Cited by 988Alzheimer's disease research and treatmentsDementia and Cognitive Impairment ResearchCholinesterase and Neurodegenerative Diseases

The DOI matches its Crossref record; 559 of the 562 references it cites were found in a registry or an index; 10 of the 349 sources its claims cite were checked for support.

Amyloid β-based therapy for Alzheimer’s disease: challenges, successes and future

Open access
Zhang, Yun, Chen, Huaqiu, Li, Ran, Sterling, Keenan, Song, Weihong·2023·Signal Transduction and Targeted Therapy

Abstract

Amyloid β protein (Aβ) is the main component of neuritic plaques in Alzheimer’s disease (AD), and its accumulation has been considered as the molecular driver of Alzheimer’s pathogenesis and progression. Aβ has been the prime target for the development of AD therapy. However, the repeated failures of Aβ-targeted clinical trials have cast considerable doubt on the amyloid cascade hypothesis and whether the development of Alzheimer’s drug has followed the correct course. However, the recent successes of Aβ targeted trials have assuaged those doubts. In this review, we discussed the evolution of the amyloid cascade hypothesis over the last 30 years and summarized its application in Alzheimer’s diagnosis and modification. In particular, we extensively discussed the pitfalls, promises and important unanswered questions regarding the current anti-Aβ therapy, as well as strategies for further study and development of more feasible Aβ-targeted approaches in the optimization of AD prevention and treatment.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This review argues that Aβ accumulation remains a central driver of AD and that recent anti-Aβ successes—including FDA approval of aducanumab and lecanemab—have revived the amyloid cascade hypothesis. It summarizes Aβ biology, biomarkers, and anti-Aβ drug development while outlining persistent challenges such as insufficient specificity, inadequate animal models, late treatment, and loss of physiological Aβ functions.

Key findings

  • Of 298 AD therapies in clinical trials (ALZFORUM, March 2023), 76 target Aβ or its aggregates; 38 were discontinued due to ineffectiveness or toxic side effects, and two antibody-based drugs—aducanumab and lecanemab—have been approved by the FDA.
  • Lecanemab’s Phase 3 trial reduced cognitive and functional decline as measured by CDR-SB by 27% versus placebo; ARIA occurred in around 21% of lecanemab-treated individuals versus just over 9% of placebo controls. Donanemab’s partial Phase 3 results showed a 35% slowing of cognitive and functional decline, with 47% of treated participants showing no clinical progression at 1 year versus 29% on placebo.
  • BACE1 inhibitors and γ-secretase inhibitors/modulators largely failed or were discontinued because of toxicity, lack of substrate specificity, or insufficient efficacy; examples include LY2886721, atabecestat, elenbecestat, lanabecestat, umibecestat, avagacestat, and several γ-secretase modulators.
  • Soluble Aβ at physiological levels has reported functions including enhancement of LTP, stimulation of neuronal differentiation, promotion of injury recovery, antimicrobial activity, tumor suppression, antioxidant effects, neurogenesis, and maintenance of BBB integrity, so therapies should ideally target fibrils, protofibrils, or oligomers while preserving normal Aβ monomers.

Methods

  • Narrative review; no systematic review protocol, search strategy, or formal evidence appraisal is stated.
  • Sources include published literature and clinical trial registries, specifically ALZFORUM (March 2023) and clinicaltrials.gov (accessed March 19, 2023), plus cited references.
  • Main analysis is a narrative synthesis of the amyloid cascade hypothesis, Aβ aggregation and pathological roles, Aβ-based biomarkers, anti-Aβ therapies, challenges, and future directions.

Limitations

  • The paper states that anti-Aβ therapy faces disturbed physiological functions of soluble Aβ, insufficient specificity (e.g., γ-secretase and BACE1 off-target effects), lack of accurate animal models, and late application relative to biomarker onset.
  • It states that current animal models mainly mimic familial AD and cannot fully reflect late-onset sporadic AD complexity, including aging, human immune differences, and extensive neuronal loss.
  • Evident from the text: as a narrative review, it does not describe systematic search or selection criteria, quality appraisal, or quantitative synthesis; conclusions rely on author interpretation of the cited literature.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1038/s41392-023-01484-7

