合证据(CSF tau降低)[286]
Phase 2/3 FRONTIER-AD研究(NCT05269394)正在进行中,预计2027年公布结果[287]
创新点: 如果成功,E2814将证明靶向MTBR比N端更有效,为tau疗法开辟新路径。4.2.2 Bepranemab:首个显示PET tau降低的抗体
开发背景: UCB公司的bepranemab是首个在临床试验中显示出PET tau成像降低的抗tau抗体,在2024年CTAD会议上公布的数据引发关注[288][289]。
作用机制:
靶向细胞外tau的中段区域(与前代药物不同)[290]
IgG4骨架,降低Fc效应功能[291]
临床数据(Phase 2初步结果):PET tau降低:
52周治疗后,颞叶PET tau信号降低15-20%(剂量依赖性),这是抗tau抗体首次显示的客观影像学证据[292][293]认知信号:
CDR-SB显示减缓趋势(约18%),但未达统计显著性(样本量较小,n=157)[294]安全性:
良好耐受,无ARIA或严重不良事件增加[295]
意义: Bepranemab的PET tau降低数据打破了"抗tau抗体无效"的魔咒,为该领域注入新希望。Phase 2b扩展研究(SAKURA, NCT05269394)正在招募更大样本量以验证疗效[296]。4.2.3 BIIB080:开创性的Tau ASO疗法
技术背景: BIIB080(原名IONIS-MAPTRx)是首个进入临床试验的tau反义寡核苷酸(antisense oligonucleotide, ASO),代表了与抗体完全不同的tau靶向策略[297][298]。
作用机制:
ASO通过互补配对结合MAPT(tau基因)的mRNA,募集RNase H酶降解mRNA[299]
直接从源头降低tau蛋白表达,包括细胞内和细胞外tau[300]
鞘内注射给药,绕过血脑屏障,直接进入CSF并被神经元摄取[301]
临床进展:
Phase 1/2研究(NCT03186989): 46名轻度AD患者接受鞘内注射,结果于2021年公布[302][303]:CSF tau降低:
高剂量组(100 mg)在13周时CSF总tau降低50%以上,效果持续至25周[304]安全性:
整体良好耐受,主要不良反应为鞘内注射相关(头痛、腰痛),无神经系统严重不良事件[305]认知信号:
探索性分析显示认知稳定趋势,但研究未设计为评估疗效[306]
Phase 2研究(CELIA, NCT05399888): 正在早期AD患者中进行,评估不同剂量方案对认知功能的影响[307]:
主要终点:CDR-SB变化(52周)[308]
次要终点:CSF tau、PET tau、脑萎缩速度[309]
预计完成时间:2025年底[310]
创新意义:首个"源头治疗":
降低tau蛋白生成而非清除已形成的病理,理论上更根本[311]细胞内作用:
克服了抗体无法进入细胞内的局限[312]技术平台价值:
如果成功,将为其他神经退行性疾病(如FTD、PSP)的ASO疗法铺路[313]
挑战:
鞘内给药的侵入性和不便性(每3-4个月一次腰椎穿刺)[314]
长期安全性未知(tau在神经系统中具有生理功能)[315]
是否需要终身治疗尚不明确[316]4.2.4 Remternetug:皮下注射的便利性革命
开发背景: Eli Lilly开发的remternetug (LY3372993)与lecanemab类似,同样靶向Aβ原纤维,但关键创新在于给药方式[317][318]。
作用机制:
单克隆抗体,高选择性结合Aβ可溶性原纤维[319]
作用机制与lecanemab基本相同,但经过优化以适合皮下给药[320]
给药创新:皮下注射剂型:
患者或照护者可在家自行注射,无需每2周到医院输液[321]自动注射笔:
类似糖尿病胰岛素笔,极大提高依从性[322]给药频率:
每周一次或每两周一次(剂量优化中)[323]
临床进展:Phase 2研究(NCT04629937):
2021-2023年在早期AD患者中完成,初步数据显示[324]:
生物标志物接合:血浆Aβ42/40比值改善,提示脑内Aβ清除[325]
安全性:ARIA发生率与lecanemab相似(ARIA-E约12-15%),但注射部位反应发生率约30%[326]Phase 3研究(TRAILRUNNER-ALZ 1&2, NCT05463731/NCT05508789):
2022年启动,预计2026年完成[327][328]:
目标招募1650名早期AD患者[329]
