Caratterizzazione pre-clinica di una nuova strategia terapeutica per l'ischemia cerebrale identificata mediante drug repurposing di un antibiotico macrolide

Abstract

Cerebral ischemia is one of the most common causes of disability and mortality worldwide and the only pharmacological treatment currently available is thrombolysis. The understanding of the mechanisms underlying ischemic injury has led to the identification of several neuroprotective compounds aimed at the recovery of the damaged brain tissue. However, most of these drugs have produced disappointing results in clinical trials because of the high toxicity or lack of efficacy in patients. Therefore, there is a real need to develop novel therapeutic strategies that do not consider neurons as the only target. In fact, the neuronal damage is strongly influenced by the inflammatory and immune processes that develop both locally and systemically after ischemia. The inflammatory response evolves slowly, and this allows to significantly expand the time window for pharmacological intervention, highlighting the therapeutic potential of anti-inflammatory and immunomodulatory drugs. Therefore, the first objective of this work was to characterize central and peripheral inflammatory responses that occur following an ischemic insult in rodents. In particular, in order to identify potential targets, we have evaluated the temporal profile of activation of specific inflammatory cells. By immunofluorescence analysis, we observed an early activation of microglia and astrocytes in the ischemic hemisphere, as a result of transient middle cerebral artery occlusion (MCAo) in rodents. We have also detected a massive brain recruitment of neutrophils and macrophages, with a peak of infiltration 48 hours after the insult, whereas T lymphocytes have been identified only at later times. Together with evidence from microarray studies demonstrating that the majority of genes modulated acutely in the blood of stroke patients resides in neutrophils and monocytes, our findings suggest that these cells may be useful therapeutic targets. Using the repurposing approach we have selected a drug, azithromycin, that is able to modulate the functions of macrophages and neutrophils in pathological conditions other than ischemia. Pre-treatment with azithromycin (150 mg/kg, orally) produces a significant reduction of the cerebral infarct volume induced by transient or permanent MCAo in rats. This suggests a potential prophylactic use of the drug during surgical procedures associated to a high risk of ischemic tissue damage. We have also observed the neuroprotective activity of azithromycin when the drug is administered systemically after a transient ischemic insult. The reduction of the infarct volume induced by transient MCAo is dose-dependent (ED50 = 0.59 mg/kg in mice, ED50 = 1.19 mg/kg in rats) and is approximately 60% (compared to vehicle) with the most effective dose of azithromycin (150 mg/kg, i.p.). The neuroprotective doses in rodents are therefore much lower than the antibiotic ones. We have also documented that the reduction of the infarct volume and the improvement of the neurological deficit due to azithromycin post-treatment (150 mg/kg, ip) are maintained up to 7 days after the insult. Furthermore, the time window of efficacy is rather wide, since neuroprotection is observed with the drug administered up to 6 hours after the insult both in rats and in mice subjected to transient MCAo. The characterization of the neuroprotective effects of azithromycin, demonstrated by the present study in models of focal ischemia in rodents, provides the basis for the validation of the drug efficacy in patients suffering from ischemic stroke.