AU2011265382A1 - Prevention and treatment of amyloidogenic disease - Google Patents

Abstract

PREVENTION AND TREATMENT OF AMYLOIDOGENIC DISEASE Abstract The invention provides improved agents and methods for treatment of diseases associated with amyloid deposits of AP in the brain of a patient. Such methods entail 5 administering agents that induce a beneficial immunogenic response against the amyloid deposit. The methods are useful for prophylactic and therapeutic treatment of Alzheimer's disease. Preferred agents including N-terminal fragments of AP and antibodies binding to the same.

Description

S&F Ref: 575439D3 AUSTRALIA PATENTS ACT 1990 COMPLETE SPECIFICATION FOR A STANDARD PATENT Name and Address Janssen Alzheimer Immunotherapy, of Little Island of Applicant: Industrial Estate, Little Island, County Cork, Republic of Ireland Actual Inventor(s): Dale B. Schenk Ted Yednock Nicki J. Vasquez Frederique Bard Address for Service: Spruson & Ferguson St Martins Tower Level 35 31 Market Street Sydney NSW 2000 (CCN 3710000177) Invention Title: Prevention and treatment of amyloidogenic disease The following statement is a full description of this invention, including the best method of performing it known to me/us: 5845c(5848585_1) PREVENTION AND TREATMENT OF AMYLOIDOGENIC DISEASE TECHNICAL FIELD The invention resides in the technical fields of immunology and medicine. BACKGROUND OF THE INVENTION 5 Alzheimer's disease (AD) is a progressive disease resulting in senile dementia. See generally Selkoe, TINS 16, 403-409 (1993); Hardy et al., WO 92/13069; Selkoe, J. Neuropathol. Exp. Neurol. 53, 438-447 (1994); Duff et al., Nature 373, 476 477 (1995); Games et al., Nature 373, 523 (1995). Broadly speaking, the disease falls into two categories: late onset, which occurs in old age (65 + years) and early onset, 10 which develops well before the senile period, i.e., between 35 and 60 years. In both types of disease, the pathology is the same but the abnormalities tend to be more severe and widespread in cases beginning at an earlier age. The disease is characterized by at least two types of lesions in the brain, senile plaques and neurofibrillary tangles. Senile plaques are areas of disorganized neuropil up to 150 pm across with extracellular amyloid 15 deposits at the center visible by microscopic analysis of sections of brain tissue. Neurofibrillary tangles are intracellular deposits of microtubule associated tau protein consisting of two filaments twisted about each other in pairs. The principal constituent of the plaques is a peptide termed AP or P amyloid peptide. Ap peptide is an internal fragment of 39-43 amino acids of a precursor 20 protein termed amyloid precursor protein (APP). Several mutations within the APP protein have been correlated with the presence of Alzheimer's disease. See, e.g., Goate et al., Nature 349, 704) (1991) (valine" 71 to isoleucine); Chartier Harlan et al. Nature 353, 844 (1991)) (valine 71 7 to glycine); Murrell et al., Science 254, 97 (1991) (valine" 7 to phenylalanine); Mullan et al., Nature Genet. 1, 345 (1992) (a double mutation changing 25 lysine -methionine96 to asparagine 595-leucine96 ). Such mutations are thought to cause Alzheimer's disease by increased or altered processing of APP to AP, particularly processing of APP to increased amounts of the long form of Ap (i.e., Ap1-42 and Apl-43). Mutations in other genes, such as the presenilin genes, PSI and PS2, are thought indirectly to affect processing of APP to generate increased amounts of long form Ap (see Hardy, TINS 20, 154 (1997)). These observations idicate that AD, and 5 particularly its long form, is a causative element in Alzheimer's disease. McMichael, EP 526,511, proposes administration of homeopathic dosages (less than or equal to 102 mg/day) of As to patients with preestablished AD. In a typical human with about 5 liters of plasma, even the upper limit of this dosage would be expected to generate a concentration of no more than 2 pg/ml. The normal concentration 10 of As in human plasma is typically in the range of 50-200 pg/mI (Seubert et al., Nature 359, 325-327 (1992)). Because EP 526,51 I's proposed dosage would barely alter the level of endogenous circulating As and because EP 526,511 does not recommend use of an adjuvant, as an immunostimulant, it seems implausible that any therapeutic benefit would result. 15 By contrast, the present invention is directed inter alia to treatment of Alzheimer's and other amyloidogenic diseases by administration of fragments of AP , or antibody to certain epitopes within AD to a patient under conditions that generate a beneficial immune response in the patient. The invention thus fulfills a longstanding need for therapeutic regimes for preventing or ameliorating the neuropathology and, in some 20 patients, the cognitive impairment associated with Alzheimer's disease. This application is related to W099/27944, filed November 30, 1998, USSN 60/067,740, filed December 2, 1997, USSN 60/080,970, filed April 7, 1998, and USSN 09/201,430, filed November 30, 1998, each of which is incorporated by reference in its entirety for all purposes. 25 SUMMARY OF THE CLAIMED INVENTION In one aspect, the invention provides methods of preventing or treating a disease associated with amyloid deposits of As in the brain of a patient. Such diseases 30 include Alzheimer's disease, Down's syndrome and cognitive impairment. The latter can occur with or without other characteristics of an anyloidogenic disease. Some methods of the invention entail administering an effective dosage of an antibody that specifically binds to a component of an amyloid deposit to the patient. Such methods are particularly 2 useful for preventing or treating Alzheimer's disease in human patients. Some methods entail administering an effective dosage of an antibody that binds to AP. Some methods entail administering an effective dosage of an antibody that specifically binds to an epitope within residues 1-10 of AP. In some methods, the antibody specifically binds to 5 an epitope within residues 1-6 of AP. In some methods, the antibody specifically binds to an epitope within residues 1-5 of AP. In some methods, the antibody specifically binds to an epitope within residues 1-7 of AP. In some methods, the antibody specifically binds to an epitope within residues 3-7 of AP. In some methods, the antibody specifically binds to an epitope within residues 1-3 of A1P. In some methods, the antibody specifically 10 binds to an epitope within residues 1-4 of AP. In some methods, the antibody binds to an epitope comprising a free N-terminal residue of A1P. In some methods, the antibody binds to an epitope within residues of 1-10 of AB wherein residue I and/or residue 7 of As is aspartic acid. In some methods, the antibody specifically binds to As peptide without binding to full-length amyloid precursor protein (APP). In some methods, the isotype of 15 the antibody is human IgG1. In some methods, the antibody binds to an amyloid deposit in the patierit and induces a clearing response against the amyloid deposit. For example, such a clearing response can be effected by Fc receptor mediated phagocytosis. The methods can be used on both asymptomatic patients and those 20 currently showing symptoms of disease. The antibody used in such methods can be a human, humanized, chimeric or nonhuman antibody and can be monoclonal or polyclonal. In some methods, the antibody is prepared from a human immunized with AP peptide, which human can be the patient to be treated with antibody. In some methods, the antibody is administered with a pharmaceutical 25 carrier as a pharmaceutical composition. In some methods, antibody is administered at a dosage of 0.0001 to 100 mg/kg, preferably, at least 1 mg/kg body weight antibody. In some methods, the antibody is administered in multiple dosages over a prolonged period, for example, of at least six months. In some methods, the antibody is administered as a sustained release composition. The antibody can be administered, for example, 30 intraperitoneally, orally, subcutaneously, intracranially, intramuscularly, topically, intranasally or intravenously. In some methods, the antibody is administered by administering a polynucleotide encoding at least one antibody chain to the patient. The polynucleotide is 3 expressed to produce the antibody chain in the patient. Optionally, the polynucleotide encodes heavy and light chains of the antibody. The polynucleotide is expressed to produce the heavy and light chains in the patient. In some methods, the patient is monitored for level of administered antibody in the blood of the patient. 5 In another aspect, the invention provides methods of preventing or treating a disease associated with amyloid deposits of As in the brain of patient. For example, the methods can be used to treat Alzheimer's disease or Down's syndrome or cognitive impairment. Such methods entail administering fragments of Ap or analogs thereof eliciting an immunogenic response against certain epitopes within Ap. Some methods 10 entail administering to a patient an effective dosage of a polypeptide comprising an N terminal segment of at least residues 1-5 of ADp, the first residue of Ap being the N terminal residue of the polypeptide, wherein the polypeptide is free of a C-terminal segment of Ap. Some methods entail administering to a patient an effective dosage of a polypeptide comprising an N-terminal segment of Ap, the segment beginning at residue 15 1-3 of As and ending at residues 7-11 of Ap. Some methods entail administering to a patient an effective dosage of an agent that induces an immunogenic response against an N-terminal segment of AD, the segment beginning at residue 1-3 of AD and ending at residues 7-11 of AD without inducing an immunogenic response against an epitope within residues 12-43 of Ap43. 20 In some of the above methods, the N-terminal segment of A1p is linked at its C-terminus to a heterologous polypeptide. In some of the above methods, the N terminal segment of As is linked at its N-terminus to a heterologous polypeptide. In some of the above methods, the N-terminal segment of Ap is linked at its N and C termini to first and second heterologous polypeptides. In some of the above methods, the N 25 terminal segment of Ap is linked at its N terminus to a heterologous polypeptide, and at its C-terminus to at least one additional copy of the N-terminal segment. In some of the above methods, the heterologous polypeptide and thereby a B-cell response against the N terminal segment. In some of the above methods, the polypeptide further comprises at least one additional copy of the N-terminal segment. In some of the above methods, the 30 polypeptide comprises from N-terminus to C-terminus, the N-terminal segment of Ap, a plurality of additional copies of the N-terminal segment, and the heterologous amino acid 4 segment. In some of the above methods, the N-terminal segment consists of AP1-7. In some of the above methods, the N-terminal segment consists of A03-7. In some methods, the fragment is free of at least the 5 C-terminal amino acids in AP43. In some methods, the fragment comprises up to 10 contiguous amino 5 acids from Ap. Fragments are typically administered at greater than 10 micrograms per dose per patient. In some methods, the fragment is administered with an adjuvant that enhances the immune response to the Ap peptide. The adjuvant and fragment can be administered in either order or together as a composition. The adjuvant can be, for 10 example, aluminum hydroxide, aluminum phosphate, MPLE", QS-21 (Stimulonr) or incomplete Freund's adjuvant. The invention further provides pharmaceutical compositions comprising fragments of As or other agents eliciting immunogenic response to the same epitopes of Ap, such as described above, and an adjuvant. The invention also provides 15 pharmaceutical compositions comprising any of the antibodies described above and a pharmaceutically acceptable carrier. In another aspect, the invention provides methods of screening an antibody for activity in treating a disease associated with deposits of A3 in the brain of a patient (e.g., Alzheimer's disease). Such methods entail contacting the antibody with a 20 polypeptide comprising at least five contiguous amino acids of an N-terminal segment of AD beginning at a residue between 1 and 3 of AD, the polypeptide being free of a C terminal segment of Ap. One then determines whether the antibody specifically binds to the polypeptide, specific binding providing an indication that the antibody has activity in treating the disease. 25 In another aspect, the invention provides methods of screening an antibody for activity in clearing an antigen-associated biological entity. Such methods entail combining the antigen-associated biological entity and the antibody and phagocytic cells bearing Fc receptors in a medium. The amount of the antigen-associated biological entity remaining in the medium is then monitored. A reduction in the amount of the antigen 30 associated biological entity indicates the antibody has clearing activity against the antigen-associated biological entity. The antigen can be provided as a tissue saniple or in isolated form. For example, the antigen can be provided as a tissue sample from the brain of an Alzheimer's disease patient or a mammal animal having Alzheimer's pathology. 5 Other tissue samples against which antibodies can be tested for clearing activity include cancerous tissue samples, virally infected tissue samples, tissue samples comprising inflammatory cells, nonmalignant abnormal cell growths, or tissue samples comprising an abnormal extracellular matrix. 5 In another aspect, the invention provides methods of detecting an amyloid deposit in a patient. Such methods entail administering to the patient an antibody that specifically binds to an epitope within amino acids 1-10 of AP, and detecting presence of the antibody in the brain of the patient. In some methods, the antibody binds to an epitope within residues 4-10 of Ap. In some methods, the antibody is labelled with a 10 paramagnetic label and detected by nuclear magnetic resonance tomography. The invention further provides diagnostic kits suitable for use in the above methods. Such a kit comprises an antibody that specifically binds to an epitope with residues 1-10 of Ap. Some kits bear a label describing use of the antibody for in vivo diagnosis or monitoring of Alzheimer's disease. 15 BRIEF DESCRIPTION OF THE DRAWINGS Fig. 1: Antibody titer after injection of transgenic mice with AP1-42. Fig. 2: Amyloid burden in the hippocampus. The percentage of the area of the hippocampal region occupied by amyloid plaques, defined by reactivity with the 20 Ap-specific monoclonal antibody 3D6, was determined by computer-assisted quantitative image analysis of immunoreacted brain sections. The values for individual mice are shown sorted by treatment group. The horizontal line for each grouping indicates the median value of the distribution. Fig 3: Neuritic dystrophy in the hippocampus. The percentage of the area 25 of the hippocampal region occupied by dystrophic neurites, defined by their reactivity with the human APP-specific monoclonal 8E5, was determined by quantitative computer assisted image analysis of immunoreacted brain sections. The values for individual mice are shown for the AN1792-treated group and the PBS-treated control group. The horizontal line for each grouping indicates the median value of the distribution. 30 Fig. 4: Astrocytosis in the retrosplenial cortex. The percentage of the area of the cortical region occupied by glial fibrillary acidic protein (GFAP)-positive astrocytes was determined by quantitative computer-assisted image analysis of 6 inmunoreacted brain sections. The values for individual mice are shown sorted by treatment group and median group values are indicated by horizontal lines. Fig. 5: Geometric mean antibody titers to Ap l-42 following immunization with a range of eight doses of AN1792 containing 0.14, 0.4, 1.2, 3.7, 11, 33, 100, or 5 300 [g. Fig. 6: Kinetics of antibody response to AN 1792 immunization. Titers are expressed as geometric means of values for the 6 animals in each group. Fig. 7: Quantitative image analysis of the cortical amyloid burden in PBS and AN 1792-treated mice. 10 Fig. 8: Quantitative image analysis of the neuritic plaque burden in PBS and AN1792-treated mice. Fig. 9: Quantitative image analysis of the percent of the retrosplenial cortex occupied by astrocytosis in PBS- and AN1792-treated mice. Fig. 10: Lymphocyte Proliferation Assay on spleen cdlls from AN1792 15 treated (upper panel) or PBS-treated (lower panel). Fig. 11: Total AD levels in the cortex. A scatterplot of individual Ap profiles in mice immunized with Ap or APP derivatives combined with Freund' adjuvant. Fig. 12: Amyloid burden in the cortex was determined by quantitative image analysis of immunoreacted brain sections for mice immunized with the Ap peptide 20 conjugates A01-5, Apl-12, and Ap13-28; the full length Ap aggregates AN1792 (Apl 42) and AN1528 (Ap1-40) and the PBS-treated control group. Fig. 13: Geometric mean titers of Afp-specific antibody for groups of mice immunized with Ap or APP derivatives combined with Freund's adjuvant. Fig. 14: Geometric mean titers of Ap-specific antibody for groups of 25 guinea pigs immunized with AN 1792, or a palmitoylated derivative thereof, combined with various adjuvants. Fig: 15(A-E): Ap levels in the cortex of 12-month old PDAPP mice treated with AN1792 or AN1528 with different adjuvants. Fig. 16: Mean titer of mice treated with polyclonal antibody to Ap. 30 Fig. 17: Mean titer of mice treated with monoclonal antibody IOD5 to Ap. Fig. 18: Mean titer of mice treated with monoclonal antibody 2F12 to ADp. Fig. 19: Epitope Map: Restricted N-terminal Response. Day 175 serum from cynomolgus monkeys was tested by ELISA against a series of I 0-mer overlapping 7 peptides (SEQ ID NOS: 1-41) covering the complete AN 1792 sequence. Animal number F10920M shows a representative N-tenninal restricted response to the peptide DAEFRHDSGY (SEQ ID NO: 9) which covers amino acids 1-10 of the AN1792 peptide which was used as immunizing antigen. 5 Fig. 20: Epitope Map: Non-restricted N-terminal response. Day 175 serum from cynomolgus monkeys was tested by ELISA against a series of I 0-mer ovedapping peptides (SEQ ID NOS: 1-41) covering the complete AN1792 sequence. Animal number F10975F shows a representative non-restricted N-terminal response. Reactivity is seen against the two peptides N-tenninal and one'peptide C-tenminal to tie p-eptide DAEFRHDSGY (SEQ ID NO: 9) 10 which covers amino acids 1-10 of the ANI 792 peptide. DEFINITIONS The term "substantial identity" means that two peptide sequences, when 15 optimally aligned, such as by the programs GAP or BESTFIT using default gap weights, share at least 65 percent sequence identity, preferably at least 80 or 90 percent sequence identity, more preferably at least 95 percent sequence identity or more (e.g., 99 percent sequence identity or higher). Preferably, residue positions which are not identical differ by conservative amino acid substitutions. 