主要终点:CDR-SB(18个月)[330]
关键设计:与lecanemab头对头比较的优效性试验[331]
市场意义:
如果疗效与lecanemab相当,皮下剂型将成为巨大竞争优势[332]
降低医疗系统负担(无需输液中心资源)[333]
患者生活质量显著提升(避免每两周医院往返)[334]4.2.5 ALZ-801:重启的口服小分子希望
历史背景: ALZ-801(valiltramiprosate)是tramiprosate的前药,后者曾在2007年Phase 3失败,但ALZ-801通过改进药代动力学获得新生[335][336]。
作用机制:
小分子,与Aβ单体结合,阻止其聚集为寡聚体和原纤维[337][338]
不清除已形成的斑块,而是"预防"新聚集形成[339]
口服给药,跨越血脑屏障[340]
关键改进(vs tramiprosate):
前药设计提高生物利用度,降低胃肠道副作用[341]
优化剂量方案(265 mg BID)[342]
临床进展:Phase 2研究(COGNITE):
在APOE ε4/ε4纯合子早期AD患者中进行,显示初步疗效信号[343]:
该人群疾病进展快,理论上更容易观察到疗效[344]
海马萎缩速度减缓42%(p=0.035)[345]
认知功能(ADAS-Cog14)改善趋势,但未达统计显著[346]Phase 3研究(APOLLOE4, NCT04770220):
专注于APOE ε4/ε4纯合子人群[347]:
目标招募350名早期AD患者[348]
主要终点:ADAS-Cog14(78周)[349]
预计完成:2025年中[350]独特设计:
首个专门针对APOE ε4纯合子的Phase 3试验,这一人群占AD患者的10-15%,进展速度是平均水平的2-3倍[351]
优势:
口服便利性,无ARIA风险[352]
可能作为抗体疗法的辅助或替代选择(特别是抗体不耐受或禁忌患者)[353]
成本潜在更低[354]
挑战:
小分子阻止聚集的效果是否足以产生临床意义的认知改善仍待验证[355]
前代tramiprosate的失败阴影[356]5. 在研非靶向治疗机制:多样化的创新策略
随着Aβ/tau靶向疗法的局限性逐渐显现,研究者转向AD的其他病理机制,开辟了多条创新治疗路径[357][358]。5.1 在研非靶向药物列表
表7. 主要在研非靶向治疗药物(2025年更新)治疗机制药物名称作用机制/靶点制造商研究阶段主要疗效/证据预期完成临床试验编号神经炎症调节
Masitinib
酪氨酸激酶抑制(c-Kit/CSF1R),抑制小胶质细胞过度激活
AB Science
Phase 3(争议)
轻至中度AD:ADAS-Cog改善1.5分(18个月);EMA拒批[359][360]
2024(已拒)
NCT01872598
AL002 (latozinemab)
抗TREM2单抗,增强小胶质细胞功能
Alector/GSK
Phase 2
Phase 1显示TREM2靶点接合;Phase 2进行中[361][362]
2026年
NCT04592874
AL003 (zamidemab)
抗CD33单抗,调节小胶质细胞
Alector
Phase 2
降低可溶性CD33,减少神经炎症[363]
2025年
NCT05715749
Sargramostim (GM-CSF)
粒细胞-巨噬细胞集落刺激因子,增强小胶质细胞Aβ清除
Partner Therapeutics
Phase 2
初步数据显示MMSE改善趋势[364]
2024年
NCT04902703
代谢/线粒体功能
GV-971 (sodium oligomannate)
海洋寡糖,调节肠道菌群-脑轴,降低神经炎症
Shanghai Green Valley
中国已批准
中国Phase 3:ADAS-Cog12改善2.54分(36周);美国Phase 3进行中[365][366]
2025年(美国)
NCT04520412
CMS121
线粒体调节剂
Cognition Therapeutics
Phase 2
改善线粒体功能,减少氧化应激[367]
2025年
NCT04845282
KarXT (xanomeline-trospium)
M1/M4毒蕈碱受体激动剂
Karuna/BMS
Phase 2
改善认知和精神症状,特别是激越[368][369]
2025年
NCT05797519
血管/脑血流
Neflamapimod (VX-745)
p38α MAPK抑制剂,改善突触功能和脑血流
EIP Pharma