Cites

559 of 559 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Figures

Fig. 1 Amyloidogenic and non-amyloidogenic processing pathways of APP. In the amyloidogenic pathway, BACE1 first cleaves APP at the Asp1 site to generate sAPPβ and a 99-amino acid membrane-bound C-terminal fragment (CTF) C99. Subsequently, γ-secretase cleaves C99 to release Aβ and CTFγ. Under physiological conditions (non-amyloidogenic pathways), APP is mostly cleaved first by α-secretase within Aβ domain at the Aβ Leu17 site, generating a secreted form of APP (sAPPα) and an 83-amino acid membrane-bound C-terminal fragment (CTF) C83, thus precluding Aβ production; BACE1 predominantly processes APP at the Aβ Glu11 β-secretase site to generate C89, and γ-secretase cleaves C89 to produce a truncated Aβ11-40; BACE2 cleaves APP at the Aβ Phe20 θ-secretase site to generate C80 and precludes Aβ generation. APP amyloid precursor protein, BACE1 β-site APP-cleaving enzyme 1, sAPP secreted APP, CTF C-terminal fragment, Aβ amyloid-β, tAβ truncated amyloid-β, BACE2 β-site APP-cleaving enzyme 2
Fig. 1 Amyloidogenic and non-amyloidogenic processing pathways of APP. In the amyloidogenic pathway, BACE1 first cleaves APP at the Asp1 site to generate sAPPβ and a 99-amino acid membrane-bound C-terminal fragment (CTF) C99. Subsequently, γ-secretase cleaves C99 to release Aβ and CTFγ. Under physiological conditions (non-amyloidogenic pathways), APP is mostly cleaved first by α-secretase within Aβ domain at the Aβ Leu17 site, generating a secreted form of APP (sAPPα) and an 83-amino acid membrane-bound C-terminal fragment (CTF) C83, thus precluding Aβ production; BACE1 predominantly processes APP at the Aβ Glu11 β-secretase site to generate C89, and γ-secretase cleaves C89 to produce a truncated Aβ11-40; BACE2 cleaves APP at the Aβ Phe20 θ-secretase site to generate C80 and precludes Aβ generation. APP amyloid precursor protein, BACE1 β-site APP-cleaving enzyme 1, sAPP secreted APP, CTF C-terminal fragment, Aβ amyloid-β, tAβ truncated amyloid-β, BACE2 β-site APP-cleaving enzyme 2CC BY · PubMed Central
Fig. 2 Milestone of the amyloid cascade hypothesis and its applications. Yellow box: key research findings; blue box: the Aβ-related toxicity; green box: the diagnostic application; pink box: important drug and non-drug anti-Aβ therapies. AD Alzheimer’s disease, CSF cerebrospinal fluid, FDA food and Drug Administration, LTP long-term potentiation
Fig. 2 Milestone of the amyloid cascade hypothesis and its applications. Yellow box: key research findings; blue box: the Aβ-related toxicity; green box: the diagnostic application; pink box: important drug and non-drug anti-Aβ therapies. AD Alzheimer’s disease, CSF cerebrospinal fluid, FDA food and Drug Administration, LTP long-term potentiationCC BY · PubMed Central
Fig. 3 The generation, aggregation and pathological functions of Aβ. Aβ is generated from APP by sequential cleavage of β-secretase (beta-site APP cleaving enzyme 1, BACE1) and γ-secretase. BACE1 first cleaves APP at the Asp1 site to generate sAPPβ and C99. Subsequently, γ-secretase cleaves C99 to release Aβ (Aβ1-40/42 are the most common isoforms) and CTFγ. After secretion, Aβ peptides first oligomerize into different soluble species then convert their conformation into profibrils and cross-β-sheet fibrils, forming amyloid plaques. Aβ aggregates interact with tau proteins to exert the toxic effects. In addition, they contribute to other AD pathological features including neuroinflammation, oxidative stress and mitochondrial dysfunction, leading to neuronal death and dysfunction. Aβ amyloid β, APP amyloid precursor protein
Fig. 3 The generation, aggregation and pathological functions of Aβ. Aβ is generated from APP by sequential cleavage of β-secretase (beta-site APP cleaving enzyme 1, BACE1) and γ-secretase. BACE1 first cleaves APP at the Asp1 site to generate sAPPβ and C99. Subsequently, γ-secretase cleaves C99 to release Aβ (Aβ1-40/42 are the most common isoforms) and CTFγ. After secretion, Aβ peptides first oligomerize into different soluble species then convert their conformation into profibrils and cross-β-sheet fibrils, forming amyloid plaques. Aβ aggregates interact with tau proteins to exert the toxic effects. In addition, they contribute to other AD pathological features including neuroinflammation, oxidative stress and mitochondrial dysfunction, leading to neuronal death and dysfunction. Aβ amyloid β, APP amyloid precursor proteinCC BY · PubMed Central
Fig. 4 The physiological functions of soluble Aβ. Soluble Aβ at physiological levels has been identified to have some important functions, including induction of long-term potentiation (LTP), stimulation of neuronal differentiation, improvement of brain recover from injuries, inhibition of oxidative stress, antimicrobial activity and tumor suppression
Fig. 4 The physiological functions of soluble Aβ. Soluble Aβ at physiological levels has been identified to have some important functions, including induction of long-term potentiation (LTP), stimulation of neuronal differentiation, improvement of brain recover from injuries, inhibition of oxidative stress, antimicrobial activity and tumor suppressionCC BY · PubMed Central