20 For sequence comparison, typically one sequence acts as a reference sequence, to which test sequences are compared. When using a sequence comparison algorithm, test and reference sequences are input into a computer, subsequence coordinates are designated, if necessary, and sequence algorithm program parameters are designated. The sequence comparison algorithm then calculates the percent sequence 25 identity for the test sequence(s) relative to the reference sequence, based on the designated program parameters. Optimal alignment of sequences for comparison can be conducted, e.g., by the local homology algorithm of Smith & Waterman, Adv. Apple. Math 2:482 (1981), by the homology alignment algorithm of Needleman & Wunsch, J. Mol. Biol. 48:443 (1970), 30 by the search for similarity method of Pearson & Lipman, Proc. Nat'l. Acad Sci. USA 85:2444 (1988), by computerized implementations of these algorithms (GAP, BESTFIT, FASTA, and TFASTA in the Wisconsin Genetics Software Package, Genetics Computer Group, 575 Science Dr., Madison, WI), or by visual inspection (see generally Ausubel et al., supra). One example of algorithm that is suitable for determining percent sequence 8 identity and sequence similarity is the BLAST algorithm, which is described in Altschul et al., J. Mol. Biol. 215:403-410 (1990). Software for performing BLAST analyses is publicly available through the National Center for Biotechnology Information (http://www.ncbi.nlm.nih.gov/). Typically, default program parameters can be used to 5 perform the sequence comparison, although customized parameters can also be used. For amino acid sequences, the BLASTP program uses as defaults a wordlength (W) of 3, an expectation (E) of 10, and the BLOSUM62 scoring matrix (see Henikoff & Henikoff, Proc. Natl. Acad Sci. USA 89, 10915 (1989)) For purposes of classifying amino acids substitutions as conservative or 10 nonconservative, amino acids are grouped as follows: Group I (hydrophobic sidechains): norleucine, met, ala, val, leu, ile; Group II (neutral hydrophilic side chains): cys, ser, thr; Group Ill (acidic side chains): asp, glu; Group IV (basic side chains): asn, gin, his, lys, arg; Group V (residues influencing chain orientation): gly, pro; and Group VI (aromatic side chains): trp, tyr, phe. Conservative substitutions involve substitutions between 15 amino acids in the same class. Non-conservative substitutions constitute exchanging a member of one of these classes for a member of another. Therapeutic agents of the invention are typically substantially pure from undesired contaminant. This means that an agent is typically at least about 50% w/w (weight/weight) purity, as well as being substantially free from interfering proteins and 20 contaminants. Sometimes the agents are at least about 80% w/w and, more preferably at least 90 or about 95% w/w purity. However, using conventional protein purification techniques, homogeneous peptides of at least 99% w/w can be obtained. Specific binding between two entities means an affinity of at least 106, 107, 10i' 109 M-', or 10'* M~'. Affinities greater than 108 M^' are preferred. 25 The term "antibody" or "immunoglobulin" is used to include intact antibodies and binding fragments thereof. Typically, fragments compete with the intact antibody from which they were derived for specific binding to an antigen fragment including separate heavy chains, light chains Fab, Fab' F(ab')2, Fabc, and Fv. Fragments are produced by recombinant DNA techniques, or by enzymatic or chemical separation of 30 intact immunoglobulins. The term "antibody" also includes one or more immunoglobulin chains that are chemically conjugated to, or expressed as, fusion proteins with other proteins. The term "antibody" also includes bispecific antibody. A bispecific or bifunctional antibody is an artificial hybrid antibody having two different heavy/light chain pairs and two different binding sites. Bispecific antibodies can be produced by a 9 variety of methods including fusion of hybridomas or linking of Fab' fragments. See, e.g., Songsivilai & Lachmann, Clin. Exp. Immunol. 79:315-321 (1990); KosteLny et al., J. Immunol. 148, 1547-1553 (1992). APP6, APP 7 m', and APP77 refer, respectively, to the 695, 751, and 770 5 amino acid residue long polypeptides encoded by the human APP gene. See Kang et al., Nature 325, 773 (1987); Ponte et al., Nature 331, 525 (1988); and Kitaguchi et al., Nature 331, 530 (1988). Amino acids within the human amyloid precursor protein (APP) are assigned numbers according to the sequence of the APP770 isoform. Terms such as Ap39, Ap40, Ap41, Ap42 and Ap43 refer to an Ap peptide containing amino acid 10 residues 1-39, 1-40, 1-41, 1-42 and 1-43. An "antigen" is an entity to which an antibody specifically binds. The term "epitope" or "antigenic determinant" refers to a site on an antigen to which B and/or T cells respond. B-cell epitopes can be formed both from contiguous amino acids or noncontiguous amino acids juxtaposed by tertiary folding of a protein. 15 Epitopes formed from contiguous amino acids are typically retained on exposure to denaturing solvents whereas epitopes formed by tertiary folding are typically lost on treatment with denaturing solvents. An epitope typically includes at least 3, and more usually, at least 5 or 8-10 amino acids in a unique spatial conformation. Methods of determining spatial conformation of epitopes include, for example, x-ray crystallography 20 and 2-dimensional nuclear magnetic resonance. See, e.g., Epitope Mapping Protocols in Methods in Molecular Biology, Vol. 66, Glenn E. Morris, Ed. (1996). Antibodies that recognize the same epitope can be identified in a simple immunoassay showing the ability of one antibody to block the binding of another antibody to a target antigen. T-cells recognize continuous epitopes of about nine amino acids for CD8 cells or about 13-15 25 amino acids for CD4 cells. T cells that recognize the epitope can be identified by in vitro assays that measure antigen-dependent proliferation, as determined by 3 H-thymidine incorporation by primed T cells in response to an epitope (Burke et al., J. Inf Dis. 170, 1110-19 (1994)), by antigen-dependent killing (cytotoxic T lymphocyte assay, Tigges et al., J. Immunol. 156, 3901-3910) or by cytokine secretion. 30 The term "immunological" or "immune" response is the development of a beneficial humoral (antibody mediated) and/or a cellular (mediated by antigen-specific T cells or their secretion products) response directed against an amyloid peptide in a recipient patient. Such a response can be an active response induced by administration of 10 immunogen or a passive response induced by administration of antibody or primed T cells. A cellular immune response is elicited by the presentation of polypeptide epitopes in association with Class I or Class I MHC molecules to activate antigen-specific CD4* T helper cells and/or CD8' cytotoxic T cells. The response may also involve activation of 5 monocytes, macrophages, NK cells, basophils, dendritic cells, astrocytes, microglia cells, eosinophils or other components of innate immunity. The presence of a cell-mediated immunological response can be determined by proliferation assays (CD4* T cells) or CTL (cytotoxic T lymphocyte) assays (see Burke, supra; Tigges, supra). The relative contributions of humoral and cellular responses to the protective or therapeutic effect of 10 an immunogen can be distinguished by separately isolating antibodies and T-cells from an immunized syngeneic animal and measuring protective or therapeutic effect in a second subject. An "immunogenic agent" or "immunogen" is capable of inducing an immunological response against itself on administration to a mammal, optionally in 15 conjunction with an adjuvant. The term "naked polynucleotide" refers to a polynucleotide not complexed with colloidal materials. Naked polynucleotides are sometimes cloned in a plasmid vector. The term "adjuvant" refers to a compound that when administered in 20 conjunction with an antigen augments the immune response to the antigen, but when administered alone does not generate an immune response to the antigen. Adjuvants can augment an immune response by several mechanisms including lymphocyte recruitment, stimulation of B and/or T cells, and stimulation of macrophages. The term "patient" includes human and other mammalian subjects that 25 receive either prophylactic or therapeutic treatment Disaggregated or monomeric AP means soluble, monomeric peptide units of Ap. One method to prepare monomeric Ap is to dissolve lyophilized peptide in neat DMSO with sonication. The resulting solution is centrifuged to remove any insoluble particulates. Aggregated Ap is a mixture of oligomers in which the monomeric units are 30 held together by noncovalent bonds. Competition between antibodies is determined by an assay in which the immunoglobulin under test inhibits specific binding of a reference antibody to a common antigen, such as Ap. Numerous types of competitive binding assays are known, for 11 example: solid phase direct or indirect radioimmunoassay (RIA), solid phase direct or indirect enzyme immunoassay (EIA), sandwich competition assay (see Stahli et al., Methods in Enzymology 9:242-253 (1983)); solid phase direct biotin-avidin EIA (see Kirkland et al., J. Immunol. 137:3614-3619 (1986)); solid phase direct labeled assay, 5 solid phase direct labeled sandwich assay (see Harlow and Lane, "Antibodies, A Laboratory Manual," Cold Spring Harbor Press (1988)); solid phase direct label RIA using 1-125 label (see Morel et al., Molec. Immunol. 25(l):7-15 (1988)); solid phase direct biotin-avidin EIA (Cheung et al., Virology 176:546-552 (1990)); and direct labeled RIA (Moldenhauer et al., Scand. J. Immunol. 32:77-82 (1990)). Typically, such an assay 10 involves the use of purified antigen bound to a solid surface or cells bearing either of these, an unlabelled test immunoglobulin and a labelled reference immunoglobulin. Competitive inhibition is measured by determining the amount of label bound to the solid surface or cells in the presence of the test immunoglobulin. Usually the test immunoglobulin is present in excess. Antibodies identified by competition assay 15 (competing antibodies) include antibodies binding to the same epitope as the reference antibody and antibodies binding to an adjacent epitope sufficiently proximal to the epitope bound by the reference antibody for steric hindrance to occur. Usually, when a competing antibody is present in excess, it will inhibit specific binding of a reference antibody to a common antigen by at least 50 or 75%. 20 Compositions or methods "comprising" one or more recited elements may include other elements not specifically recited. For example, a composition that comprises AP peptide encompasses both an isolated AP peptide and As peptide as a component of a larger polypeptide sequence. 25 DETAILED DESCRIPTION I. General Several amyloidogenic diseases and conditions are characterized by presence of deposits of AlP peptide aggregated to an insoluble mass in the brain of a patient. Such diseases include Alzheimer's disease, Down's syndrome and cognitive 30 impairment. The latter is a symptom of Alzheimer's disease and Down's syndrome but can also without other characteristics of either of these diseases. For example, Inild cognitive impairment or age-associated memory loss occurs in some patient who have not yet developed, or may never develop full Alzheimer's disease. Mild cognitive impairment 12 can be defined by score on the Mini-Mental State Exam in accordance with convention. Such diseases are characterized by aggregates of As that have a p-pleated sheet structure and stain with Congo Red dye. The basic approach of preventing or treating Alzheimer's disease or other amyloidogenic diseases by generating an immunogenic response to a 5 component of the amyloid deposit in a patient is described in WO 99/27944 (incorporated by reference). The present application reiterates and confirms the efficacy of the basic approach. The present application is, however, principally directed to improved reagents and methods. These improvements are premised, in part, on the present inventors having localized the preferred epitopes within AD against which an immunogenic response 10 should be directed. The identification of preferred epitopes within As results in agents and methods having increased efficacy, reduced potential for side effects, and/or greater ease of manufacture, formulation and administration. II. Therapeutic Agents 15 An immunogenic response can be active, as when an immunogen is administered to induce antibodies reactive with As in a patient, or passive, as when an antibody is administered that itself binds to As in a patient. 1. Agents Inducing Active Immune Response 20 Therapeutic agents induce an immunogenic response specifically directed to certain epitopes within Ap peptides. Preferred agents are the As peptide itself and segments thereof. Variants of such segments, analogs and mimetics of natural AP peptide that induce and/or crossreact with antibodies to the preferred epitopes of Ap peptide can also be used. 25 Ap, also known as p-amyloid peptide, or A4 peptide (see US 4,666,829; Glenner & Wong, Biochem. Biophys. Res. Comnun. 120, 1131 (1984)), is a peptide of 39-43 amino acids, which is the principal component of characteristic plaques of Alzheimer's disease. As is generated by processing of a larger protein APP by two enzymes, termed p and y secretases (see Hardy, TINS 20, 154 (1997)). Known mutations 30 in APP associated with Alzheimer's disease occur proximate to the site of P or y secretase, or within Ap. For example, position 717 is proximate to the site of y-secretase cleavage of APP in its processing to AD, and positions 670/671 are proximate to the site of p secretase cleavage. It is believed that the mutations cause AD by interacting with the 13 cleavage reactions by which As is formed so as to increase the amount of the 42/43 amino acid form of Ap generated. As has the unusual property that it can fix and activate both classical and alternate complement cascades. In particular, it binds to Clq and ultimately to C3bi. This 5 association facilitates binding to macrophages leading to activation of B cells. In addition, C3bi breaks down further and then binds to CR2 on B cells in a T cell dependent manner leading to a 10,000 increase in activation of these cells. This mechanism causes Ap to generate an immune response in excess of that of other antigens. Ap has several natural occurring forms. The human forms of As are 10 referred to as AP39, A040, Ap41, Ap42 and Ap43. The sequences of these peptides and their relationship to the APP precursor are illustrated by Fig. 1 of Hardy et al., TINS 20, 155-158 (1997). For example, A342 has the sequence: H2N-Asp-Ala-Glu-Phe-Arg-His-Asp-Ser-Gly-Tyr-Glu-Val-His-His-Gln Lys-Leu-Val-Phe-Phe-Ala-Glu-Asp-Val-Gly-Ser-Asn-Lys-Gly-Ala-Ile-Ile-Gly-Leu-Met 15 Val-Gly-Gly-Val-Val-fle-Ala-OH (SEQ ID NO: 42). Ap41, Ap40 and Ap39 differ from Ap42 by the omission of Ala, Ala-Ile, and Ala-Ile-Val respectively from the C-terminal end. A043 differs from Ap42 by the presence of a threonine residue at the C-terminus. Immunogenic fragments of AP are advantageous relative to the intact 20 molecule in the present methods for several reasons. First, because only certain epitopes within As induce a useful immunogenic response for treatment of Alzheimer's disease, an equal dosage of mass of a fragment containing such epitopes provides a greater molar concentration of the useful immunogenic epitopes than a dosage of intact Ap. Second, certain immunogenic fragments of As generate an immunogenic response against 25 amyloid deposits without generating a significant immunogenic response against APP . protein from which As derives. Third, fragments of As are simpler to manufacture than intact As due to their shorter size. Fourth, fragments of As do not aggregate in the same manner as intact AP, simplifying preparation of pharmaceutical compositions and administration thereof. 30 Some immunogenic fragments of AD have a sequence of at least 2, 3, 5, 6, 10 or 20 contiguous amino acids from a natural peptide. Some immunogenic fragments have no more than 10, 9, 8, 7, 5 or 3 contiguous residues from Ap. Fragments from the 14 N-terminal half of Ap are preferred. Preferred immunogenic fragments include A 1 -5, 1 6, 1-7, 1-10, 3-7, 1-3, and 1-4. The designation Apl-5 for example, indicates a fragment including residues 1-5 of Ap and lacking other residues of Ap. Fragments beginning at residues 1-3 of AD and ending at residues 7-11 of As are particularly preferred. The 5 fragment API-12 can also be used but is less preferred. In some methods, the fragment is an N-terminal fragment other than AP1-10. Other less preferred fragments include Ap13-28, 17-28, 1-28, 25-35, 35-40 and 35-42. These fragments require screening for activity in clearing or preventing amyloid deposits as described in the Examples before use. Fragments lacking at least one, and sometimes at least 5 or 10 C-terminal amino acid 10 present in a naturally occurring forms of AD are used in some methods. For example, a fragment lacking 5 amino acids from the C-terminal end of Ap43 includes the first 38 amino acids from the N-terminal end of Ap. Other components of amyloid plaques, for example, synuclein, and epitopic fragments thereof can also be used to induce an immunogenic response. 15 Unless otherwise indicated, reference to AD includes the natural human amino acid sequences indicated above as well as analogs including allelic, species and induced variants. Analogs typically differ from naturally occurring peptides at one, two or a few positions, often by virtue of conservative substitutions. Analogs typically exhibit at least 80 or 90% sequence identity with natural peptides. Some analogs also include 20 unnatural amino acids or modifications of N or C terminal amino acids at a one, two or a few positions. For example, the natural aspartic acid residue at position I and/or 7 of Ap can be replaced with iso-aspartic acid. Examples of unnatural amino acids are D-amino acids, a, a-disubstituted amino acids, N-alkyl amino acids, lactic acid, 4-hydroxyproline, y-carboxyglutamate, c -NN,N-trimethyllysine, c -N-acetyllysine, 0-phosphoserine, N 25 acetylserine, N-formylmethionine, 3-methylhistidine, 5-hydroxylysine, r>-N methylarginine, and isoaspartic acid. Fragments and analogs can be screened for prophylactic or therapeutic efficacy in transgenic animal models in comparison with untreated or placebo controls as described below. A$, its fragments, and analogs can be synthesized by solid phase peptide 30 synthesis or recombinant expression, or can be obtained from natural sources. Automatic peptide synthesizers are commercially available from numerous suppliers, such as Applied Biosystems, Foster City, Califomia. Recombinant expression can be in bacteria, 15 such as E. coli, yeast, insect cells or mammalian cells. Procedures for recombinant expression are described by Sambrook et al., Molecular Cloning: A Laboratory Manual (C.S.H.P. Press, NY 2d ed., 1989). Some forms of AD peptide are also available commercially (e.g., American Peptides Company, Inc., Sunnyvale, CA and California 5 Peptide Research, Inc. Napa, CA). Therapeutic agents also include longer polypeptides that include, for example, an active fragment of Ap peptide, together with other amino acids. For example, preferred agents include fusion proteins comprising a segment of As fused to a heterologous amino acid sequence that induces a helper T-cell response against the 10 heterologous amino acid sequence and thereby a B-cell response against the As segment. Such polypeptides can be screened for prophylactic or therapeutic efficacy in animal models in comparison with untreated or placebo controls as described below. The Ap peptide, analog, active fragment or other polypeptide can be administered in associated or multimeric form or in dissociated form Therapeutic agents also include multimers of 15 monomeric immunogenic agents. In a further variation, an immunogenic peptide, such as a fragment of AP, can be presented by a virus or a bacteria as part of an immunogenic composition. A nucleic acid encoding the immunogenic peptide is incorporated into a genome or episome of the virus or bacteria. Optionally, the nucleic acid is incorporated in such a manner that 20 the immunogenic peptide is expressed as a secreted protein or as a fusion protein with an outer surface protein of a virus or a transmembrane protein of a bacteria so that the peptide is displayed. Viruses or bacteria used in such methods should be nonpathogenic or attenuated. Suitable viruses include adenovirus, HSV, Venezuelan equine encephalitis virus and other alpha viruses, vesicular stomatitis virus, and other rhabdo viruses, 25 vaccinia and fowl pox. Suitable bacteria include Salmonella and Shigella. Fusion of an immunogenic peptide to HBsAg of HBV is particularly suitable. Therapeutic agents also include peptides and other compounds that do not necessarily have a significant amino acid sequence similarity with Ap but nevertheless serve as mimetics of As and induce a similar immune response. For example, any peptides and proteins forming p-pleated 30 sheets can be screened for suitability. Anti-idiotypic antibodies against monoclonal antibodies to AD or other amyloidogenic peptides can also be used. Such anti-Id antibodies mimic the antigen and generate an immune response to it (see Essential Immunology (Roit ed., Blackwell Scientific Publications, Palo Alto, 6th ed.), p. 18 1). 