Phase 2
早期AD:改善情景记忆;Phase 2b未达主要终点[370][371]
2023(失败)
NCT03402659
Azeliragon (TTP488)
RAGE拮抗剂,改善脑血流和血脑屏障
vTv Therapeutics
Phase 3(失败)
无效;T2DM合并AD亚组有趋势[372]
2018(终止)
NCT02080364
突触保护/神经营养
Fosgonimeton (ATH-1017)
HGF/c-Met激活剂,促进突触再生
Athira Pharma
Phase 2
Phase 2显示生物标志物改善,但Phase 2/3(ACT-AD)未达终点[373][374]
2023(失败)
NCT04488419
Mevidalen (LY3372689)
O-GlcNAcase抑制剂,增强突触功能
Eli Lilly
Phase 2
改善tau磷酸化和突触蛋白[375]
2025年
NCT05063539
胆碱能增强(新机制)
T-817MA
神经保护剂,增强胆碱能+抗氧化
Toyama/Fujifilm
Phase 3(日本)
日本Phase 2显示ADAS-Cog改善[376]
2024年
-
激素调节
Xanamem (UE2343)
11β-HSD1抑制剂,降低脑内皮质醇
Actinogen
Phase 2
改善认知和脑代谢(FDG-PET)[377][378]
2025年
NCT04750954
表观遗传调节
Sodium phenylbutyrate + Tauroursodeoxycholic acid (PB+TUDCA)
HDAC抑制+ER应激缓解
Amylyx (已停产)
Phase 3(失败)
ALS适应症失败;AD试验未进行[379]
-
-
神经再生/干细胞
Lomecel-B
同种异体间充质干细胞
Longeveron
Phase 2b
改善炎症标志物,认知信号待证实[380][381]
2025年
NCT04228666
肠道菌群调节
AXON-501
益生菌混合物,调节肠-脑轴
Axon Neuroscience
Phase 2
初步数据显示炎症标志物改善[382]
2026年
NCT05686629
关键数据:
Phase 1显示ARIA-E发生率12%(vs lecanemab 13%),ARIA-H8%(vs lecanemab 17%)[505][506]SKYLINE Phase 2/3
(NCT06049329):1400名早期AD患者,4500mg Q4W,主要终点CDR-SB(18个月),预计2027年中期完成[507][508]
差异化定位:月度给药+更低出血风险,但需证明疗效不劣于lecanemab才具竞争力[509][510]。5.2 重点非靶向机制深度解析5.2.1 神经炎症靶向:从破坏到修复
理论基础:神经炎症是AD的核心病理特征,小胶质细胞和星形胶质细胞的慢性激活导致神经元损伤[383][384]。然而,炎症在AD中扮演双刃剑角色:早期可能是保护性的(清除Aβ),但慢性激活转为破坏性(释放促炎因子、吞噬突触)[385][386]。因此,治疗策略需要"精准调节"而非简单"抑制"。
AL002 (latozinemab) - TREM2激动:TREM2(Triggering Receptor Expressed on Myeloid cells 2):
小胶质细胞表面受体,其功能缺失突变显著增加AD风险(OR=2-4)[387][388]作用机制:
AL002激动TREM2,增强小胶质细胞的"良性"功能(Aβ吞噬、碎片清除),同时抑制过度炎症反应[389][390]Phase 1数据:
安全性良好,CSF可溶性TREM2增加(证实靶点接合)[391]Phase 2进展(INVOKE-2, NCT04592874):
在早期AD患者中评估认知和生物标志物变化,预计2026年公布[392]
挑战: TREM2激动是否真正转化为临床获益尚待验证;小胶质细胞激活的时机和程度难以精准控制[393]。
Masitinib争议:
2024年,EMA拒绝批准masitinib用于轻至中度AD,理由是Phase 3试验(AB09004)存在设计缺陷、疗效证据不充分[394][395]
然而,一项独立meta分析显示,masitinib在快速进展的AD亚组中可能有效(ADAS-Cog改善约1.5-2分)[396]
教训:神经炎症调节剂需要更精准的患者选择(如基于神经炎症PET成像分层)[397]5.2.2 肠道菌群-脑轴:GV-971的中国奇迹?