Verification

Claims the paper makes

199 Not checked yet · 21 Own interpretation · 9 No basis given · 5 Partly supported · 1 Supported · 1 Supported so far · 1 Own result · accuracy not yet measured

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Show all 144 claims

  • It may state two separate claims as one. 79
  • Probably not a substantial claim. 16
  • The quote only partly states this claim. 1
93 of 93
  • The paper relies on this without support.

    The single molecular assay (Simoa) allows measurement of Aβ40 and Aβ42 levels at sub-femtomolar concentration.

    “Recently, the development of single molecular assay (Simoa), an ultra-sensitive immunoassay technology, allows the measurement of Aβ40 and Aβ42 levels at sub-femtomolar concentration.”
  • The paper relies on this without support.

    The currently approved AD drugs can only help alleviate symptoms instead of modifying the disease.

    “However, these drugs can only help alleviate the symptoms instead of modifying the disease.”
  • The paper relies on this without support.

    38 of the Aβ-targeting therapies have been discontinued due to ineffectiveness or toxic side effects.

    “So far, two antibody-based drugs aducanumab and lecanemab have been approved by the FDA and 38 of them have been discontinued due to ineffectiveness or toxic side effects.”
  • The paper relies on this without support.

    All γ-secretase modulators have been discontinued in clinical trials.

    “Unfortunately, all of them have been discontinued in the clinical trials.”
  • The paper relies on this without support.

    The Aβ-mAb complex induces complement-dependent cytotoxicity, resulting in lysis of target cells.

    “In addition, the Aβ-mAb complex induces the complement-dependent cytotoxicity, resulting in the lysis of the target cells.”
  • The paper relies on this without support.

    Most traditional Chinese medicine treatments are derived from natural products with multi-target, multi-pathway capacity and mild adverse events.

    “Most TCM treatment are derived from natural products with multi-target, multi-pathway capacity and mild adverse events.”
  • The paper relies on this without support.

    Brain organoids can only be cultured within six months; otherwise volume shrinkage and cellular apoptosis occur because oxygen and nutrients cannot reach the innermost organoid regions.

    “So far, brain organoids can only be cultured within six months, otherwise volume shrinkage and cellular apoptosis occur as neither the oxygen nor nutrients will be able to reach the innermost organoid regions.”
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Citations

Cites

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Research works printed but not linked: 1

  1. Walker, L. C. Abeta plaques. Free Neuropathol. 1, 31 (2020).

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Metadata

Authors
Zhang, Y., Chen, H., Li, R., Sterling, K., & Song, W.
Affiliations
  • Capital Medical University (CN)
  • Wenzhou Medical University (CN)
  • University of British Columbia (CA)
Corresponding author
  • Zhang, Yun
  • Song, Weihong
Venue
Signal Transduction and Targeted Therapy
Published
2023-06-30
Volume
8
Issue
1
Pages
248-248
ISSN
2059-3635 (ISSN-L)
OpenAlex
W4382601497
Cited by
988
References
562
Citations by year
2026: 278 · 2025: 422 · 2024: 257 · 2023: 30
FWCI
35.22
Type
journal article
Language
en
Open access
Locations
  • Signal Transduction and Targeted Therapy (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
National Natural Science Foundation of China (82150710557, 82201576)
Topics
  • Life Sciences › Neuroscience › Cellular and Molecular Neuroscience › Alzheimer's disease research and treatments
  • Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
  • Health Sciences › Medicine › Pharmacology (medical) › Cholinesterase and Neurodegenerative Diseases
Keywords
amyloid-beta, Alzheimer's disease, amyloid hypothesis, anti-amyloid therapy, neuritic plaques, Alzheimer's disease prevention, Alzheimer's disease treatment, Alzheimer's disease diagnosis
MeSH terms
Alzheimer Disease, Humans, Amyloid beta-Peptides, Plaque, Amyloid

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