16 Agents other than Ap peptides should induce an immunogenic response against one or more of the preferred segments of As listed above (e.g., 1-10, 1-7, 1-3, and 3-7). Preferably, such agents induce an immunogenic response that is specifically directed to one of these segments vithout being directed to other segments of AD. 5 Random libraries of peptides or other compounds can also be screened for suitability. Combinatorial libraries can be produced for many types of compounds that can be synthesized in a step-by-step fashion. Such compounds include polypeptides, beta-turn mimetics, polysaccharides, phospholipids, hormones, prostaglandins, steroids, aromatic compounds, heterocyclic compounds, benzodiazepines, oligomeric N 10 substituted glycines and oligocarbamates. Large combinatorial libraries of the compounds can be constructed by the encoded synthetic libraries (ESL) method described in Affymax, WO 95/12608, Affymax, WO 93/06121, Columbia University, WO 94/08051, Pharmacopeia, WO 95/35503 and Scripps, WO 95/30642 (each of which is incorporated by reference for all purposes). Peptide libraries can also be generated by 15 phage display methods. See, e.g., Devlin, WO 91/18980. Combinatorial libraries and other compounds are initially screened for suitability by determining their capacity to bind to antibodies or lymphocytes (B or T) known to be specific for Ap or other amyloidogenic peptides. For example, initial screens can be performed with any polyclonal sera or monoclonal antibody to Ap or a 20 fragment thereof. Compounds can then be screened for binding to a specific epitope within Ap (e.g., 1-10, 1-7, 1-3, 1-4, 1-5 and 3-7). Compounds can be tested by the same procedures described for mapping antibody epitope specificities. Compounds identified by such screens are then further analyzed for capacity to induce antibodies or reactive lymphocytes to AD or fragments thereof. For example, multiple dilutions of sera can be 25 tested on microtiter plates that have been precoated with Ap or a fragment thereof and a standard ELISA can be performed to test for reactive antibodies to As or the fragment. Compounds can then be tested for prophylactic and therapeutic efficacy in transgenic animals predisposed to an amyloidogenic disease, as described in the Examples. Such animals include, for example, mice bearing a 717 mutation of APP described by Games et 30 al., supra, and mice bearing a 670/671 Swedish mutation of APP such as described by McConlogue et al., US 5,612,486 and Hsiao et al., Science 274, 99 (1996); Stauftnbiel et al., Proc. Nall. Acad. Sci. USA 94, 13287-13292 (1997); Sturchler-Pierrat et al., Proc. Natl. Acad. Sci. USA 94, 13287-13292 (1997); Borchelt et al., Neuron 19, 939-945 17 (1997)). The same screening approach can be used on other potential agents analogs of As and longer peptides including fragments of Ap, described above. 2. Agents Inducing Passive Immune Response 5 Therapeutic agents of the invention also include antibodies that specifically bind to AP or other component of amyloid plaques. Such antibodies can be monoclonal or polyclonal. Some such antibodies bind specifically to the aggregated form of As without binding to the dissociated form. Some bind specifically to the dissociated form without binding to the aggregated form. Some bind to both aggregated and 10 dissociated forms. Some such antibodies bind to a naturally occurring short form of Ap (i.e., A039, 40 or 41) without binding to a naturally occurring long form of AP (i.e., Ap42 and Afp43). Some antibodies bind to a long form without binding to a short form. Some antibodies bind to AP without binding to full-length amyloid precursor protein. Antibodies used in therapeutic methods usually have an intact constant region or at least 15 sufficient of the constant region to interact with an Fc receptor. Human isotype IgGI is preferred because of it having highest affinity of human isotypes for the FcRI receptor on phagocytic cells. Bispecific Fab fragments can also be used, in which one arm of the antibody has specificity for AP, and the other for an Fc receptor. Some antibodies bind to AfI with a binding affinity greater than or equal to about 106, 107, 101, 109, or 10" M-. 20 Polyclonal sera typically contain mixed populations of antibodies binding to several epitopes along the length of Ap. However, polyclonal sera can be specific to a particular segment of AfP, such as APIp-10. Monoclonal antibodies bind to a specific epitope within As that can be a conformational or nonconformational epitope. Prophylactic and therapeutic efficacy of antibodies can be tested using the transgenic 25 animal model procedures described in the Examples. Preferred monoclonal antibodies bind to an epitope within residues 1-10 of Ap (with the first N terminal residue of natural Ap designated 1). Some preferred monoclonal antibodies bind to an epitope within amino acids 1-5, and some to an epitope within 5-10. Some preferred antibodies bind to epitopes within amino acids 1-3, 1-4, 1-5, 1-6, 1-7 or 3-7. Some preferred antibodies bind 30 to an epitope starting at resides 1-3 and ending at residues 7-1l of Ap. Less preferred antibodies include those binding to epitopes with residues 10-15, 15-20, 25-30, 10-20, 20, 30, or 10-25 of Ap. It is recommended that such antibodies be screened for activity in 18 the mouse model described in the Examples before use. For example, it has been found that certain antibodies to epitopes within residues 10-18, 16-24, 18-21 and 33-42 lack activity. In some methods, multiple monoclonal antibodies having binding specificities to different epitopes are used. Such antibodies can be administered sequentially or 5 simultaneously. Antibodies to amyloid components other than As can also be used. For example, antibodies can be directed to the amyloid associated protein synuclein. When an antibody is said to bind to an epitope within specified residues, such as Ap 1-5 for example, what is meant is that the antibody specifically binds to a polypeptide containing the specified residues (i.e., Ap 1-5 in this an example). Such an 10 antibody does not necessarily contact every residue within AD 1-5. Nor does every single amino acid substitution or deletion with in AP 1-5 necessarily significantly affect binding affinity. Epitope specificity of an antibody can be determined, for example, by forming a phage display library in which different members display different subsequences of Ap. The phage display library is then selected for members specifically binding to an antibody 15 under test. A family of sequences is isolated. Typically, such a family contains a common core sequence, and varying lengths of flanking sequences in different members. The shortest core sequence showing specific binding to the antibody defines the epitope bound by the antibody. Antibodies can also be tested for epitope specificity in a competition assay with an antibody whose epitope specificity has already been 20 determined. For example, antibodies that compete with the 3D6 antibody for binding to AD bind to the same or similar epitope as 3D6, i.e., within residues Ap 1-5. Likewise antibodies that compete with the 1OD5 antibody bind to the same or similar epitope, i.e, within residues Ap 3-6. Screening antibodies for epitope specificity is a useful predictor of therapeutic efficacy. For example, an antibody determined to bind to an epitope within 25 residues 1-7 of Ap is likely to be effective in preventing and treating Alzheimer's disease. Monoclonal or polyclonal antibodies that specifically bind to a preferred segment of AP without binding to other regions of Ap have a number of advantages relative to monoclonal antibodies binding to other regions or polyclonal sera to intact A$. First, for equal mass dosages, dosages of antibodies that specifically bind to preferred 30 segments contain a higher molar dosage of antibodies effective. in clearing amyloid plaques. Second, antibodies specifically binding to preferred segments can induce a clearing response against amyloid deposits without inducing a clearing response against intact APP polypeptide, thereby reducing the potential for side effects. 19 i. General Characteristics of Immunoglobulins The basic antibody structural unit is known to comprise a tetramer of subunits. Each tetramer is composed of two identical pairs of polypeptide chains, each pair having one "light" (about 25 kDa) and one "heavy" chain (about 50-70 kDa). The 5 amino-terminal portion of each chain includes a variable region of about 100 to 110 or more amino acids primarily responsible for antigen recognition. The carboxy-terminal portion of each chain defines a constant region primarily responsible for effector function. Light chains are classified as either kappa or lambda. Heavy chains are classified as gamma, mu, alpha, delta, or epsilon, and define the antibody's isotype as 10 IgG, IgM, IgA, lgD and IgE, respectively. Within light and heavy chains, the variable and constant regions are joined by a "J" region of about 12 or more amino acids, with the heavy chain also including a "D" region of about 10 more amino acids. (See generally, Fundamental Immunology (Paul, W., ed., 2nd ed. Raven Press, N.Y., 1989), Ch. 7 (incorporated by reference in its entirety for all purposes). 15 The variable regions of each light/heavy chain pair form the antibody binding site. Thus, an intact antibody has two binding sites. Except in bifunctional or bispecific antibodies, the two binding sites are the same. The chains all exhibit the same general structure of relatively conserved framework regions (FR) joined by three hypervariable regions, also called complementarity determining regions or CDRs. The 20 CDRs from the two chains of each pair are aligned by the framework regions, enabling binding to a specific epitope. From N-terminal to C-terminal, both light and heavy chains comprise the domains FRI, CDRI, FR2, CDR2, FR3, CDR3 and FR4. The assignment of amino acids to each domain is in accordance with the definitions of Kabat, Sequences ofProteins of Immunological Interest (National Institutes of Health, Bethesda, MD, 1987 25 and 1991), or Chothia & Lesk, J. Mol. Biol. 196:901-917 (1987); Chothia et al., Nature 342:878-883 (1989). ii. Production of Nonhuman Antibodies The production of non-human monoclonal antibodies, e.g., murine, guinea 30 pig, primate, rabbit or rat, can be accomplished by, for example, immunizing the animal with Ap. A longer polypeptide comprising Ap or an immunogenic fragment of Ap or anti-idiotypic antibodies to an antibody to AP can also be used. See Harlow & Lane, Antibodies, A Laboratory Manual (CSHP NY, 1988) (incorporated by reference for all 20 purposes). Such an immunogen can be obtained from a natural source, by peptide synthesis or by recombinant expression. Optionally, the immunogen can be administered fused or otherwise complexed with a carrier protein, as described below. Optionally, the immunogen can be administered with an adjuvant. Several types of adjuvant can be used 5 as described below. Complete Freund's adjuvant followed by incomplete adjuvant is preferred for immunization of laboratory animals. Rabbits or guinea pigs are typically used for making polyclonal antibodies. Mice are typically used for making monoclonal antibodies. Antibodies are screened for specific binding to A1. Optionally, antibodies are further screened for binding to a specific region of AD. The latter screening can be 10 accomplished by determining binding of an antibody to a collection of deletion mutants of an Ap peptide and determining which deletion mutants bind to the antibody. Binding can be assessed, for example, by Western blot or ELISA. The smallest fragment to show specific binding to the antibody defines the epitope of the antibody. Alternatively, epitope specificity can be determined by a competition assay is which a test and reference 15 antibody compete for binding to Ap. If the test and reference antibodies compete, then they bind to the same epitope or epitopes sufficiently proximal that binding of one antibody interferes with binding of the other. The preferred isotype for such antibodies is mouse isotype IgG2a or equivalent isotype in other species. Mouse isotype IgG2a is the equivalent of human isotype IgG1. 20 iii. Chimeric and Humanized Antibodies Chimeric and humanized antibodies have the same or similar binding specificity and affinity as a mouse or other nonhuman antibody that provides the starting material for construction of a chimeric or humanized antibody. Chimeric antibodies are 25 antibodies whose light and heavy chain genes have been constructed, typically by genetic engineering, from immunoglobulin gene segments belonging to different species. For example, the variable (V) segments of the genes from a mouse monoclonal antibody may be joined to human constant (C) segments, such as IgGI and IgG4. Human isotype IgGI is preferred. A typical chimeric antibody is thus a hybrid protein consisting of the V or 30 antigen-binding domain from a mouse antibody and the C or effector domain from a human antibody. Humanized antibodies have variable region framework residues substantially from a human antibody (termed an acceptor antibody) and complementarity 21 determining regions substantially from a mouse-antibody, (referred to as the donor immunoglobulin). See , Queen et al., Proc. Natl. Acad. Sci. USA 86:10029-10033 (1989) and WO 90/07861, US 5,693,762, US 5,693,761, US 5,585,089, US 5,530,101 and Winter, US 5,225,539 (incorporated by reference in their entirety for all purposes). The 5 constant region(s), if present, are also substantially or entirely from a human immunoglobulin. The human variable domains are usually chosen from human antibodies whose framework sequences exhibit a high degree of sequence identity with the murine variable region domains from which the CDRs were derived. The heavy and light chain variable region framework residues can be derived from the same or different 10 human antibody sequences. The human antibody sequences can be the sequences of naturally occurring human antibodies or can be consensus sequences of several human antibodies. See Carter et al., WO 92/22653. Certain amino acids from the human variable region framework residues are selected for substitution based on their possible influence on CDR conformation and/or binding to antigen. Investigation of such possible 15 influences is by modeling, examination of the characteristics of the amino acids at particular locations, or empirical observation of the effects of substitution or mutagenesis of particular amino acids. For example, when an amino acid differs between a murine variable region framework residue and a selected human variable region framework residue, the human 20 framework amino acid should usually be substituted by the equivalent framework amino acid from the mouse antibody when it is reasonably expected that the amino acid: (1) noncovalently binds antigen directly, (2) is adjacent to a CDR region, (3) otherwise interacts with a CDR region (e.g. is within about 6 A of a 25 CDR region), or (4) participates in the VL-VH interface. Other candidates for substitution are acceptor human framework amino acids that are unusual for a human immunoglobulin at that position. These amino acids can be substituted with amino acids from the equivalent position of the mouse donor 30 antibody or from the equivalent positions of more typical human immunoglobulins. Other candidates for substitution are acceptor human framework amino acids that are unusual for a human immunoglobulin at that position.. The variable region frameworks of humanized immunoglobulins usually show at least 85% sequence identity to a human variable region framework sequence or consensus of such sequences. 22 iv. Human Antibodies Human antibodies against AD are provided by a variety of techniques described below. Some human antibodies are selected by competitive binding 5 experiments, or otherwise, to have the same epitope specificity as a particular mouse antibody, such as one of the mouse monoclonals described in Example XI. Human antibodies can also be screened for a particular epitope specificity by using only a fragment of Ap as the immunogen, and/or by screening antibodies against a collection of deletion mutants of Ap. Human antibodies preferably have isotype specificity human 10 IgG1. (1) Trioma Methodology The basic approach and an exemplary cell fusion partner, SPAZ-4, for use in this approach have been described by Oestberg et al., Hybridoma 2:361-367 (1983); Oestberg, U.S. Patent No. 4,634,664; and Engleman et al., US Patent 4,634,666 (each of 15 which is incorporated by reference in its entirety for all purposes). The antibody producing cell lines obtained by this method are called triomas, because they are descended from three cells-two human and one mouse. Initially, a mouse myeloma line is fused with a human B-lymphocyte to obtain a non-antibody-producing xenogeneic hybrid cell, such as the SPAZ-4 cell line described by Oestberg, supra. The xenogeneic 20 cell is then fused with an immunized human B-lymphocyte to obtain an antibody producing trioma cell line. Triomas have been found to produce antibody more stably than ordinary hybridomas made from human cells. The immunized B-lymphocytes are obtained from the blood, spleen, lymph nodes or bone marrow of a human donor. If antibodies against a specific antigen 25 or epitope are desired, it is preferable to use that antigen or epitope thereof for immunization. Immunization can be either in vivo or in vitro. For in vivo immunization, B cells are typically isolated from a human immunized with Ap, a fragment thereof, larger polypeptide containing Ap or fragment, or an anti-idiotypic antibody to an antibody to ADp. In some methods, B cells are isolated from the same patient who is 30 ultimately to be administered antibody therapy. For in vitro immunization, B lymphocytes are typically exposed to antigen for a period of 7-14 days in a media such as RPMI-1640 (see Engleman, supra) supplemented with 10% human plasma. 23 The immunized B-lymphocytes are fused to a xenogeneic hybrid cell such as SPAZ-4 by well known methods. For example, the cells are treated with 40-50% polyethylene glycol of MW 1000-4000, at about 37 degrees C, for about 5-10 min. Cells are separated from the fusion mixture and propagated in media selective for the desired 5 hybrids (e.g., HAT or AH). Clones secreting antibodies having the required binding specificity are identified by assaying the trioma culture medium for the ability to bind to A or a fragment thereof. Triomas producing human antibodies having the desired specificity are subcloned by the limiting dilution technique and grown in vitro in culture medium. The trioma cell lines obtained are then tested for the ability to bind AP or a 10 fragment thereof. Although triomas are genetically stable they do not produce antibodies at very high levels. Expression levels can be increased by cloning antibody genes from the trioma into one or more expression vectors, and transforming the vector into standard mammalian, bacterial or yeast cell lines. 15 (2) Transgenic Non-Human Mammals Human antibodies against Ap can also be produced from non-human transgenic mammals having transgenes encoding at least a segment of the human immunoglobulin locus. Usually, the endogenous immunoglobulin locus of such 20 transgenic mammals is functionally inactivated. Preferably, the segment of the human immunoglobulin locus includes unrearranged sequences of heavy and light chain components. Both inactivation of endogenous immunoglobulin genes and introduction of exogenous immunoglobulin genes can be achieved by targeted homologous recombination, or by introduction of YAC chromosomes. The transgenic mammals 25 resulting from this process are capable of functionally rearranging the immunoglobulin component sequences, and expressing a repertoire of antibodies of various isotypes encoded by human immunoglobulin genes, without expressing endogenous immunoglobulin genes. The production and properties of mammals having these properties are described in detail by, e.g., Lonberg et al., W093/12227 (1993); US 30 5,877,397, US 5,874,299, US 5,814,318, US 5,789,650, US 5,770,429, US 5,661,016, US 5,633,425, US 5,625,126, US 5,569,825, US 5,545,806, Nature 148, 1547-1553 (1994), Nature Biotechnology 14, 826 (1996), Kucherlapati, WO 91/10741 (1991) (each of which is incorporated by reference in its entirety for all purposes). Transgenic mice are 24 particularly suitable. Anti-Ap antibodies are obtained by immunizing a transgenic nonhuman mammal, such as described by Lonberg or Kucherlapati, supra, with AP or a fragment thereof. Monoclonal antibodies are prepared by, e.g., fusing B-cells from such mammals to suitable myeloma cell lines using conventional Kohler-Milstein technology. 5 Human polyclonal antibodies can also be provided in the form of serum from humans immunized with an immunogenic agent. Optionally, such polyclonal antibodies can be concentrated by affinity purification using As or other amyloid peptide as an affinity reagent. 