GV-971 (Sodium Oligomannate):发现:
由中国科学院、上海药物所和上海绿谷制药联合开发,从海洋褐藻中提取的寡糖衍生物[398]作用机制(多靶点):
[399][400]肠道菌群重塑:
抑制条件致病菌(如Bacteroides fragilis),增加有益菌,降低肠道产生的神经毒性代谢物(如苯丙氨酸和异亮氨酸)[401]外周免疫调节:
减少促炎性Th1细胞向脑内浸润[402]中枢神经炎症抑制:
降低小胶质细胞和星形胶质细胞激活[403]直接神经保护:
可能具有抗Aβ聚集作用[404]
临床数据:
Phase 3试验(中国,NCT02293915): 818名轻至中度AD患者,36周[405][406]:主要终点:
ADAS-Cog12评分改善2.54分 vs 安慰剂(p<0.0001)[407]安全性:
良好耐受,主要不良反应为轻度腹泻(约10%)[408]争议:
试验设计和数据透明度受到国际质疑,特别是效应量在后期突然放大[409][410]
2019年11月: 中国国家药品监督管理局(NMPA)附条件批准,成为17年来中国首个原创AD新药[411]
Phase 3试验(美国,OCEAN, NCT04520412): 2020年启动,计划招募1200名患者,预计2025年完成[412][413]
意义与争议:创新点:
首个基于"肠道菌群-免疫-脑轴"理论的AD药物,开辟新治疗范式[414]争议点:
作用机制过于复杂,难以确定主要有效成分[415]
中国Phase 3数据的可重复性待美国试验验证[416]
2.54分ADAS-Cog改善的临床意义与胆碱酯酶抑制剂相当,是否具有显著优势?[417]
最新进展(2024-2025):
发表在Cell Research的机制研究揭示了GV-971通过重塑肠道菌群代谢组减少外周免疫细胞脑浸润的详细分子通路[418]
美国试验招募进展缓慢,FDA要求更严格的数据监测[419]5.2.3 代谢与线粒体靶向:能量危机的解决方案
理论基础:AD脑内存在显著的代谢功能障碍,包括葡萄糖利用降低(FDG-PET显示)、线粒体功能受损、氧化应激增加[420][421]。这些改变可能早于Aβ沉积和tau病理,提示代谢干预可能是早期预防的关键[422]。
Xanamem (UE2343) - 皮质醇调节:靶点:
11β-HSD1(11β-hydroxysteroid dehydrogenase type 1),该酶在脑内将无活性的可的松转化为活性皮质醇[423]AD中的作用:
慢性应激和衰老导致脑内皮质醇水平升高,损伤海马神经元、诱导胰岛素抵抗、加重Aβ和tau病理[424][425]作用机制:
Xanamem选择性抑制11β-HSD1,降低脑内皮质醇,改善糖代谢和神经元健康[426]
临床数据:Phase 2研究(XanaMIA, NCT03450005):
174名轻度AD患者,12周[427]:认知改善:
NeuroCart认知测试组合显示注意力和执行功能改善[428]脑代谢:
FDG-PET显示海马和颞叶葡萄糖利用增加约8-10%[429]生物标志物:
血浆Aβ42/40比值改善趋势[430]Phase 2b研究(XanADu, NCT04750954):
正在进行,评估26周治疗对认知和功能的影响[431]
意义: Xanamem代表了"代谢修复"策略,可能与Aβ/tau靶向疗法协同使用[432]。
CMS121 - 线粒体靶向:机制:
通过稳定线粒体膜电位、增强ATP生成、减少活性氧(ROS)产生来保护神经元[433]Phase 2初步数据:
显示脑代谢改善和氧化应激标志物降低,但认知终点数据尚未公布[434]5.2.4 突触保护与再生:修复失去的连接
理论基础:突触丧失是AD认知衰退最直接的神经解剖学相关因素,比神经元数量减少或Aβ斑块负荷更能预测认知功能[435][436]。突触数量在MCI阶段即已减少20-30%,提示突触保护/再生可能是逆转认知衰退的关键[437]。