10 (3) Phage Display Methods A further approach for obtaining human anti-Ap antibodies is to screen a DNA library from human B cells according to the general protocol outlined by Huse et al., Science 246:1275-1281 (1989). As described for trioma methodology, such B cells can be obtained from a human immunized with AP, fragments, longer polypeptides 15 containing A@ or fragments or anti-idiotypic antibodies. Optionally, such B cells are obtained from a patient who is ultimately to receive antibody treatment. Antibodies binding to As or a fragment thereof are selected. Sequences encoding such antibodies (or a binding fragments) are then cloned and amplified. The protocol described by Huse is rendered more efficient in combination with phage-display technology. See, e.g., Dower 20 et al., WO 91/17271 and McCafferty et al., WO 92/01047, US 5,877,218, US 5,871,907, US 5,858,657, US 5,837,242, US 5,733,743 and US 5,565,332 (each of which is incorporated by reference in its entirety for all purposes). In these methods, libraries of phage are produced in which members display different antibodies on their outer surfaces. Antibodies are usually displayed as Fv or Fab fragments. Phage displaying antibodies 25 with a desired specificity are selected by affinity enrichment to an AP peptide or fragment thereof In a variation of the phage-display method, human antibodies having the binding specificity of a selected murine antibody can be produced. See Winter, WO 92/20791. In this method, either the heavy or light chain variable region of the selected 30 murine antibody is used as a starting material. If, for example, a light chain variable region is selected as the starting material, a phage library is constructed in which members display the same light chain variable region (i.e., the murine starting material) and a different heavy chain variable region. The heavy chain variable regions are 25 obtained from a library of rearranged human heavy chain variable regions. A phage showing strong specific binding for AP (e.g., at least 108 and preferably at least 0 M'') is selected. The human heavy chain variable region from this phage then serves as a starting material for constructing a further phage library. In this library, each phage 5 displays the same heavy chain variable region (i.e., the region identified from the first display library) and a different light chain variable region. The light chain variable regions are obtained from a library of rearranged human variable light chain regions. Again, phage showing strong specific binding for Apare selected. These phage display the variable regions of completely human anti-AD antibodies. These antibodies usually 10 have the same or similar epitope specificity as the murine starting material. v. Selection of Constant Region The heavy and light chain variable regions of chimeric, humanized, or human antibodies can be linked to at least a portion of a human constant region. The 15 choice of constant region depends, in part, whether antibody-dependent complement and/or cellular mediated toxicity is desired. For example, isotopes IgGI and IgG3 have complement activity and isotypes IgG2 and IgG4 do not. Choice of isotype can also affect passage of antibody into the brain. Human isotype IgGI is preferred. Light chain constant regions can be lambda or kappa. Antibodies can be expressed as tetramers 20 containing two light and two heavy chains, as separate heavy chains, light chains, as Fab, Fab' F(ab')2, and Fv, or as single chain antibodies in which heavy and light chain variable domains are linked through a spacer. vi. Expression of Recombinant Antibodies 25 Chimeric, humanized and human antibodies are typically produced by recombinant expression. Recombinant polynucleotide constructs typically include an expression control sequence operably linked to the coding sequences of antibody chains, including naturally-associated or heterologous promoter regions. Preferably, the expression control sequences are eukaryotic promoter systems in vectors capable of 30 transforming or transfecting eukaryotic host cells. Once the vector has been incorporated into the appropriate host, the host is maintained under conditions suitable for higli level expression of the nucleotide sequences, and the collection and purification of the crossreacting antibodies. 26 These expression vectors are typically replicable in the host organisms either as episomes or as an integral part of the host chromosomal DNA. Commonly, expression vectors contain selection markers, e.g., ampicillin-resistance or hygromycin resistance, to permit detection of those cells transformed with the desired DNA 5 sequences. E. coli is one prokaryotic host particularly useful for cloning the DNA sequences of the present invention. Microbes, such as yeast are also useful for expression. Saccharomyces is a preferred yeast host, with suitable vectors having expression control sequences, an origin of replication, termination sequences and the like 10 as desired. Typical promoters include 3-phosphoglycerate kinase and other glycolytic enzymes. Inducible yeast promoters include, among others, promoters from alcohol dehydrogenase, isocytochrome C, and enzymes responsible for maltose and galactose utilization. Mammalian cells are a preferred host for expressing nucleotide segments 15 encoding immunoglobulins or fragments thereof. See Winnacker, From Genes to Clones, (VCH Publishers, NY, 1987). A number of suitable host cell lines capable of secreting intact heterologous proteins have been developed in the art, and include CHO cell lines, various COS cell lines, HeLa cells, L cells and myeloma cell lines. Preferably, the cells are nonhuman. Expression vectors for these cells can include expression control 20 sequences, such as an origin of replication, a promoter, an enhancer (Queen et al., Immunol. Rev. 89:49 (1986)), and necessary processing information sites, such as ribosome binding sites, RNA splice sites, polyadenylation sites, and transcriptional terminator sequences. Preferred expression control sequences are promoters derived from endogenous genes, cytomegalovirus, SV40, adenovirus, bovine papillomavirus, and the 25 like. See Co et al., J. Immunol. 148:1149 (1992). Alternatively, antibody coding sequences can be incorporated in transgenes for introduction into the genome of a transgenic animal and subsequent expression in the milk of the transgenic animal (see, e.g., US 5,741,957, US 5,304,489, US 5,849,992). Suitable transgenes include coding sequences for light and/or heavy 30 chains in operable linkage with a promoter and enhancer from a mammary gland specific gene, such as casein or beta lactoglobulin. The vectors containing the DNA segments of interest can be transferred into the host cell by well-known methods, depending on the type of cellular host. For example, calcium chloride transfection is commonly utilized for prokaryotic cells, 27 whereas calcium phosphate treatment, electroporation, lipofection, biolistics or viral based transfection can be used for other cellular hosts. Other methods used to transform mammalian cells include the use of polybrene, protoplast fusion, liposomes, electroporation, and microinjection (see generally, Sambrook et al., supra). For 5 production of transgenic animals, transgenes can be microinjected into fertilized oocytes, or can be incorporated into the genome of embryonic stem cells, and the nuclei of such cells transferred into enucleated oocytes. Once expressed, antibodies can be purified according to standard procedures of the art, including HPLC purification, column chromatography, gel 10 electrophoresis and the like (see generally, Scopes, Protein Purification (Springer-Verlag, NY, 1982)). 3. Carrier Proteins Some agents for inducing an immune response contain the appropriate 15 epitope for inducing an immune response against amyloid deposits but are too small to be immunogenic. In this situation, a peptide immunogen can be linked to a suitable carrier to help elicit an immune response. Suitable carriers include serum albumins, keyhole limpet hemocyanin, inmunoglobulin molecules, thyroglobulin, ovalbumin, tetanus toxoid, or a toxoid from other pathogenic bacteria, such as diphtheria, E. coli, cholera, or 20 H. pylori, or an attenuated toxin derivative. Other carriers include T-cell epitopes that bind to multiple MHC alleles, e.g., at least 75% of all human MHC alleles. Such carriers are sometimes known in the art as "universal T-cell epitopes." Examples of universal T cell epitopes include: Influenza Hemagluttinin: HA 3 o 7

.

3 j 9 PKYVKQNTLKLAT (SEQ ID NO: 43) 25 PADRE (common residues bolded) AXVAAWTLKAAA (SEQ ID NO: 44) Malaria CS: T3 epitope EKKIAKMEKASSVFNV (SEQ ID NO: 45) Hepatitis B surface antigen: HBsAgI 9 .2S FFLLTRILTI (SEQ ID NO: 46) Heat Shock Protein 65: hsp65 1 5 3- 17 , DQS IGDLIAEAMDKVGNEG (SEQ ID NO: 47) bacille Calmette-Guerin QVH FQ PL P PAVVKL (SEQ ID NO: 48) 30 Tetanus toxoid: TTso.44 QYIKANSKFIGITEL (SEQ ID NO: 49) Tetanus toxoid: TT 94 7.o FNNFTVSFWLRVPKVSASHLE (SEQ ID NO: 50) HIV gpl2O Tl: KQIINMWQEVGKAMYA (SEQ IDNO: 51) 28 Other carriers for stimulating or enhancing an immune response include cytokines such as IL-I, IL-I a and P peptides, IL-2, yINF, IL-10, GM-CSF, and chemokines, such as MIPIa and P and RANTES. Immunogenic agents can also be linked to peptides that enhance transport across tissues, as described in O'Mahony, WO 5 97/17613 and WO 97/17614. Immunogenic agents can be linked to carriers by chemical crosslinking. Techniques for linking an immunogen to a carrier include the formation of disulfide linkages using N-succinimidyl-3-(2-pyridyl-thio) propionate (SPDP) and succinimidyl 4 (N-maleimidomethyl)cyclohexane- I-carboxylate (SMCC) (if the peptide lacks a 10 sulfhydryl group, this can be provided by addition of a cysteine residue). These reagents create a disulfide linkage between themselves and peptide cysteine resides on one protein and an amide linkage through the c -amino on a lysine, or other free amino group in other amino acids. A variety of such disulfide/amide-forming agents are described by Immun. Rev. 62, 185 (1982). Other bifunctional coupling agents form a thioether rather than a 15 disulfide linkage. Many of these thio-ether-forming agents are commercially available and include reactive esters of 6-maleimidocaproic acid, 2-bromoacetic acid, and 2 iodoacetic acid, 4-(N-maleimido-methyl)cyclohexane-l-carboxylic acid. The carboxyl groups can be activated by combining them with succinimide or 1 -hydroxyl-2-nitro-4 sulfonic acid, sodium salt. 20 Immunogenic peptides can also be expressed as fusion proteins with carriers (i.e., heterologous peptides). The immunogenic peptide can be linked at its amino terminus, its carboxyl terminus, or both to a carrier. Optionally, multiple repeats of the immunogenic peptide can be present in the fusion protein. Optionally, an immunogenic peptide can be linked to multiple copies of a heterologous peptide, for 25 example, at both the N and C termini of the peptide. Some carrier peptides serve to induce a helper T-cell response against the carrier peptide. The induced helper T-cells in turn induce a B-cell response against the immunogenic peptide linked to the carrier peptide. Some agents of the invention comprise a fusion protein in which an N 30 terminal fragment of AfP is linked at its C-terminus to a carrier peptide. In such agents, the N-terminal residue of the fragment of A1P constitutes the N-terminal residue of the fusion protein. Accordingly, such fusion proteins are effective in inducing antibodies that bind to an epitope that requires the N-terminal residue of AP to be in free form. Some 29 agents of the invention comprises a plurality of repeats of an N-terminal segment of Ap linked at the C-terminus to one or more copy of a carrier peptide. The N-terminal fragment of Ap incorporated into such fusion proteins sometimes begins at AD 1-3 and ends at A1p7-1 1. APl-7, AD1-3, 1-4, 1-5, and 3-7 are preferred N-terminal fragment of 5 Ap. Some fusion proteins comprise different N-terminal segments of As in tandem. For example, a fusion protein can comprise Ap 1-7 followed by AP 1-3 followed by a heterologous peptide. In some fusion proteins, an N-terminal segment of Ap is fused at its N terminal end to a heterologous carrier peptide. The same variety of N-terminal segments 10 of Ap can be used as with C-terminal fusions. Some fusion proteins comprise a heterologous peptide linked to the N-terminus of an N-terminal segment of AP, which is in turn linked to one or more additional N-terminal segments of AD in tandem. Some examples of fusion proteins suitable for use in the invention are shown below. Some of these fusion proteins comprise segments of AP linked to tetanus 15 toxoid epitopes such as described in US 5,196,512, EP 378,881 and EP 427,347. Some fusion proteins comprises segments of AP linked to carrier peptides described in US 5,736,142. Some heterologous peptides are universal T-cell epitopes. In some methods, the agent for administration is simply a single fusion protein with an Ap segment linked to a heterologous segment in linear configuration. In some methods, the agent is 20 multimer of fusion proteins represented by the formula 2', in which x is an integer from 1-5. Preferably x is 1, 2 or 3, with 2 being most preferred. When x is two, such a multimer has four fusion proteins linked in a preferred configuration referred to as MAP4 (see US 5,229,490). Epitopes of AP are underlined. The MAP4 configuration is shown below, where branched structures are 25 produced by initiating peptide synthesis at both the N terminal and side chain amines of lysine. Depending upon the number of times lysine is incorporated into the sequence and allowed to branch, the resulting structure will present multiple N termini. In this example, four identical N termini have been produced on the branched lysine-containing core. Such multiplicity greatly enhances the responsiveness of cognate B cells. 30 30 Peptide Peptide 5 KA Peptide Peptide KGG 10 AN90549 (As 1-7/Tetanus toxoid 830-844 in a MAP4 configuration): DAEFRH DQYIKANSKFIGITEL (SEQ ID NO: 52) AN90550 (As 1-7/fetanus toxoid 947-967 in a MAP4 configuration): 15 DAEFRHDFNNFTVS FWLRVPKVSASHLE (SEQ ID NO: 53) AN90542 (Ap 1-7/Tetanus toxoid 830-844 + 947-967 in a linear configuration): DAEFRHDQYIKANSKFIGITELFNNFTVSFWLRVPKVSASHLE (SEQ ID NO: 54) 20 AN90576: (AP 3-9)/fetanus toxoid 830-844 in a MAP4 configuration): EFRHDSGQYIKANSKFIGITEL(SEQ ID NO: 55) Peptide described in US 5,736,142 (all in linear configurations): AN90562 (AP 1-7/ peptide) AKXVAAWTLKAAADAE FRH D (SEQ ID NO: 56) 25 AN90543(A1-7x3/peptide): DAEFRHDDAEFRHDDAEFRHDAKXVAAWIKAAA (SEQ IDNO: 57) Other examples of fusion proteins (immunogenic epitope of As bolded) include AKOVAAWMA ADA DnXUHDDAEFRHD(QN)3 DAEFRHD-AKXVAAWTLKAAA (SEQ ID NO: 59) 30 DAEFRHD-ISQAVHAAHAEINEAGR (SEQ ID NO: 60) FRIIDSGY-ISQAVHAAHAEINEAGR (SEQ ID NO: 61) EFRHDSG-ISQAVHAAHAEINEAGR (SEQ ID NO: 62) FKYVKQNIlATDAERHDDAHDDAfRHD(DND.63) DAEFRHD-PKYVKQNTLKLAT-DAEFRHD (SEQ ID NO: 64) 35 DAERHDDAERH AEFRHDPK NMIIX(90DNO:65) 31 DAEFRHD-DAEFRHD-PKYVKQNUILAT(SEQ I)NO.66) DAEFRHD-PKYVKQNrhKLAT-EKKIAKMEKASSVFNV QYKANSKFIGffEL-FNNFTVSFWLRVPKVSASHLE-DAEFRIiD (SEQ IDNO:67) DAEFRHD-DAEFRHD-DAEFRHD-QYKANSKFIGlTEL FNNFTVSFWLRVPKVSASHLE (SEQ ID NO: 68) DAEFRHD-QYKANSKFIGITELCFNNFTVSFWLRVPKVSASHLE (SEQ IDNO: 69)

DAEFRHD-QYIKANSKFIGITELCFNNFTVSFWLRVPKVSASHLE

DAEFRHD (SEQ ID NO: 70) 10 DAEFRHD-QYKANSKFIGITEL (SEQ ID NO: 52) on a 2 branched resin peptide--_ Lys-Gly-Cys peptide EQVTNVGGASQAVHAAHAEINEAGR(SEQ IDNO: 71) (Synuclein fusion protein in 15 MAP-4 configuration) The same or similar carrier proteins and methods of linkage can be used for generating immunogens to be used in generation of antibodies against As for use in passive immunization. For example, Ap or a fragment linked to a carrier can be administered to a laboratory animal in the production of monoclonal antibodies to AP. 20 4. Nucleic Acid Encoding Therapeutic Agents Immune responses against amyloid deposits can also be induced by administration of nucleic acids encoding segments of As peptide, and fragments thereof, other peptide immunogens, or antibodies and their component chains used for passive 25 immunization. Such nucleic acids can be DNA or RNA. A nucleic acid segment encoding an innunogen is typically linked to regulatory elements, such as a promoter and enhancer, that allow expression of the DNA segment in the intended target cells of a patient. For expression in blood cells, as is desirable for induction of an immune response, promoter and enhancer elements from light or heavy chain immunoglobulin 30 genes or the CMV major intermediate early promoter and enhancer are suitable to direct expression. The linked regulatory elements and coding sequences are often cloned into a vector. For administration of double-chain antibodies, the two chains can be cloned in the same or separate vectors. 32 A number of viral vector systems are available including retroviral systems (see, e.g., Lawrie and Tumin, Cur. Opin. Genet. Develop. 3, 102-109 (1993)); adenoviral vectors (see, e.g., Bett et al., J. Virol. 67, 5911 (1993)); adeno-associated virus vectors (see, e.g., Zhou et al., J. Exp. Med. 179, 1867 (1994)), viral vectors from the'pox family 5 including vaccinia virus and the avian pox viruses, viral vectors from the alpha virus genus such as those derived from Sindbis and Semliki Forest Viruses (see, e.g., Dubensky et al., J Virol. 70, 508-519 (1996)), Venezuelan equine encephalitis virus (see US 5,643,576) and rhabdoviruses, such as vesicular stomatitis virus (see WO 96/34625)and papillomaviruses (Ohe et al., Human Gene Therapy 6, 325-333 (1995); Woo et al., WO 10 94/12629 and Xiao & Brandsma, Nucleic Acids. Res. 24, 2630-2622 (1996)). DNA encoding an immunogen, or a vector containing the same, can be packaged into liposomes. Suitable lipids and related analogs are described by US 5,208,036,5,264,618, 5,279,833 and 5,283,185. Vectors and DNA encoding an immunogen can also be adsorbed to or associated with particulate carriers, examples of 15 which include polymethyl methacrylate polymers and polylactides and poly(lactide-co glycolides), see, e.g., McGee et al., J. Micro Encap. (1996). Gene therapy vectors or naked DNA can be delivered in vivo by administration to an individual patient, typically by systemic administration (e.g., intravenous, intraperitoneal, nasal, gastric, intradermal, intramuscular, subdermal, or 20 intracranial infusion) or topical application (see e.g., US 5,399,346). Such vectors can further include facilitating agents such as bupivacine (US 5,593,970). DNA can also be administered using a gene gun. See Xiao & Brandsma, supra. The DNA encoding an immunogen is precipitated onto the surface of microscopic metal beads. The microprojectiles are accelerated with a shock wave or expanding helium gas, and 25 penetrate tissues to a depth of several cell layers. For example, The Accel' Gene Delivery Device manufactured by Agacetus, Inc. Middleton WI is suitable. Alternatively, naked DNA can pass through skin into the blood stream simply by spotting the DNA onto skin with chemical or mechanical irritation (see WO 95/05853). In a further variation, vectors encoding immunogens can be delivered to 30 cells ex vivo, such as cells explanted from an individual patient (e.g., lymphocytes, bone marrow aspirates, tissue biopsy) or universal donor hematopoietic stem cells, followed by reimplantation of the cells into a patient, usually after selection for cells which have incorporated the vector. 