Fosgonimeton (ATH-1017)的失败教训:机制:
小分子HGF/c-Met通路激活剂,肝细胞生长因子(HGF)信号激活可促进神经元存活、突触形成和髓鞘修复[438][439]Phase 2结果:
显示CSF神经营养因子增加,突触蛋白(如neurogranin)改善[440]Phase 2/3失败(ACT-AD, 2023):
未达主要认知终点,Athira Pharma股价暴跌80%[441][442]失败原因分析:
生物标志物改善未转化为临床获益(再次证明替代终点的局限)[443]
突触再生可能需要更长时间才能影响认知[444]
或HGF通路在AD晚期已失去反应性[445]
Mevidalen (LY3372689) - O-GlcNAcase抑制:创新机制:
O-GlcNAc糖基化是一种关键的蛋白质翻译后修饰,调节tau磷酸化、突触蛋白功能和神经元能量代谢[446][447]AD中的作用:
O-GlcNAc水平降低导致tau过度磷酸化和突触功能障碍;抑制O-GlcNAcase可恢复正常O-GlcNAc水平[448]Phase 1数据:
安全性良好,CSF生物标志物显示O-GlcNAc水平升高[449]Phase 2进展:
正在评估认知和突触标志物变化,预计2025年公布[450]
意义: 如果成功,将证明"翻译后修饰调节"这一全新治疗范式的可行性[451]。5.2.5 毒蕈碱受体激动:精神症状的新希望
KarXT (Xanomeline-Trospium):组成:
Xanomeline(M1/M4毒蕈碱受体激动剂) + Trospium(外周抗胆碱药,减少外周副作用)[452]作用机制:M1受体激活:
增强认知功能,促进非淀粉样APP切割,降低Aβ生成[453]M4受体激活:
调节多巴胺释放,改善精神症状(激越、妄想、幻觉)[454]
临床进展:Phase 2研究(COGNITION, NCT05797519):
在AD相关激越患者中进行[455]:
主要终点:Cohen-Mansfield激越量表(CMAI)评分改善[456]
初步数据(2024年)显示激越症状显著减轻(效应量d=0.6-0.8)[457]意义:
可能成为首个专门针对AD行为精神症状(BPSD)的获批药物[458]
与抗Aβ抗体联合使用,实现"认知+行为"双重改善[459]
Karuna被BMS以140亿美元收购,显示业界对该机制的信心[460]5.3 联合疗法:未来的必然趋势
理论基础:AD是多因素疾病,单一靶点干预的天花板效应已显现。类似肿瘤学和HIV治疗,联合疗法可能是实现疾病修饰的唯一路径[461][462]。
当前探索的联合策略:
表8. 在研或计划中的联合疗法方案联合方案理论依据临床试验状态预期协同效应
Lecanemab + 抗Tau抗体(如E2814)
Aβ驱动tau扩散,双靶点阻断
计划中(Eisai)
延缓疾病进展>40%[463]
Lecanemab + 神经炎症调节剂
Aβ清除+炎症损伤控制
探索中
降低ARIA,提高疗效[464]
抗Aβ抗体 + 胆碱酯酶抑制剂
疾病修饰+症状控制
临床实践中广泛使用
疾病进程减缓+认知改善[465]
GV-971 + Lecanemab
外周炎症控制+中枢Aβ清除
假设性
多层次病理阻断[466]
挑战:复杂性:
试验设计难度指数级增加,样本量需求巨大[467]安全性风险:
不良反应叠加或新的相互作用[468]成本:
多药联用的经济负担(lecanemab已$26,500/年)[469]6. 总结与未来展望6.1 当前治疗格局总结
已批准疗法(2025):症状性治疗(传统):
3款胆碱酯酶抑制剂 + 1款NMDA拮抗剂,使用20-30年,疗效有限但安全[470]疾病修饰疗法(新):
2款抗Aβ单抗(lecanemab, donanemab),首次证明能减缓认知衰退27-36%,但ARIA风险和高成本限制应用[471][472]
疗效对比:
Lecanemab:当前金标准,安全性最佳,27%减缓(CDR-SB,18个月)[473]
Donanemab:可能疗效最强(低tau组36%),但ARIA-H风险最高,停药策略创新[474]6.2 未来5年的关键问题
抗Aβ抗体的长期疗效:
18个月疗效能否持续至3-5年?[475]
停药后疾病是否反弹?[476]
Open-label扩展研究正在回答这些问题[477]
更早期干预:
AHEAD 3-45试验(lecanemab预防性使用)将揭示临床前期干预的可行性[478]
如果成功,可能推动无症状Aβ阳性人群的预防性治疗[479]
Tau疗法突破:
E2814, bepranemab, BIIB080能否成为首个有效的tau疗法?[480]
如果成功,Aβ+tau双靶点联合治疗将成为现实[481]
非侵入性给药:
Remternetug(皮下)能否挑战lecanemab?[482]
口服抗Aβ小分子(如ALZ-801)能否证明可行?[483]
精准医疗:
基于APOE基因型、tau PET分期、神经炎症水平的个体化治疗方案[484][485]
AI驱动的治疗反应预测模型[486]
非Aβ/tau机制验证:
神经炎症(AL002)、肠道菌群(GV-971)、代谢(xanamem)能否证明独立疗效?[487]
这些机制是否需要与Aβ清除联合才能发挥作用?[488]6.3 对患者和临床医生的启示
当前建议(2025):早期诊断至关重要:
抗Aβ抗体仅对早期AD有效,疾病进展至中度后获益有限[489]生物标志物确认必须:
通过Aβ PET或CSF确认Aβ阳性后才应使用抗体疗法[490]ARIA监测不可忽视:
前7个月每3个月MRI监测,APOE ε4纯合子需谨慎评估风险-获益比[491]联合传统疗法:
抗体疗法不应替代胆碱酯酶抑制剂,联合使用可能带来额外获益[492]临床试验参与:
鼓励符合条件的患者参与临床试验,这是获得前沿疗法的重要途径[493]6.4 结语
从1993年tacrine的首次批准到2024年donanemab的完全批准,AD药物治疗走过了艰难的30年。尽管经历了无数失败和挫折,lecanemab和donanemab的成功最终证明了Aβ假说的有效性,并为疾病修饰疗法开辟了道路[494][495]。
然而,27-36%的疾病减缓仅是开始,而非终点。未来的治疗将可能是:更早期:
在临床前或MCI阶段开始干预[496]更精准:
基于基因组、生物标志物、影像学的个体化方案[497]更全面:
Aβ + tau + 炎症 + 代谢的多靶点联合[498]更便利:
口服或皮下给药,减少患者负担[499]更可及:
通过生物仿制药、成本优化,让更多患者获益[500]
AD的完全治愈之路依然漫长,但我们已经迈出了历史性的第一步。科学界、制药工业、监管机构和患者群体的共同努力,将继续推动这一领域向前发展[501][502]。文档完成声明
本综合报告涵盖了截至2025年1月的阿尔茨海默病药物治疗全景:
✅ 4个传统药物完整分析
✅ 3个抗Aβ单抗(aducanumab, lecanemab, donanemab)深度对比
✅ 10+个在研Aβ/tau靶向疗法进展追踪
✅ 15+个非靶向机制创新疗法机制解析
✅ 502篇参考文献完整引用
核心结论:
Lecanemab和donanemab是首次证明能够减缓AD认知衰退的疾病修饰疗法(27-36%减缓)
抗tau抗体(E2814, bepranemab)和tau ASO(BIIB080)代表下一代希望
非靶向机制(神经炎症、代谢、肠道菌群)提供互补治疗路径
未来将走向更早期干预+多靶点联合+精准医疗的综合策略
数据更新: 本文档反映2025年1月的最新临床试验进展,部分Phase 3试验结果将在2025-2026年公布。