33 Ill. Screening Antibodies for Clearing Activity The invention provides methods of screening an antibody for activity in clearing an amyloid deposit or any other antigen, or associated biological entity, for which clearing activity is desired. To screen for activity against an amyloid deposit, a 5 tissue sample from a brain of a patient with Alzheimer's disease or an animal model having characteristic Alzheimer's pathology is contacted with phagocytic cells bearing an Fc receptor, such as microglial cells, and the antibody under test in a medium in vitro. The pagocytic cells can be a primary culture or a cell line, such as BV-2, C8-B4, or THP 1. In some methods, the components are combined on a microscope slide to facilitate 10 microscopic monitoring. In some methods, multiple reactions are performed in parallel in the wells of a microtiter dish. In such a format, a separate miniature microscope slide can be mounted in the separate wells, or a nonmicroscopic detection format, such as ELISA detection of Ajp can be used. Preferably, a series of measurements is made of the amount of amyloid deposit in the in vitro reaction mixture, starting from a baseline value 15 before the reaction has proceeded, and one or more test values during the reaction. The antigen can be detected by staining, for example, with a fluorescently labelled antibody to AD or other component of amyloid plaques. The antibody used for staining may or may not be the same as the antibody being tested for clearing activity. A reduction relative to baseline during the reaction of the amyloid deposits indicates that the antibody under test 20 has clearing activity. Such antibodies are likely to be useful in preventing or treating Alzheimer's and other amyloidogenic diseases. Analogous methods can be used to screen antibodies for activity in clearing other types of biological entities. The assay can be used to detect clearing activity against virtually any kind of biological entity. Typically, the biological entity 25 has some role in human or animal disease. The biological entity can be provided as a tissue sample or in isolated form. If provided as a tissue sample, the tissue sample is preferably unfixed to allow ready access to components of the tissue sample and to avoid perturbing the conformation of the components incidental to fixing. Examples of tissue samples that can be tested in this assay include cancerous tissue, precancerous tissue, 30 tissue containing benign growths such as warts or moles, tissue infected with pathogenic microorganisms, tissue infiltrated with inflammatory cells, tissue bearing patholdgical matrices between cells (e.g., fibrinous pericarditis), tissue bearing aberrant antigens, and scar tissue. Examples of isolated biological entities that can be used include AP, viral 34 antigens or viruses, proteoglycans, antigens of other pathogenic microorganisms, tumor antigens, and adhesion molecules. Such antigens can be obtained from natural sources, recombinant expression or chemical synthesis, among other means. The tissue sample or isolated biological entity is contacted with phagocytic cells bearing Fc receptors, such as 5 monocytes or microglial cells, and an antibody to be tested in a medium. The antibody can be directed to the biological entity under test or to an antigen associated with the entity In the latter situation, the object is to test whether the biological entity is vicariously phagocytosed with the antigen. Usually, although not necessarily, the antibody and biological entity (sometimes with an associated antigen) are contacted with 10 each other before adding the phagocytic cells. The concentration of the biological entity and/or the associated antigen, if present, remaining in the medium is then monitored. A reduction in the amount or concentration of antigen or the associated biological entity in the medium indicates the antibody has a clearing response against the antigen and/or associated biological entity in conjunction with the phagocytic cells (see, e.g., Example 15 14). IV. PATIENTS AMENABLE TO TREATMENT Patients amenable to treatment include individuals at risk of disease but 20 not showing symptoms, as well as patients presently showing symptoms. In the case of Alzheimer's disease, virtually anyone is at risk of suffering from Alzheimer's disease if he or she lives long enough. Therefore, the present methods can be administered prophylactically to the general population without the need for any assessment of the risk of the subject patient. The present methods are especially useful for individuals who do 25 have a known genetic risk of Alzheimer's disease. Such individuals include those having relatives who have experienced this disease, and those whose risk is determined by analysis of genetic or biochemical markers. Genetic markers of risk toward Alzheimer's disease include mutations in the APP gene, particularly mutations at position 717 and positions 670 and 671 referred to as the Hardy and Swedish mutations respectively (see 30 Hardy, TINS, supra). Other markers of risk are mutations in the presenilin genes, PSI and PS2, and ApoE4, family history of AD, hypercholesterolemia or atherosclerosis. Individuals presently suffering from Alzheimer's disease can be recognized from characteristic dementia, as well as the presence of risk factors described above. In addition, a number of diagnostic tests are available for identifying individuals who have 35 AD. These include measurement of CSF tau and Ap42 levels. Elevated tau and decreased Ap42 levels signify the presence of AD. Individuals suffering from Alzheimer's disease can also be diagnosed by ADRDA criteria as discussed in the Examples section. 5 In asymptomatic patients, treatment can begin at any age (e.g., 10, 20, 30). Usually, however, it is not necessary to begin treatment until a patient reaches 40, 50, 60 or 70. Treatment typically entails multiple dosages over a period of time. Treatment can be monitored by assaying antibody, or activated T-cell or B-cell responses to the therapeutic agent (e.g., A P peptide) over time. If the response falls, a booster dosage is 10 indicated. In the case of potential Down's syndrome patients, treatment can begin antenatally by administering therapeutic agent to the mother or shortly after birth. V. TREATMENT REGIMES In prophylactic applications, pharmaceutical compositions or medicaments 15 are administered to a patient susceptible to, or otherwise at risk of, Alzheimer's disease in an amount sufficient to eliminate or reduce the risk, lessen the severity, or delay the outset of the disease, including biochemical, histologic and/or behavioral symptoms of the disease, its complications and intermediate pathological phenotypes presenting during development of the disease. In therapeutic applications, compositions or medicants are 20 administered to a patient suspected of, or already suffering from such a disease in an amount sufficient to cure, or at least partially arrest, the symptoms of the disease (biochemical, histologic and/or behavioral), including its complications and intermediate pathological phenotypes in development of the disease. In some methods, administration of agent reduces or eliminates myocognitive impairment in patients that have not yet 25 developed characteristic Alzheimer's pathology. An amount adequate to accomplish therapeutic or prophylactic treatment is defined as a therapeutically- or prophylactically effective dose. In both prophylactic and therapeutic regimes, agents are usually administered in several dosages until a sufficient immune response has been achieved. Typically, the immune response is monitored and repeated dosages are given if the 30 immune response starts to wane. Effective doses of the compositions of the present invention, for the treatment of the above described conditions vary depending upon many different factors, including means of administration, target site, physiological state of the patient, whether 36 the patient is human or an animal, other medications administered, and whether treatment is prophylactic or therapeutic. Usually, the patient is a human but nonhuman mammals including transgenic mammals can also be treated. Treatment dosages need to be titrated to optimize safety and efficacy. The amount of immunogen depends on wheumer adjuvant 5 is also administered, with higher dosages being required in the absence of adjuvant. The amount of an immunogen for administration sometimes varies from 1-500 pg per patient and more usually from 5-500 jig per injection for human administration. Occasionally, a higher dose of 1-2 mg per injection is used. Typically about 10, 20, 50 or 100 pg is used for each human injection. The mass of immunogen also depends on the mass ratio of 10 immunogenic epitope within the immunogen to the mass of immunogen as a whole. Typically, 10-3 to 10-5 micromoles of immunogenic epitope are used for microgram of immunogen. The timing of injections can vary significantly from once a day, to once a year, to once a decade. On any given day that a dosage of immunogen is given, the dosage is greater than I jig/patient and usually greater than 10 pg! patient if adjuvant is 15 also administered, and greater than 10 jig/patient and usually greater than 100 pg/patient in the absence of adjuvant. A typical regimen consists of an immunization followed by booster injections at time intervals, such as 6 week intervals. Another regimen consists of an immunization followed by booster injections 1, 2 and 12 months later. Another regimen entails an injection every two months for life. Alternatively, booster injections 20 can be on an irregular basis as indicated by monitoring of immune response. For passive immunization with an antibody, the dosage ranges from about 0.0001 to 100 mg/kg, and more usually 0.01 to 5 mg/kg, of the host body weight. For example dosages can be 1 mg/kg body weight or 10 mg/kg body weight or within the range of 1-10 mg/kg. An exemplary treatment regime entails administration once per 25 every two weeks or once a month or once every 3 to 6 months. In some methods, two or more monoclonal antibodies with different binding specificities are administered simultaneously, in which case the dosage of each antibody administered falls within the ranges indicated. Antibody is usually administered on multiple occasions. Intervals between single dosages can be weekly, monthly or yearly. Intervals can also be irregular 30 as indicated by measuring blood levels of antibody to AP in the patient. In some methods, dosage is adjusted to achieve a plasma antibody concentration of 1-1000 ug/ml and in some methods 25 - 300 ug/ml. Alternatively, antibody can be administered as a sustained release formulation, in which case less frequent administration is required. 37 Dosage and frequency vary depending on the half-life of the antibody in the patient. In general, human antibodies show the longest half life, followed by humanized antibodies, chimeric antibodies, and nonhuman antibodies. The dosage and frequency of administration can vary depending on whether the treatment is prophylactic or 5 therapeutic. In prophylactic applications, a relatively low dosage is administered at relatively infrequent intervals over a long period of time. Some patients continue to receive treatment for the rest of their lives. In therapeutic applications, a relatively high dosage at relatively short intervals is sometimes required until progression of the disease is reduced or terminated, and preferably until the patient shows partial or complete 10 amelioration of symptoms of disease. Thereafter, the patent can be administered a prophylactic regime. Doses for nucleic acids encoding immunogens range from about 10 ng to I g, 100 ng to 100 mg, I Ig to 10 mg, or 30-300 jig DNA per patient. Doses for infectious viral vectors vary from 10-100, or more, virions per dose. 15 Agents for inducing an immune response can be administered by parenteral, topical, intravenous, oral, subcutaneous, intraarterial, intracranial, intraperitoneal, intranasal or intramuscular means for prophylactic and/or therapeutic treatment. The most typical route of administration of an immunogenic agent is subcutaneous although other routes can be equally effective. The next most common 20 route is intramuscular injection. This type of injection is most typically performed in the arm or leg muscles. In some methods, agents are injected directly into a particular tissue where deposits have accumulated, for example intracranial injection. Intramuscular injection on intravenous infusion are preferred for administration of antibody. In some methods, particular therapeutic antibodies are injected directly into the cranium. In some 25 methods, antibodies are administered as a sustained release composition or device, such as a MedipadTm device. Agents of the invention can optionally be administered in combination with other agents that are at least partly effective in treatment of amyloidogenic disease. In the case of Alzheimer's and Down's syndrome, in which amyloid deposits occur in the 30 brain, agents of the invention can also be administered in conjunction with other agents that increase passage of the agents of the invention across the blood-brain barrier.' Immunogenic agents of the invention, such as peptides, are sometimes administered in combination with an adjuvant. A variety of adjuvants can be used in 38 combination with a peptide, such as Ap, to elicit an immune response. Preferred adjuvants augment the intrinsic response to an immunogen without causing conformational changes in the immunogen that affect the qualitative form of the response. Preferred adjuvants include aluminum hydroxide and aluminum phosphate, 3 De-O 5 acylated monophosphoryl lipid A (MPLm) (see GB 2220211 (RIBI ImmunoChem Research Inc., Hamilton, Montana, now part of Corixa). Stimulonim QS-21 is a triterpene glycoside or saponin isolated from the bark of the Quillaja Saponaria Molina tree found in South America (see Kensil et al., in Vaccine Design: The Subunit and Adjuvant Approach (eds. Powell & Newman, Plenum Press, NY, 1995); US Patent No. 10 5,057,540),(Aquila BioPharmaceuticals, Framingham, MA). Other adjuvants are oil in water emulsions (such as squalene or peanut oil), optionally in combination with immune stimulants, such as monophosphoryl lipid A (see Stoute et al., N. EngL. J. Med 336, 86-91 (1997)). Another adjuvant is CpG ( WO 98/40100). Alternatively, AD can be coupled to an adjuvant. However, such coupling should not substantially change the conformation of 15 A p so as to affect the nature of the immune response thereto. Adjuvants can be administered as a component of a therapeutic composition with an active agent or can be administered separately, before, concurrently with, or after administration of the therapeutic agent. A preferred class of adjuvants is aluminum salts (alum), such as aluminum 20 hydroxide, aluminum phosphate, aluminum sulfate. Such adjuvants can be used with or without other specific immunostimulating agents such as MPL or 3-DMP, QS-21, polymeric or monomeric amino acids such as polyglutamic acid or polylysine. Another class of adjuvants is oil-in-water emulsion formulations. Such adjuvants can be used with or without other specific immunostimulating agents such as muramyl peptides (e.g., N 25 acetylmuramyl-L-threonyl-D-isoglutamine (thr-MDP), N-acetyl-normuramyl-L-alanyl-D isoglutamine (nor-MDP), N-acetylmuramyl-L-alanyl-D-isoglutaminyl-L-alanine-2-(l' 2'dipalmitoyl-sn-glycero-3-hydroxyphosphoryloxy)-ethylamine (MTP-PE), N acetylglucsaminyl-N-acetylmuramyl-L-Al-D-isoglu-L-Ala-dipalmitoxy propylamide (DTP-DPP) theramideTM), or other bacterial cell wall components. Oil-in-water 30 emulsions include (a) MF59 (WO 90/14837), containing 5% Squalene, 0.5% Tween 80, and 0.5% Span 85 (optionally containing various amounts of MTP-PE) formulated into submicron particles using a microfluidizer such as Model 110 Y microfluidizer (Microfluidics, Newton MA), (b) SAF, containing 10% Squalene, 0.4% Tween 80, 5% 39 pluronic-blocked polymer L 121, and thr-MDP, either microfluidized into a submicron emulsion or vortexed to generate a larger particle size emulsion, and (c) RibiTM adjuvant system (RAS), (Ribi ImmunoChem, Hamilton, MT) containing 2% squalene, 0.2% Tween 80, and one or more bacterial cell wall components from the group consisting of 5 monophosphoryllipid A (MPL), trehalose dimycolate (TDM), and cell wall skeleton (CWS), preferably MPL + CWS (Detox

T

"). Another class of preferred adjuvants is saponin adjuvants, such as StimulonTM (QS-2 1, Aquila, Framingham, MA) or particles generated therefrom such as ISCOMs (immunostimulating complexes) and ISCOMATRIX. Other adjuvants include Complete Freund's Adjuvant (CFA) and 10 Incomplete Freund's Adjuvant (IFA). Other adjuvants include cytokines, such as interleukins (IL-1, IL-2, and IL-12), macrophage colony stimulating factor (M-CSF), tumor necrosis factor (TNF). An adjuvant can be administered with an immunogen as a single composition, or can be administered before, concurrent with or after administration of the 15 immunogen. Immunogen and adjuvant can be packaged and supplied in the same vial or can be packaged in separate vials and mixed before use. Immunogen and adjuvant are typically packaged with a label indicating the intended therapeutic application. If inmunogen and adjuvant are packaged separately, the packaging typically includes instructions for mixing before use. The choice of an adjuvant and/or carrier depends on 20 the stability of the immunogenic formulation containing the adjuvant, the route of administration, the dosing schedule,.the efficacy of the adjuvant for the species being vaccinated, and, in humans, a pharmaceutically acceptable adjuvant is one that has been approved or is approvable for human administration by pertinent regulatory bodies. For example, Complete Freund's adjuvant is not suitable for human administration. Alum, 25 MPL and QS-21 are preferred. Optionally, two or more different adjuvants can be used simultaneously. Preferred combinations include alum with MPL, alum with QS-21, MPL with QS-21, and alum, QS-21 and MPL together. Also, Incomplete Freund's adjuvant can be used (Chang et al., Advanced Drug Delivery Reviews 32, 173-186 (1998)), optionally in combination with any of alum, QS-2 1, and MPL and all combinations thereof. 30 Agents of the invention are often administered as pharmaceutical compositions comprising an active therapeutic agent, i.e., and a variety of other pharmaceutically acceptable components. See Remington's Pharmaceutical Science (15th ed., Mack Publishing Company, Easton, Pennsylvania, 1980). The preferred form 40 depends on the intended mode of administration and therapeutic application. The compositions can also include, depending on the formulation desired, pharmaceutically acceptable, non-toxic carriers or diluents, which are defined as vehicles commonly used to formulate pharmaceutical compositions for animal or human administration. ihe 5 diluent is selected so as not to affect the biological activity of the combination. Examples of such diluents are distilled water, physiological phosphate-buffered saline, Ringer's solutions, dextrose solution, and Hank's solution. In addition, the pharmaceutical composition or formulation may also include other carriers, adjuvants, or nontoxic, nontherapeutic, nonimmunogenic stabilizers and the like. 10 Pharmaceutical compositions can also include large, slowly metabolized macromolecules such as proteins, polysaccharides such as chitosan, polylactic acids, polyglycolic acids and copolymers (such as latex functionalized sepharose(TM), agarose, cellulose, and the like), polymeric amino acids, amino acid copolymers, and lipid aggregates (such as oil droplets or liposomes). Additionally, these carriers can function 15 as immunostimulating agents (i.e., adjuvants). For parenteral administration, agents of the invention can be administered as injectable dosages of a solution or suspension of the substance in a physiologically acceptable diluent with a pharmaceutical carrier that can be a sterile liquid such as water oils, saline, glycerol, or ethanol. Additionally, auxiliary substances, such as wetting or 20 emulsifying agents, surfactants, pH buffering substances and the like can be present in compositions. Other components of pharmaceutical compositions are those of petroleum, animal, vegetable, or synthetic origin, for example, peanut oil, soybean oil, and mineral oil. In general, glycols such as propylene glycol or polyethylene glycol are preferred liquid carriers, particularly for injectable solutions. Antibodies can be administered in the 25 form of a depot injection or implant preparation which can be formulated in such a manner as to permit a sustained release of the active ingredient. An exemplary composition comprises monoclonal antibody at 5 mg/mL, formulated in aqueous buffer consisting of 50 mM L-histidine, 150 mM NaCl, adjusted to pH 6.0 with HCI. Typically, compositions are prepared as injectables, either as liquid 30 solutions or suspensions; solid forms suitable for solution in, or suspension in, liquid vehicles prior to injection can also be prepared. The preparation also can be emulsified or encapsulated in liposomes or micro particles such as polylactide, polyglycolide, or copolymer for enhanced adjuvant effect, as discussed above (see Langer, Science 249, 1527 (1990) and Hanes, Advanced Drug Delivery Reviews 28, 97-119 (1997). The agents 41 of this invention can be administered in the form of a depot injection or implant preparation which can be formulated in such a manner as to permit a sustained or pulsatile release of the active ingredient. Additional formulations suitable for other modes of administration include 5 oral, intranasal, and pulmonary formulations, suppositories, and transdermal applications. For suppositories, binders and carriers include, for example, polyalkylene glycols or triglycerides; such suppositories can be formed from mixtures containing the active ingredient in the range of 0.5% to 10%, preferably 1%-2%. Oral formulations include excipients, such as pharmaceutical grades of mannitol, lactose, starch, magnesium 10 stearate, sodium saccharine, cellulose, and magnesium carbonate. These compositions take the form of solutions, suspensions, tablets, pills, capsules, sustained release formulations or powders and contain 10%-95% of active ingredient, preferably 25%-70%. Topical application can result in transdermal or intradermal delivery. Topical administration can be facilitated by co-administration of the agent with cholera 15 toxin or detoxified derivatives or subunits thereof or other similar bacterial toxins (See Glenn et al., Nature 391, 851 (1998)). Co-administration can be achieved by using the components as a mixture or as linked molecules obtained by chemical crosslinking or expression as a fusion protein. Alternatively, transdermal delivery can be achieved using a skin path or 20 using transferosomes (Paul et al., Eur. J. Immunol. 