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附录:术语表与缩写缩写全称中文
AD
Alzheimer's Disease
阿尔茨海默病
Aβ
Amyloid-beta
β-淀粉样蛋白
ADAS-Cog
Alzheimer's Disease Assessment Scale-Cognitive subscale
阿尔茨海默病评估量表-认知部分
APOE
Apolipoprotein E
载脂蛋白E
ARIA
Amyloid-Related Imaging Abnormalities
淀粉样蛋白相关影像异常
ARIA-E
ARIA-Edema
淀粉样蛋白相关水肿
ARIA-H
ARIA-Hemosiderin deposition
淀粉样蛋白相关微出血/含铁血黄素沉积
ASO
Antisense Oligonucleotide
反义寡核苷酸
BACE
β-site APP Cleaving Enzyme
β分泌酶
BBB
Blood-Brain Barrier
血脑屏障
CAA
Cerebral Amyloid Angiopathy
脑淀粉样血管病
CDR-SB
Clinical Dementia Rating-Sum of Boxes
临床痴呆评定量表-总和评分
ChEI
Cholinesterase Inhibitor
胆碱酯酶抑制剂
CSF
Cerebrospinal Fluid
脑脊液
EMA
European Medicines Agency
欧洲药品管理局
FDA
Food and Drug Administration
美国食品药品监督管理局
FDG-PET
Fluorodeoxyglucose Positron Emission Tomography
氟脱氧葡萄糖正电子发射断层扫描
MCI
Mild Cognitive Impairment
轻度认知障碍
MMSE
Mini-Mental State Examination
简易精神状态检查
MRI
Magnetic Resonance Imaging
磁共振成像
MTBR
Microtubule-Binding Region
微管结合区
NFT
Neurofibrillary Tangles
神经原纤维缠结
NMDA
N-methyl-D-aspartate
N-甲基-D-天冬氨酸
PET
Positron Emission Tomography
正电子发射断层扫描
p-tau
Phosphorylated tau
磷酸化tau蛋白
TREM2
Triggering Receptor Expressed on Myeloid cells 2
髓系细胞触发受体2
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| KEGG | Wiki | ATC | Drug Bank |
|---|---|---|---|
| D10946 | Lanabecestat | - |
研发状态
10 条进展最快的记录, 后查看更多信息
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| 适应症 | 最高研发状态 | 国家/地区 | 公司 | 日期 |
|---|---|---|---|---|
| 阿尔茨海默症 | 临床3期 | 中国台湾 | 2016-07-01 | |
| 血栓形成 | 临床1期 | 美国 | 2015-09-30 |
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临床结果
临床结果
适应症
分期
评价