25, 3521-24 (1995); Cevc et al., Biochem. Biophys. Acia 1368, 201-15 (1998)). VI. Methods of Diagnosis The invention provides methods of detecting an immune response against 25 As peptide in a patient suffering from or susceptible to Alzheimer's disease. The methods are particularly useful for monitoring a course of treatment being administered to a patient. The methods can be used to monitor both therapeutic treatment on symptomatic patients and prophylactic treatment on asymptomatic patients. The methods are useful for monitoring both active immunization (e.g., antibody produced in response 30 to administration of immunogen) and passive immunization (e.g., measuring level of administered antibody). 42 1. Active Immunization Some methods entail determining a baseline value of an immune response in a patient before administering a dosage of agent, and comparing this with a value for the immune response after treatment. A significant increase (i.e., greater than the typical 5 margin of experimental error in repeat measurements of the same sample, expressed as one standard deviation from the mean of such measurements) in value of the immune response signals a positive treatment outcome (i.e., that administration of the agent has achieved or augmented an immune response). If the value for immune response does not change significantly, or decreases, a negative treatment outcome is indicated. In general, 10 patients undergoing an initial course of treatment with an immunogenic agent are expected to show an increase in immune response with successive dosages, which eventually reaches a plateau. Administration of agent is generally continued while the immune response is increasing. Attainment of the plateau is an indicator that the administered of treatment can be discontinued or reduced in dosage or frequency. 15 In other methods, a control value (i.e., a mean and standard deviation) of immune response is determined for a control population. Typically the individuals in the control population have not received prior treatment. Measured values of immune response in a patient after administering a therapeutic agent are then compared with the control value. A significant increase relative to the control value (e.g., greater than one 20 standard deviation from the mean) signals a positive treatment outcome. A lack of significant increase or a decrease signals a negative treatment outcome. Administration of agent is generally continued while the immune response is increasing relative to the control value. As before, attainment of a plateau relative to control values in an indicator that the administration of treatment can be discontinued or reduced in dosage or 25 frequency. In other methods, a control value of immune response (e.g., a mean and standard deviation) is determined from a control population of individuals who have undergone treatment with a therapeutic agent and whose immune responses have plateaued in response to treatment. Measured values of immune response in a patient are 30 compared with the control value. If the measured level in a patient is not significantly different (e.g., more than one standard deviation) from the control value, treatment can be discontinued. If the level in a patient is significantly below the control value, continued administration of agent is warranted. If the level in the patient persists below the control 43 value, then a change in treatment regime, for example, use of a different adjuvant may be indicated. In other methods, a patient who is not presently receiving treatment but has undergone a previous course of treatment is monitored for immune response to 5 determine whether a resumption of treatment is required. The measured value of immune response in the patient can be compared with a value of immune response previously achieved in the patient after a previous course of treatment. A significant decrease relative to the previous measurement (i.e., greater than a typical margin of error in repeat measurements of the same sample) is an indication that treatment can be resumed. 10 Alternatively, the value measured in a patient can be compared with a control value (mean plus standard deviation) determined in a population of patients after undergoing a course of treatment. Alternatively, the measured value in a patient can be compared with a control value in populations of prophylactically treated patients who remain free of symptoms of disease, or populations of therapeutically treated patients who show 15 amelioration of disease characteristics. In all of these cases, a significant decrease relative to the control level (i.e., more than a standard deviation) is an indicator that treatment should be resumed in a patient. The tissue sample for analysis is typically blood, plasma, serum, mucous or cerebrospinal fluid from the patient. The sample is analyzed for indication of an 20 immune response to any form of AP peptide, typically Ap42. The immune response can be determined from the presence of, e.g., antibodies or T-cells that specifically bind to A p peptide. ELISA methods of detecting antibodies specific to AP are described in the Examples section. Methods of detecting reactive T-cells have been described above (see Definitions). In some methods, the immune response is determined using a clearing 25 assay, such as described in Section III above. In such methods, a tissue sample from a patient being tested is contacted with amyloid deposits (e.g., from a PDAPP mouse) and phagocytic cells bearing Fc receptors. Subsequent clearing of the amyloid deposit is then monitored. The existence and extent of clearing response provides an indication of the existence and level of antibodies effective to clear ADp in the tissue sample of the patient 30 under test. 44 2. Passive Immunization In general, the procedures for monitoring passive immunization are similar to those for monitoring active immunization described above. However, the antibody profile following passive immunization typically shows an immediate peak in antibody 5 concentration followed by an exponential decay. Without a further dosage, the decay approaches pretreatment levels within a period of days to months depending on the half life of the antibody administered. For example the half-life of some human antibodies is of the order of 20 days. In some methods, a baseline measurement of antibody to AP in the patient 10 is made before administration, a second measurement is made soon thereafter to determine the peak antibody level, and one or more further measurements are made at intervals to monitor decay of antibody levels. When the level of antibody has declined to baseline or a predetermined percentage of the peak less baseline (e.g., 50%, 25% or 10%), administration of a further dosage of antibody is administered. In some methods, peak or 15 subsequent measured levels less background are compared with reference levels previously determined to constitute a beneficial prophylactic or therapeutic treatment regime in other patients. If the measured antibody level is significantly less than a reference level (e.g., less than the mean minus one standard deviation of the reference value in population of patients benefiting from treatment) administration of an additional 20 dosage of antibody is indicated. 3. Diagnostic Kits The invention further provides diagnostic kits for performing the diagnostic methods described above. Typically, such kits contain an agent that 25 specifically binds to antibodies to Ap. The kit can also include a label. For detection of antibodies to AP, the label is typically in the form of labelled anti-idiotypic antibodies. For detection of antibodies, the agent can be supplied prebound to a solid phase, such as to the wells of a microtiter dish. Kits also typically contain labeling providing directions for use of the kit. The labeling may also include a chart or other correspondence regime 30 correlating levels of measured label with levels of antibodies to Ap. The term labeling refers to any written or recorded material that is attached to, or otherwise accompanies a kit at any time during its manufacture, transport, sale or use. For example, the term labeling encompasses advertising leaflets and brochures, packaging materials, 45 instructions, audio or video cassettes, computer discs, as well as writing imprinted directly on kits. The invention also provides diagnostic kits for performing in vivo imaging. Such kits typically contain an antibody binding to an epitope of AP, preferably 5 within residues 1-10. Preferably, the antibody is labelled or a secondary labeling reagent is included in the kit. Preferably, the kit is labelled with instructions for performing an in vivo imaging assay. VII. In Vivo Imaging 10 The invention provides methods of in vivo imaging amyloid deposits in a patient. Such methods are useful to diagnose or confirm diagnosis of Alzheimer's disease, or susceptibility thereto. For example, the methods can be used on a patient presenting with symptoms of dementia. If the patient has abnormal amyloid deposits, then the patient is likely suffering from Alzheimer's disease. The methods can also be 15 used on asymptomatic patients. Presence of abnormal deposits of amyloid indicates susceptibility to future symptomatic disease. The methods are also useful for monitoring disease progression and/or response to treatment in patients who have been previously diagnosed with Alzheimer's disease. The methods work by administering a reagent, such as antibody, that binds 20 to AP to the patient, and then detecting the agent after it has bound. Preferred antibodies bind to AP deposits in a patient without binding to full length APP polypeptide. Antibodies binding to an epitope of Ap within amino acids 1-10 are particularly preferred. In some methods, the antibody binds to an epitope within amino acids 7-10 of Ap. Such antibodies typically bind without inducing a substantial clearing response. In 25 other methods, the antibody binds to an epitope within amino acids 1-7 of A1p. Such antibodies typically bind and induce a clearing response to A p. However, the clearing response can be avoided by using antibody fragments lacking a full length constant region, such as Fabs. In some methods, the same antibody can serve as both a treatment and diagnostic reagent. In general, antibodies binding to epitopes C-terminal of residue 30 10 of AIpdo not show as strong signal as antibodies binding to epitopes within residues I 10, presumably because the C-terminal epitopes are inaccessible in amyloid deposits. Accordingly, such antibodies are less preferred. 46 Diagnostic reagents can be administered by intravenous injection into the body of the patient, or directly into the brain by intracranial injection or by drilling a hole through the skull. The dosage of reagent should be within the same ranges as for treatment methods. Typically, the reagent is labelled, although in some methods, the 5 primary reagent with affinity for A3 is unlabelled and a secondary labeling agent is used to bind to the primary reagent. The choice of label depends on the means of detection. For example, a fluorescent label is suitable for optical detection. Use of paramagnetic labels is suitable for tomographic detection without surgical intervention. Radioactive labels can also be detected using PET or SPECT. 10 Diagnosis is performed by comparing the number, size and/or intensity of labelled loci to corresponding base line values. The base line values can represent the mean levels in a population of undiseased individuals. Base line values can also represent previous levels determined in the same patient. For example, base line values can be determined in a patient before beginning treatment, and measured values thereafter 15 compared with the base line values. A decrease in values relative to base line signals a positive response to treatment. EXAMPLES I. PROPHYLACTIC EFFICACY OF Ap AGAINST AD 20 These examples describe administration of Ap42 peptide to transgenic mice overexpressing APP with a mutation at position 717 (APP717V->F) that predisposes them to develop Alzheimer's-like neuropathology. Production and characteristics of these mice (PDAPP mice) is described in Games et al., Nature, supra. These animals, in their heterozygote form, begin to deposit AD at six months of age forward. By fifteen months 25 of age they exhibit levels of Ap deposition equivalent to that seen in Alzheimer's disease. PDAPP mice were injected with aggregated Ap 4 2 (aggregated Ap 42 ) or phosphate buffered saline. Aggregated A0 42 was chosen because of its ability to induce antibodies to multiple epitopes of Ap. 30 A. METHODS 1. Source of Mice Thirty PDAPP heterogenic female mice were randomly divided into the following groups: 10 mice to be injected with aggregated Ap42 (one died in transit), 47 5 mice to be injected with PBS/adjuvant or PBS, and 10 uninjected controls. Five mice were injected with peptides derived from the sequence of serum amyloid protein (SAP). 2. Preparation of Immunogens 5 Preparation of aggregated Ap42: two milligrams of Ap42 (US Peptides Inc, lot K-42-12) was dissolved in 0.9 ml water and made up to 1 ml by adding 0.1 ml 10 x PBS. This was vortexed and allowed to incubate overnight 37* C, under which conditions the peptide aggregated. Any unused A1P was stored as a dry lyophilized powder at -20* C until the next injection. 10 3. Preparation of Injections For each injection, 100 ig of aggregated A$42 in PBS per mouse was emulsified 1:1 with Complete Freund's adjuvant (CFA) in a final volume of 400 pl emulsion for the first immunization, followed by a boost of the same amount of 15 immunogen in Incomplete Freund's adjuvant (IFA) at 2 weeks. Two additional doses in IFA were given at monthly intervals. The subsequent immunizations were done at monthly intervals in 500 p1 of PBS. Injections were delivered intraperitoneally (i.p.). PBS injections followed the same schedule and mice were injected with a 1:1 mix of PBS/ Adjuvant at 400 pl per mouse, or 500 ld of PBS per mouse. SAP 20 injections likewise followed the same schedule using a dose of 100 pig per injection. 4. Titration of Mouse Bleeds, Tissue Preparation and Immunohistochemistry The above methods are described infra in General Materials and Methods. 25 B. RESULTS PDAPP mice were injected with either aggregated AM2 (aggregated Ap42), SAP peptides, or phosphate buffered saline. A group of PDAPP mice were also left as uninjected, positive controls. The titers of the mice to aggregated Ap42 were 30 monitored every other month from the fourth boost until the mice were one year of age. Mice were sacrificed at 13 months. At all time points examined, eight of the nine aggregated Ap42 mice developed a high antibody titer, which remained high throughout the series of injections (titers greater than 1/10000). The ninth mouse had a low, but 48 measurable titer of approximately 1/1000 (Figure 1, Table 1). SAPP-injected mice had titers of 1:1,000 to 1:30,000 for this immunogen with only a single mouse exceeding 1:10,0000. The PBS-treated mice were titered against aggregated Ap42 at six, ten and 5 twelve months. At a 1/100 dilution the PBS mice, when titered against aggregated Ap42, only exceeded 4 times background at one data point, otherwise, they were less than 4 times background at all time points (Table 1). The SAP-specific response was negligible at these time points with all titers less than 300. Seven out of the nine mice in the aggregated AP1-42 treated group had no 10 detectable amyloid in their brains. In contrast, brain tissue from mice in the SAP and PBS groups contained numerous amyloid deposits in the hippocampus, as well as in the frontal and cingulate cortices. The pattern of deposition was similar to that of untreated controls, with characteristic involvement of vulnerable subregions, such as the outer molecular layer of the hippocampal dentate gyms. One mouse from the AlP 1-42-injected 15 .group had a greatly reduced amyloid burden, confined to the hippocampus. An isolated plaque was identified in another APl 1-42-treated mouse. Quantitative image analyses of the amyloid burden in the hippocampus verified the dramatic reduction achieved in the Ap42(AN 1792)-treated animals (Fig. 2). The median values of the amyloid burden for the PBS group (2.22%), and for the 20 untreated control group (2.65%) were significantly greater than for those immunized with AN 1792 (0.00%, p=0.0005). In contrast, the median value for the group immunized with SAP peptides (SAPP) was 5.74%. Brain tissue from the untreated, control mice contained numerous AP amyloid deposits visualized with the Ap-specific monoclonal antibody (mAb) 3D6 in the hippocampus, as well as in the retrosplenial cortex. A similar 25 pattern of amyloid deposition was also seen in mice immunized with SAPP or PBS (Fig. 2). In addition, in these latter three groups there was a characteristic involvement of vulnerable subregions of the brain classically seen in AD, such as the outer molecular layer of the hippocampal dentate gyrus, in all three of these groups. The brains that contained no AlP deposits were also devoid of neuritic 30 plaques that are typically visualized in PDAPP mice with the human APP antibody 8E5. All of brains from the remaining groups (SAP-injected, PBS and uninjected mice) had numerous neuritic plaques typical of untreated PDAPP mice. A small number of neuritic plaques were present in one mouse treated with AN 1792, and a single cluster of 49 dystrophic neurites was found in a second mouse treated with AN 1792. Image analyses of the hippocampus, and shown in Fig. 3, demonstrated the virtual elimination of dystrophic neurites in AN 1792-treated mice (median 0.00%) compared to the PBS recipients (median 0.28%, p = 0.0005). 5 Astrocytosis characteristic of plaque-associated inflammation was also absent in the brains of the Apl-42 injected group. The brains from the mice in the other groups contained abundant and clustered GFAP-positive astrocytes typical of AP plaque associated gliosis. A subset of the GFAP-reacted slides were counter-stained with Thioflavin S to localize the Ap deposits. The GFAP-positive astrocytes were associated 10 with As plaques in the SAP, PBS and untreated controls. No such association was found in the plaque-negative Apl-42 treated mice, while minimal plaque-associated gliosis was identified in one mouse treated with AN 1792. Image analyses, shown in Fig. 4 for the retrosplenial cortex, verified that the reduction in astrocytosis was significant with a median value of 1.56% for those 15 treated with AN 1792 versus median values greater than 6% for groups immunized with SAP peptides, PBS or untreated (p=0.00 17) Evidence from a subset of the AD 1-42- and PBS-injected mice indicated plaque-associated MHC II immunoreactivity was absent in the A31-42 injected mice, consistent with lack of an Ap-related inflammatory response. 20 Sections of the mouse brains were also reacted with a mAb specific with a monoclonal antibody specific for MAC-1, a cell surface protein. MAC-I (CDII b) is an integrin family member and exists as a heterodimer with CD18. The CDI Ib/CD18 complex is present on monocytes, macrophages, neutrophils and natural killer cells (Mak and Simard). The resident MAC-I-reactive cell type in the brain is likely to be microglia 25 based on similar phenotypic morphology in MAC-1 immunoreacted sections. Plaque associated MAC-1 labeling was lower in the brains of mice treated with AN 1792 compared to the PBS control group, a finding consistent with the lack of an Ap-induced inflammatory response. 30 C. CONCLUSION The lack of As plaques and reactive neuronal and gliotic change in the brains of the ApI-42-injected mice indicate that no or extremely little amyloid was deposited in their brains, and pathological consequences, such as gliosis and neuritic 50 pathology, were absent. PDAPP mice treated with AD 1-42 show essentially the same lack of pathology as control nontransgenic mice. Therefore, ApI-42 injections are highly effective in the prevention of deposition or clearance of human AP from brain tissue, and eliminatiDn of subsequent neuronal and inflammatory degenerative changes. Thus, 5 administration of A1P peptide can have both preventative and therapeutic benefit in prevention of AD. 11. DOSE RESPONSE STUDY Groups of five-week old, female Swiss Webster mice (N=6 per group) 10 were immunized with 300, 100, 33, 11, 3.7, 1.2, 0.4, or 0.13 ug of AP formulated in CFA/IFA administered intraperitoneally. Three doses were given at biweekly intervals followed by a fourth dose one month later. The first dose was emulsified with CFA and the remaining doses were emulsified with IFA. Animals were bled 4-7 days following each immunization starting after the second dose for measurement of antibody titers. 15 Animals in a subset of three groups, those immunized with 11, 33, or 300 pig of antigen, were additionally bled at approximately monthly intervals for four months following the fourth immunization to monitor the decay of the antibody response across a range of doses of immunogenic formulations. These animals received a final fifth immunization at seven months after study initiation. They were sacrificed one week later to measure 20 antibody responses to AN 1792 and to perform toxicological analyses. A declining dose response was observed from 300 to 3.7 pg with no response at the two lowest doses. Mean antibody titers are about 1:1000 after 3 doses and about 1:10,000 after 4 doses of 11-300 pg of antigen (see Fig. 5). Antibody titers rose dramatically for all but the lowest dose group 25 following the third immunization with increases in GMTs ranging from 5- to 25-fold. Low antibody responses were then detectable for even the 0.4 pg recipients. The 1.2 and 3.7 pg groups had comparable titers with GMTs of about 1000 and the highest four doses clustered together with GMTs of about 25,000, with the exception of the 33 jig dose group with a lower GMT of 3000. Following the fourth immunization, the titer increase 30 was more modest for most groups. There was a clear dose response across the lower antigen dose groups from 0.14 pg to 11 jig ranging from no detectable antibody for recipients of 0.14 pg to a GMT of 36,000 for recipients of 11 pg. Again, titers for the four highest dose groups of 11 to 300 jig clustered together. Thus following two 51 immunizations, the antibody titer was dependent on the antigen dose across the broad range from 0.4 to 300 pg. By the third immunization, titers of the highest four doses were all comparable and they remained at a plateau after an additional immunization. One month following the fourth immunization, titers were 2- to 3-fold 5 higher in the 300 pg group than those measured from blood drawn five days following the immunization (Fig. 6). This observation suggests that the peak anamnestic antibody response occurred later than 5 days post-immunization. A more modest (50%) increase was seen at this time in the 33 pg group. In the 300 pg dose group at two months following the last dose, GMTs declined steeply by about 70%. After another month, the 10 decline was less steep at 45% (100 pg) and about 14% for the 33 and 11 pg doses. Thus, the rate of decline in circulating antibody titers following cessation of immunization appears to be biphasic with a steep decline the first month following peak response followed by a more modest rate of decrease thereafter. The antibody titers and the kinetics of the response of these Swiss Webster 15 mice are similar to those of young heterozygous PDAPP transgenic mice immunized in a parallel manner. Dosages effective to induce an immune response in humans are typically similar to dosages effective in mice. III. SCREEN FOR THERAPEUTIC EFFICACY AGAINST ESTABLISHED AD 20 This assay is designed to test immunogenic agents for activity in arresting or reversing neuropathologic characteristics of AD in aged animals. Immunizations with 42 amino acid long Ap (AN] 792) were begun at a time point when amyloid plaques are already present in the brains of the PDAPP mice. Over the time course used in this study, untreated PDAPP mice develop a 25 number of neurodegenerative changes that resemble those found in AD (Games et aL., supra and Johnson-Wood et al., Proc. Nail. Acad Sci. USA 94, 1550-1555 (1997)). The deposition of Ap into amyloid plaques is associated with a degenerative neuronal response consisting of aberrant axonal and dendritic elements, called dystrophic neurites. Arnyloid deposits that are surrounded by and contain dystrophic neurites called neuritic 30 plaques. In both AD and the PDAPP mouse, dystrophic neurites have a distinctive globular structure, are immunoreactive with a panel of antibodies recognizing APP and cytoskeletal components, and display complex subcellular degenerative changes at the ultrastructural level. These characteristics allow for disease-relevant, selective and 52 reproducible measurements of neuritic plaque formation in the PDAPP brains. The dystrophic neuronal component of PDAPP neuritic plaques is easily visualized with an antibody specific for human APP (monoclonal antibody 8E5), and is readily measurable by computer-assisted image analysis. Therefore, in addition to measuring the effects of 5 AN 1792 on amyloid plaque formation, we monitored the effects of this treatment on the development of neuritic dystrophy. Astrocytes and microglia are non-neuronal cells that respond to and reflect the degree of neuronal injury. GFAP-positive astrocytes and MHC I-positive microglia are commonly observed in AD, and their activation increases with the severity of the 10 disease. Therefore, we also monitored the development of reactive astrocytosis and microgliosis in the AN 1792-treated mice. A. Materials and Methods Forty-eight, heterozygous female PDAPP mice, 11 to 11.5 months of age, 15 obtained from Charles River, were randomly divided into two groups: 24 mice to be immunized with 100 ptg of AN 1792 and 24 mice to be immunized with PBS, each combined with Freund's adjuvant. The ANI 792 and PBS groups were again divided when they reached -15 months of age. At 15 months of age approximately half of each group of the AN 1792- and PBS-treated animals were euthanized (n=10 and 9, 20 respectively), the remainder continued to receive immunizations until termination at -18 months (n=9 and 12, respectively). A total of 8 animals (5 AN 1792, 3 PBS) died during the study. In addition to the immunized animals, one-year old (n=10), 15-month old (n=1 0) and 18-month old (nl 0) untreated PDAPP mice were included for comparison in the ELISAs to measure AP and APP levels in the brain; the one-year old animals were 25 also included in the imnmunohistochemical analyses. Methodology was as in Example 1 unless otherwise indicated. US Peptides lot 12 and California Peptides lot ME0339 of AN1792 were used to prepare the antigen for the six immunizations administered prior to the 15-month time point. California Peptides lots ME0339 and ME0439 were used for the three additional 30 immunizations administered between 15 and 18 months. For immunizations, 100 jig of AN1792 in 200 pd PBS or PBS alone was emulsified 1:1 (vol:vol) with Complete Freund's adjuvant (CFA) or Incomplete Freund's adjuvant (IFA) or PBS in a final volume of 400 pl. The first immunization was delivered 53 with CFA as adjuvant, the next four doses were given with IFA and the final four doses with PBS alone without added adjuvant. A total of nine immunizations were given over the seven-month period on a two-week schedule for the first three doses followed by a four-week interval for the remaining injections. The four-month treatment group, 5 euthanized at 15 months of age, received only the first 6 immunizations. B. Results I. Effects of AN1792 Treatment on Amyloid Burden The results of AN1792 treatment on cortical amyloid burden determined 10 by quantitative image analysis are shown in Fig. 7. The median value of cortical amyloid burden was 0.28% in a group of untreated 12-month old PDAPP mice, a value representative of the plaque load in mice at the study's initiation. At 18 months, the amyloid burden increased over 17-fold to 4.87% in PBS-treated mice, while AN 1792 treated mice had a greatly reduced amyloid burden of only 0.01%, notably less than the 15 12-month untreated and both the 15- and 18-month PBS-treated groups. The amyloid burden was significantly reduced in the AN 1792 recipients at both 15 (96% reduction; p=0.00 3 ) and 18 (>99/o reduction; p=0.000 2 ) months. Typically, cortical amyloid deposition in PDAPP mice initiates in the frontal and retrosplenial cortices (RSC) and progresses in a ventral-lateral direction to 20 involve the temporal and entorhinal cortices (EC). Little or no amyloid was found in the EC of 12 month-old mice, the approximate age at which AN 1792 was first administered. After 4 months of AN 1792 treatment, amyloid deposition was greatly diminished in the RSC, and the progressive involvement of the EC was entirely eliminated by AN1792 treatment. The latter observation showed that AN 1792 completely halted the progression 25 of amyloid that would normally invade the temporal and ventral cortices, as well as arrested or possibly reversed deposition in the RSC. The profound effects of AN 1792 treatment on developing cortical amyloid burden in the PDAPP mice are further demonstrated by the 18-month group, which had been treated for seven months. A near complete absence of cortical amyloid was found in 30 the AN1792-treated mouse, with a total lack of diffuse plaques, as well as a reduction in compacted deposits. 54 2. ANI'192 Treatment-associated Cellular and Morphological Changes A population of Ap-positive cells was found in brain regions that typically contain amyloid deposits. Remarkably, in several brains from AN 1792 recipients, very 5 few or no extracellular cortical amyloid plaques were found. Most of the As immunoreactivity appeared to be contained within cells with large lobular or clumped soma. Phenotypically,.these cells resembled activated microglia or monocytes. They were immunoreactive with antibodies recognizing ligands expressed by activated monocytes and microglia (MHC 11 and CD IIb) and were occasionally associated with the 10 wall or lumen of blood vessels. Comparison of near-adjacent sections labeled with Al and MHC Il-specific antibodies revealed that similar patterns of these cells were recognized by both classes of antibodies. Detailed examination of the AN1792-treated brains revealed that the MHC I-positive cells were restricted to the vicinity of the limited amyloid remaining in these animals. Under the fixation conditions employed, the cells 15 were not inimunoreactive with antibodies that recognize T cell (CD3, CD3e) or B cell (CD45RA, CD45RB) ligands or leukocyte common antigen (CD45), but were reactive with an antibody recognizing leukosialin (CD43) which cross-reacts with monocytes. No such cells were found in any of the PBS-treated mice. PDAPP mice invariably develop heavy amyloid deposition in the outer 20 molecular layer of the hippocampal dentate gyrus. The deposition forms a distinct streak within the perforant pathway, a subregion that classically contains amyloid plaques in AD. The characteristic appearance of these deposits in PBS-treated mice resembled that previously characterized in untreated PDAPP mice. The amyloid deposition consisted of both diffuse and compacted plaques in a continuous band. In contrast, in a number of 25 brains from AN 1792-treated mice this pattern was drastically altered. The hippocampal amyloid deposition no longer contained diffuse amyloid, and the banded pattern was completely disrupted. Instead, a number of unusual punctate structures were present that are reactive with anti-Al antibodies, several of which appeared to be amyloid-containing cells. 30 MHC II-positive cells were frequently observed in the vicinity of extracellular amyloid in AN1792-treated animals. The pattern of association of AD positive cells with amyloid was very similar in several brains from AN 1792-treated mice. The distribution of these monocytic cells was restricted to the proximity of the deposited amyloid and was entirely absent from other brain regions devoid of AP plaques. 55 Confocal microscopy of MHCII- and Ap-labelled sections revealed that plaque material was contained within many of the monocytic cells. Quantitative image analysis of MHC 11 and MAC I-labeled sections revealed a trend towards increased immunoreactivity in the RSC and hippocampus of 5 ANI 792-treated mice compared to the PBS group which reached significance with the measure of MAC I reactivity in hippocampus. These results are indicative of active, cell-mediated clearance of amyloid in plaque-bearing brain regions. 10 3.AN1792 Effects on AP Levels: ELISA Determinations (a) Cortical Levels In untreated PDAPP mice, the median level of total AP in the cortex at 12 months was 1,600 ng/g, which increased to 8,700 ng/g by 15 months (Table 2). At 18 months the value was 22,000 ng/g, an increase of over 10-fold during the time course 15 of the experiment. PBS-treated animals had 8,600 ng/g total AP at 15 months which increased to 19,000 ng/g at 18 months. In contrast, AN1792-treated animals had 81% less total AP at 15 months (1,600 ng/g) than the PBS-immunized group. Significantly less (p=0.000 1) total AP (5,200 ng/g) was found at 18 months when the AN 1792 and PBS groups were compared (Table 2), representing a 72% reduction in the AP that would 20 otherwise be present. Similar results were obtained when cortical levels of Afp42 were compared, namely that the ANI 792-treated group contained much less Ap42, but in this case the differences between the AN 1792 and PBS groups were significant at both 15 months (p=0.0 4 ) and 18 months (p=0.0001, Table 2). 25 Table 2: Median AP Levels (ng/g) in Cortex UNTREATED PBS AN1792 Age Total AQ42 (n) Total A42 (n) Total Ap42 (n) 12 1,600 1,300 (10) 15 8,700 8,300 (10) 8,600 7,200 (9) 1,600 1,300' (10) 18 22,200 18,500 (10) 19,000 15,900 (12) 5,200' 4,000' (9) * p = 0.0412 **p = 0

.

00 0 1 (b) Hippocampal Levels 56 In untreated PDAPP mice, median hippocampal levels of total Ap at twelve months of age were 15,000 ng/g which increased to 51,000 ng/g at 15 months and further to 81,000 ng/g at 18 months (Table 3). Similarly, PBS immunized mice showed values of 40,000 ng/g and 65,000 ng/g at 15 months and 18 months, respectively. 5 AN1792 immunized animals exhibited less total AP, specifically 25,000 ng/g and 51,000 ng/g at the respective 15-month and 18-month timepoints. The 18-month AN1792 treated group value was significantly lower than that of the PBS treated group (p= 0.0105; Table 3). Measurement of A$42 gave the same pattern of results, namely that levels in the AN 1792-treated group were significantly lower than in the PBS group (39,000 ng/g 10 vs. 57,000 ng/g, respectively; p=0.002) at the 18-month evaluation (Table 3). Table 3: Median As Levels (ng/g) in Hippocampus UNTREATED PBS AN1792 Age Total A42 (n) Total AB42 (n) Total AD42 (n) 12 15,500 11,100 (10) 15 51,500 44,400 (10) 40,100 35,70 (9) 24,50 22,100 (10) 18 80R00 64.200 (10) 65,400 57,10 (12) 15090 38 900'' (9) *p =0.0105 **p = 0.0022 15 (c) Cerebellar Levels In 12-month untreated PDAPP mice, the median cerebellar level of total Ap was 15 ng/g (Table 4). At 15 months, this median increased to 28 ng/g and by 18 months had risen to 35 ng/g. PBS-treated animals displayed median total Ap values of 21 20 ng/g at 15 months and 43 ng/g at 18 months. AN 1 792-treated animals were found to have 22 ng/g total Ap at 15 months and significantly less (p=0.002) total As at 18 months (25 ng/g) than the corresponding PBS group (Table 4). Table 4: Median Ap Levels (ng/g) in Cerebellum UNTREATED PBS AN1792 Age Total Ap (n) Total Ap (n) Total Ap (n) 12 15.6 (10) 15 27.7 (10) 20.8 (9) 21.7 (10) 18 35.0 (10) 43.1 (12) 24.8 (9) 25 p = 0.0018 57 4. Effects of AN1792 Treatment on APP Levels APP-a and the full-length APP molecule both contain all or part of the As sequence and thus could be potentially impacted by the generation of an AN 1792-directed immune response. In studies to date, a slight increase in APP levels has been noted as 5 neuropathology increases in the PDAPP mouse- In the cortex, levels of either APP-a /FL (full length) or APP-a were essentially unchanged by treatment with the exception that APP-a was reduced by 19% at the 18-month timepoint in the AN1792-treated vs. the PBS-treated group. The 18-month ANI 792-treated APP values were not significantly different from values of the 12-month and 15-month untreated and 15-month PBS groups. 10 In all cases the APP values remained within the ranges that are normally found in PDAPP mice. 5. Effects of AN1792 Treatment on Neurodegenerative and Gliotic Pathology 15 Neuritic plaque burden was significantly reduced in the frontal cortex of AN1792-treated mice compared to the PBS group at both 15 (84%; p=0.03) and 18 (55%; p=0.01) months of age (Fig. 8). The median value of the neuritic plaque burden increased from 0.32% to 0.49% in the PBS group between 15 and 18 months of age. This contrasted with the greatly reduced development of neuritic plaques in the AN 1792 20 group, with median neuritic plaque burden values of 0.05% and 0.22%, in the 15 and 18 month groups, respectively. Immunizations with AN1792 seemed well tolerated and reactive astrocytosis was also significantly reduced in the RSC of AN 1792-treated mice when compared to the PBS group at both 15 (56%; p=0.01 1) and 18 (39/c; p=0.0 2 8 ) months of 25 age (Fig. 9). Median values of the percent of astrocytosis in the PBS group increased between 15 and 18 months from 4.26% to 5.21%. AN1792-treatment suppressed the development of astrocytosis at both time points to 1.89% and 3.2%, respectively. This suggests the neuropil was not being damaged by the clearance process. 30 6. Antibody Responses As described above, eleven-month old, heterozygous PDAPP mice (N=24) received a series of 5 immunizations of 100 pg of AN 1792 emulsified with Freund's adjuvant and administered intraperitoneally at weeks 0, 2, 4, 8, and 12, and a sixth immunization with PBS alone (no Freund's adjuvant) at week 16. As a negative control, a 58 parallel set of 24 age-matched transgenic mice received immunizations of PBS emulsified with the same adjuvants and delivered on the same schedule. Animals were bled within three to seven days following each immunization starting after the second dose. Antibody responses to AN 1792 were measured by ELISA. Geometric mean titers (GMT) for the 5 animals that were immunized with AN1792 were approximately 1,900, 7,600, and 45,000 following the second, third and last (sixth) doses respectively. No Ap-specific antibody was measured in control animals following the sixth immunization. Approximately one-half of the animals were treated for an additional three months, receiving immunizations at about 20, 24 and 27 weeks. Each of these doses was 10 delivered in PBS vehicle alone without Freund's adjuvant. Mean antibody titers remained unchanged over this time period. In fact, antibody titers appeared to remain stable from the fourth to the eighth bleed corresponding to a period covering the fifth to the ninth injections. To determine if the AD-specific antibodies elicited by immunization that 15 were detected in the sera of AN1792-treated mice were also associated with deposited brain amyloid, a subset of sections from the AN 1792- and PBS-treated mice were reacted with an antibody specific for mouse IgG. In contrast to the PBS group, AP plaques in AN 1792-treated brains were coated with endogenous IgG. This difference between the two groups was seen in both 15-and 18-month groups. Particularly striking was the lack 20 of labeling in the PBS group, despite the presence of a heavy amyloid burden in these mice. These results show that immunization with a synthetic As protein generates antibodies that recognize and bind in vivo to the AP in amyloid plaques. 