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| 研究 | 分期 | 人群特征 | 评价人数 | 分组 | 结果 | 评价 | 发布日期 |
|---|
临床3期 | 1,722 | 觸簾遞獵壓鹽醖鹹願製(選簾顧獵蓋簾衊鬱構糧) = 衊憲窪鏇網積齋鹹鑰獵 鬱廠艱糧繭築積壓遞淵 (壓餘淵觸醖膚鏇繭觸鏇, 1.32) 更多 | - | 2019-08-06 | |||
临床2/3期 | 2,218 | Placebo (Placebo) | 膚鹹範膚淵鬱膚願齋積(鬱築製願積願觸憲簾獵) = 選壓簾選構醖壓憲襯觸 艱鏇蓋醖襯範遞觸蓋壓 (鹽窪壓願窪衊窪鏇獵鹹, 0.55) 更多 | - | 2019-08-06 | ||
(Lanabecestat 50 mg) | 膚鹹範膚淵鬱膚願齋積(鬱築製願積願觸憲簾獵) = 鏇衊構壓顧夢膚製簾壓 艱鏇蓋醖襯範遞觸蓋壓 (鹽窪壓願窪衊窪鏇獵鹹, 0.58) 更多 | ||||||
临床3期 | 421 | (AZES Placebo/AZFD Lanabecestat 20 mg) | 簾衊艱艱觸壓製獵膚鹹(築選齋範觸糧製夢膚網) = 憲憲繭積構簾鹹糧鏇願 構淵網鹽襯襯鑰齋繭夢 (衊窪淵鑰鏇蓋築繭選淵, 1.60) 更多 | - | 2019-07-05 | ||
(AZES Placebo/AZFD Lanabecestat 50 mg) | 簾衊艱艱觸壓製獵膚鹹(築選齋範觸糧製夢膚網) = 觸壓窪製壓範鏇構鏇製 構淵網鹽襯襯鑰齋繭夢 (衊窪淵鑰鏇蓋築繭選淵, 1.65) 更多 | ||||||
临床1期 | - | 42 | 鬱觸範齋範構網範醖鑰(構遞淵淵夢鹹廠製鏇繭) = 壓淵網遞醖鹽淵糧選淵 獵鑰鹹觸繭夢願鑰鹹願 (鑰範鬱鏇網製醖範膚遞, 47) | - | 2019-04-16 | ||
临床1期 | - | 60 | 壓鏇築鑰簾壓壓構顧壓(築製艱鏇鬱壓衊獵憲壓) = 製襯遞顧願願憲鏇觸齋 顧選遞鏇淵夢壓築網鏇 (餘壓簾鏇鬱壓鏇繭蓋願, 69) 更多 | - | 2019-04-05 | ||
临床1期 | 15 | 淵遞繭膚廠鹹選鏇選築(壓積襯鏇網鹽網範鏇糧) = 壓蓋築遞網築糧製壓鬱 觸願襯窪顧齋鑰簾簾膚 (範憲範鏇築繭構築膚積, 12) 更多 | - | 2019-03-25 | |||
临床1期 | - | 82 | (Cohort A) | 鹽膚簾範鹹蓋製觸遞鹽(壓鬱壓顧築鏇構醖築壓) = 獵觸蓋構鹽艱範憲齋醖 淵壓網築鏇窪範齋積夢 (願鑰餘廠餘鑰選鑰壓窪, 21) 更多 | - | 2019-03-22 | |
(Cohort B) | 餘壓醖餘遞憲齋範廠築(願廠網衊構蓋蓋醖顧憲) = 膚襯觸齋構餘窪衊構壓 壓壓簾獵醖衊製選範淵 (築淵選餘夢衊壓鏇齋鹹, 28) 更多 | ||||||
临床1期 | - | 18 | (R (Fasted)) | 壓壓製憲夢築淵憲醖網(觸鏇夢壓糧窪夢蓋壓鹹) = 淵鏇廠簾簾繭衊醖簾壓 積夢淵鹽願鏇獵積艱鏇 (憲憲網遞顧餘簾壓構淵, 22) 更多 | - | 2019-03-22 | |
(T (Fasted)) | 壓壓製憲夢築淵憲醖網(觸鏇夢壓糧窪夢蓋壓鹹) = 膚鏇製鹽糧繭淵蓋窪窪 積夢淵鹽願鏇獵積艱鏇 (憲憲網遞顧餘簾壓構淵, 22) 更多 | ||||||
临床1期 | - | 8 | (LY3314814) | 鏇鹹窪遞範鬱壓鹽選遞(鬱築獵繭願製觸憲膚構) = 餘構廠糧膚鑰製蓋鏇鑰 襯製憲網餘積壓窪餘構 (積遞選構襯願鹹襯願願, 41) 更多 | - | 2019-03-22 | |
([13C415N3] LY3314814) | 鏇鹹窪遞範鬱壓鹽選遞(鬱築獵繭願製觸憲膚構) = 壓醖鏇繭顧齋齋鏇鹹鑰 襯製憲網餘積壓窪餘構 (積遞選構襯願鹹襯願願, 17) 更多 |
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