7. Cellular-Mediated Immune Responses 25 Spleens were removed from nine AN1792-immunized and 12 PBS immunized 18-month old PDAPP mice 7 days after the ninth immunization. Splenocytes were isolated and cultured for 72 h in the presence of A040, A p42, or Ap40-1 (reverse order protein). The mitogen Con A served as a positive control. Optimum responses were obtained with >1.7 liM protein. Cells from all nine AN 1792-treated animals 30 proliferated in response to either Ap1-40 or Ap1-42 protein, with equal levels of incorporation for both proteins (Fig. 10, Upper Panel). There was no response to the AD40- I reverse protein. Cells from control animals did not respond to any of the As proteins (Fig. 10, Lower Panel). 59 C. Conclusion The results of this study show that AN 1792 immunization of PDAPP mice possessing existing amyloid deposits slows and prevents progressive amyloid deposition 5 and retard consequential neuropathologic changes in the aged PDAPP mouse brain. Immunizations with AN 1792 essentially halted amyloid developing in structures that would normally succumb to amyloidosis. Thus, administration of AP peptide has therapeutic benefit in the treatment of AD. 10 IV. SCREEN OF AP FRAGMENTS 100 PDAPP mice age 9-11 months were immunized with 9 different regions of APP and AP to determine which epitopes convey the efficacious response. The 9 different immunogens and one control are injected i.p. as described above. The immunogens include four human AP peptide conjugates 1-12, 13-28, 32-42, 1-5, all 15 coupled to sheep anti-mouse IgG via a cystine link; an APP polypeptide amino acids 592 695, aggregated human AP 1-40, and aggregated human AP 25-35, and aggregated rodent Ap42. Aggregated Ap42 and PBS were used as positive and negative controls, respectively. Ten mice were used per treatment group. Titers were monitored as above and mice were euthanized at the end of 4 months of injections. Histochemistry, AP 20 levels, and toxicology analysis was determined post mortem. A. Materials and Methods I. Preparation of Immunogens Preparation of coupled AP peptides: four human AJP peptide conjugates 25 (amino acid residues 1-5, 1-12, 13-28, and 33-42, each conjugated to sheep anti-mouse IgG) were prepared by coupling through an artificial cysteine added to the AP peptide using the crosslinking reagent sulfo-EMCS. The As peptide derivatives were synthesized with the following final amino acid sequences. In each case, the location of the inserted cysteine residue is indicated by underlining. The AP 13-28 peptide derivative also had 30 two glycine residues added prior to the carboxyl terminal cysteine as indicated. 60 A01-12 peptide NH2-DAEFRHDSGYEVC-COOH (SEQ ID NO: 72) A,01-5 peptide NH2-DAEFRC-COOH (SEQ ID NO: 73) A033-42 peptide NH2-C-amino-heptanoic acid-GLMVGGVVIA-COOH (SEQ ID NO: 74) A,01 3-28 peptide Ac-NH-HQKLVFFAEDVGSNKGGC-COOH (SEQ ID NO: 75) 5 To prepare for the coupling reaction, ten mg of sheep anti-mouse IgG (Jackson ImmunoResearch Laboratories) was dialyzed overnight against 10 mM sodium borate buffer, pH 8.5. The dialyzed antibody was then concentrated to a volume of 2 mL using an Amicon Centriprep tube. Ten mg sulfo-EMCS 10 [N (E -maleimidocuproyloxy) succinimide] (Molecular Sciences Co.) was dissolved in one mL deionized water. A 40-fold molar excess of sulfo-EMCS was added dropwise with stirring to the sheep anti-mouse IgG and then the solution was stirred for an additional ten min. The activated sheep anti-mouse IgG was purified and buffer exchanged by passage over a 10 mL gel filtration column (Pierce Presto Column, 15 obtained from Pierce Chemicals) equilibrated with 0.1 M NaPO4, 5 mM EDTA, pH 6.5. Antibody containing fractions, identified by absorbance at 280 nm, were pooled and diluted to a concentration of approximately 1 mg/mL, using 1.4 mg per OD as the extinction coefficient. A 40-fold molar excess of AP peptide was dissolved in 20 mL of 10 mM NaPO4, pH 8.0, with the exception of the Ap33-42 peptide for which 10 mg was 20 first dissolved in 0.5 mL of DMSO and then diluted to 20 mL with the 10 mM NaPO4 buffer. The peptide solutions were each added to 10 mL of activated sheep anti-mouse IgG and rocked at room temperature for 4 hr. The resulting conjugates were concentrated to a final volume of less than 10 mL using an Amicon Centriprep tube and then dialyzed against PBS to buffer exchange the buffer and remove free peptide. The conjugates were 25 passed through 0.22 pm-pore size filters for sterilization and then aliquoted into fractions of I mg and stored frozen at -20*C. The concentrations of the conjugates were determined using the BCA protein assay (Pierce Chemicals) with horse IgG for the standard curve. Conjugation was documented by the molecular weight increase of the conjugated peptides relative to that of the activated sheep anti-mouse Igg. The As 1-5 30 sheep anti-mouse conjugate was a pool of two conjugations, the rest were from a single preparation. 61 2. Preparation of aggregated AP peptides Human 1-40 (AN 1528; California Peptides Inc., Lot ME0541), human I 42 (AN1792; California Peptides Inc., Lots ME0339 and ME0439), human 25-35, and rodent 1-42 (California Peptides Inc., Lot ME0218) peptides were freshly solubilized for 5 the preparation of each set of injections from lyophilized powders that had been stored desiccated at -20*C. For this purpose, two mg of peptide were added to 0.9 ml of deionized water and the mixture was vortexed to generate a relatively uniform solution or suspension. Of the four, AN1528 was the only peptide soluble at this step. A 100 tl aliquot of lOX PBS (IX PBS: 0.15 M NaCl, 0.01 M sodium phosphate, pH 7.5) was then 10 added at which point AN 1528 began to precipitate. The suspension was vortexed again and incubated overnight at 37*C for use the next day. Preparation of the pBx6 protein: An expression plasmid encoding pBx6, a fusion protein consisting of the 100-amino acid bacteriophage MS-2 polymerase N terminal leader sequence followed by amino acids 592-695 of APP (PAPP) was 15 constructed as described by Oltersdorf et al., J. Biol. Chem. 265, 4492-4497 (1990). The plasmid was transfected into E. coli and the protein was expressed after induction of the promoter. The bacteria were lysed in 8M urea and pBx6 was partially purified by preparative SDS PAGE. Fractions containing pBx6 were identified by Western blot using a rabbit anti-pBx6 polyclonal antibody, pooled, concentrated using an Amicon 20 Centriprep tube and dialysed against PBS. The purity of the preparation, estimated by Coomassie Blue stained SDS PAGE, was approximately 5 to 10%. B. Results and Discussion 1. Study Design 25 One hundred male and female, nine- to eleven-month old heterozygous PDAPP transgenic mice were obtained from Charles River Laboratory and Taconic Laboratory. The mice were sorted into ten groups to be immunized with different regions of AP or APP combined with Freund's adjuvant. Animals were distributed to match the gender, age, parentage and source of the animals within the groups as closely as possible. 30 The immunogens included four As peptides derived from the human sequence, 1-5, 1-12, 13-28, and 33-42, each conjugated to sheep anti-mouse IgG; four aggregated AP peptides, human 1-40 (AN1528), human 1-42 (AN1792), human 25-35, and rodent 1-42; and a 62 fusion polypeptide, designated as pBx6, containing APP amino acid residues 592-695. A tenth group was immunized with PBS combined with adjuvant as a control. For each immunization, 100 pg of each As peptide in 200 pl. PBS or 200 p'g of the APP derivative pBx6 in the same volume of PBS or PBS alone was emulsified 5 1:1 (vol:vol) with Complete Freund's adjuvant (CFA) in a final volume of 400 pl for the first immunization, followed by a boost of the same amount of immunogen in Incomplete Freund's adjuvant (IFA) for the subsequent four doses and with PBS for the final dose. Immunizations were delivered intraperitoneally on a biweekly schedule for the first three doses, then on a monthly schedule thereafter. Animals were bled four to seven days 10 following each immunization starting after the second dose for the measurement of antibody titers. Animals were euthanized approximately one week after the final dose. 2. AP and APP Levels in the Brain Following about four months of immunization with the various AP 15 peptides or the APP derivative, brains were removed from saline-perfused animals. One hemisphere was prepared for immunohistochemical analysis and the second was used for the quantitation of AP and APP levels. To measure the concentrations of various forms of beta amyloid peptide and amyloid precursor protein, the hemisphere was dissected and homogenates of the hippocampal, cortical, and cerebellar regions were prepared in 5 M 20 guanidine. These were diluted and the level of amyloid or APP was quantitated by comparison to a series of dilutions of standards of AP peptide or APP of known concentrations in an ELISA format. The median concentration of total As for the control group immunized with PBS was 5.8-fold higher in the hippocampus than in the cortex (median of 24,318 25 ng/g hippocampal tissue compared to 4,221 ng/g for the cortex). The median level in the cerebellum of the control group (23.4 ng/g tissue) was about 1,000-fold lower than in the hippocampus. These levels are similar to those that we have previously reported for heterozygous PDAPP transgenic mice of this age (Johnson-Woods et al., 1997, supra). For the cortex, a subset of treatment groups had median total Ap.and As I 30 42 levels which differed significantly from those of the control group (p < 0.05), those animals receiving AN1792, rodent AP1-42 or the API-5 peptide conjugate as shown in Fig. 11. The median levels of total AP were reduced by 75%, 79% and 61%, respectively, compared to the control for these treatment groups. There were no 63 discernable correlations between AP-specific antibody titers and Ap levels in the cortical region, of the brain for any of the groups. In the hippocampus, the median reduction of total Ap associated with AN 1792 treatment (46%, p = 0.0543) was not as great as that observed in the cortex 5 (75%, p = 0.0021). However, the magnitude of the reduction was far greater in the hippocampus than in the cortex, a net reduction of 11,186 ng/g tissue in the hippocampus versus 3,171 ng/g tissue in the cortex. For groups of animals receiving rodent Ap1-42 or Ap l-5, the median total A p levels were reduced by 36% and 26%, respectively. However, given the small group sizes and the high variability of the amyloid peptide 10 levels from animal to animal within both groups, these reductions were not significant. When the levels of AI 1-42 were measured in the hippocampus, none of the treatment induced reductions reached significance. Thus, due to the smaller Ap burden in the cortex, changes in this region are a more sensitive indicator of treatment effects. The changes in A0 levels measured by ELISA in the cortex are similar, but not identical, to 15 the results from the immunohistochemical analysis (see below). Total As was also measured in the cerebellurm, a region typically minimally affected with AD pathology. None of the median As concentrations of any of the groups immunized with the various Ap peptides or the APP derivative differed from that of the control group in this region of the brain. This result suggests that non 20 pathological levels of Ap are unaffected by treatment. APP concentration was also determined by ELISA in the cortex and cerebellum from treated and control mice. Two different APP assays were utilized. The first, designated APP-a /FL, recognizes both APP-alpha (a, the secreted form of APP which has been cleaved within the As sequence), and full-length forms (FL) of APP, 25 while the second recognizes only APP-a. In contrast to the treatment-associated diminution of AP* in a subset of treatment groups, the levels of APP were unchanged in all of the treated compared to the control animals. These results indicate that the immunizations with Ap peptides are not depleting APP; rather the treatment effect is specific to Ap. 30 In summary, total Ap and AD p-42 levels were significantly reduced in the cortex by treatment with AN1792, rodent Apl-42 or Ap1-5 conjugate. In the hippocampus, total Ap was significantly reduced only by AN 1792 treatment. No other 64 treatment-associated changes in Ap or APP levels in the hippocampal, cortical or cerebellar regions were significant. 2. Histochemical Analyses 5 Brains from a subset of six groups were prepared for inmunohistochemical analysis, three groups immunized with the Ap peptide conjugates Ap1-5, Apl-12, and A p13-28; two groups immunized with the full length As aggregates AN1792 and AN1528 and the PBS-treated control group. The results of image analyses of the amyloid burden in brain sections from these groups are shown in Fig. 12. There 10 were significant reductions of amyloid burden in the cortical regions of three of the treatment groups versus control animals. The greatest reduction of amyloid burden was observed in the group receiving AN 1792 where the mean value was reduced by 97% (p = 0.001). Significant reductions were also observed for those animals treated with AN1528 (95%, p = 0.005) and the Ap p-5 peptide conjugate (67%, p = 0.02). 15 The results obtained by quantitation of total As or ApI-42 by ELISA and amyloid burden by image analysis differ to some extent. Treatment with AN 1528 had a significant impact on the level of cortical amyloid burden when measured by quantitative image analysis but not on the concentration of total Ap in the same region when measured by ELISA. The difference between these two results is likely to be due to the 20 specificities of the assays. Image analysis measures only insoluble Ap aggregated into plaques. In contrast, the ELISA measures all forms of AD, both soluble and insoluble, monomeric and aggregated. Since the disease pathology is thought to be associated with the insoluble plaque-associated form of Ap, the image analysis technique may have more sensitivity to reveal treatment effects. However since the ELISA is a more rapid and 25 easier assay, it is very useful for screening purposes. Moreover it may reveal that the treatment-associated reduction of AD is greater for plaque-associated than total Ap. To determine if the Ap-specific antibodies elicited by immunization in the treated animals reacted with deposited brain amyloid, a subset of the sections from the treated animals and the control mice were reacted with an antibody specific for house 30 IgG. In contrast to the PBS group, A p-containing plaques were coated with endogenous IgG for animals immunized with the As peptide conjugates ADs1-5, Ap11-12, and Apt 3 28; and the full length ADp aggregates AN1792 and AN1528. Brains from animals 65 immunized with the other Ap peptides or the APP peptide pBx6 were not analyzed by this assay. 3. Measurement of Antibody Titers 5 Mice were bled four to seven days following each immunization starting after the second immunization, for a total of five bleeds. Antibody titers were measured as AD1 -42-binding antibody using a sandwich ELISA with plastic multi-well plates coated with AP1-42. As shown in Fig. 13, peak antibody titers were elicited following the fourth dose for those four immunogenic formulations which elicited the highest titers 10 of AN 1792-specific antibodies: AN1792 (peak GMT: 94,647), AN1528 (peak GMT: 88,231), APl-12 conjugate (peak GMT: 47,216)and rodent AD 1-42 (peak GMT: 10,766). Titers for these groups declined somewhat following the fifth and sixth doses. For the remaining five immunogens, peak titers were reached following the fifth or the sixth dose and these were of much lower magnitude than those of the four highest titer groups: 15 AP1-5 conjugate (peak GMT: 2,356), pBx6 (peak GMT: 1,986), Ap13-28 conjugate (peak GMT: 1,183), A033-42 conjugate (peak GMT: 658), A025-35 (peak GMT: 125). Antibody titers were also measured against the homologous peptides using the same ELISA sandwich format for a subset of the immunogens, those groups immunized with Api-5, AP13-28, Ap25-35, Ap33-42 or rodent Ap1-42. These titers were about the same 20 as those measured against A 1-42 except for the rodent Ap 1-42 immunogen in which case antibody titers against the homologous immunogen were about two-fold higher. The magnitude of the AN 1792-specific antibody titer of individual animals or the mean values of treatment groups did not correlate with efficacy measured as the reduction of As in the cortex. 25 4. Lymphoproliferative Responses AP-dependent lymphoproliferation was measured using spleen cells harvested approximately one week following the final, sixth, immunization. Freshly harvested cells, 105 per well, were cultured for 5 days in the presence of AP 1 -40 at a 30 concentration of 5 iM for stimulation. Cells from a subset of seven of the ten groups were also cultured in the presence of the reverse peptide, Ap40-1. As a positive control, additional cells were cultured with the T cell mitogen, PHA, and, as a negative control, cells were cultured without added peptide. 66 Lymphocytes from a majority of the animals proliferated in response to PHA. There were no significant responses to the Ap40-1 reverse peptide. Cells from animals immunized with the larger aggregated Ap peptides, AN 1792, rodent A 1-42 and AN 1528 proliferated robustly when stimulated with As1-40 with the highest cpm in the 5 recipients of AN1792. One animal in each of the groups immunized with Apl-12 conjugate, Ap13-28 conjugate and Ap25-35 proliferated in response to Apl-40. The remaining groups receiving Ap 1-5 conjugate, Ap33-42 conjugate pBx6 or PBS had no animals with an Ap-stimulated response. These results are summarized in Table 5 below. Table 5 Immunogen Conjugate Ap Amino Acids Responders As1-5 Yes 5-mer 0/7 Ap1-12 Yes 12-mer 1/8 p13-28 Yes 16-mer 1/9 Ap25-35 11-mer 1/9 Ap33-42 Yes 10-mer 0/10 Ap1-40 40-mer 5/8 Ap1-42 42-mer 9/9 r AD1-42 42-mer 8/8 pBx6 0/8 PBS 0-mer 0/8 10 These results show that AN 1792 and AN 1528 stimulate strong T cell responses, most likely of the CD4+ phenotype. The absence of an Ap-specific T cell response in animals immunized with Ap1 -5 is not surprising since peptide epitopes recognized by CD4+ T cells are usually about 15 amino acids in length, although shorter 15 peptides can sometimes function with less efficiency. Thus the majority of helper T cell epitopes for the four conjugate peptides are likely to reside in the IgG conjugate partner, not in the A1p region. This hypothesis is supported by the very low incidence of proliferative responses for animals in each of these treatment groups. Since the AP1-5 conjugate was effective at significantly reducing the level of AD in the brain, in the 20 apparent absence of AP-specific T cells, the key effector immune response induced by immunization with this peptide appears to be antibody. 67 Lack of T-cell and low antibody response from fusion peptide pBx6, encompassing APP amino acids 592-695 including all of the AP residues may be due to the poor immunogenicity of this particular preparation. The poor immnunogenicity of the Ap25-35 aggregate is likely due to the peptide being too small to be likely to contain a 5 good T cell epitope to help the induction of an antibody response. If this peptide were conjugated to a carrier protein, it would probably be more immunogenic. V. Preparation of Polyclonal Antibodies for Passive Protection 125 non-transgenic mice were immunized with 100 tg AP 1-42, plus 10 CFA/IFA adjuvant, and euthanized at 4-5 months. Blood was collected from immunized mice. IgG was separated from other blood components. Antibody specific for the imnmunogen may be partially purified by affinity chromatography. An average of about 0.5-1 mg of immunogen-specific antibody is obtained per mouse, giving a total of 60-120 Mg. 15 VI. Passive Immunization with Antibodies to Ap Groups of 7-9 month old PDAPP mice each were injected with 0.5 mg in PBS of polyclonal anti-Ap or specific anti-Ap monoclonals as shown below. All antibody preparations were purified to have low endotoxin levels. Monoclonals can be 20 prepared against a fragment by injecting the fragment or longer form of AP into a mouse, preparing hybridomas and screening the hybridomas for an antibody that specifically binds to a desired fragment of As without binding to other nonoverlapping fragments of Ap. 68 Table 6 Antibody Epitope 2H3 As 1-12 1OD5 AD 1-12 266 AP 13-28 21F12 As 33-42 Mouse polyclonal Anti-Aggregated Ap42 anti-human A042 Mice were injected ip as needed over a 4 month period to maintain a circulating antibody concentration measured by ELISA titer of greater than 1/1000 5 defined by ELISA to Ap42 or other immunogen. Titers were monitored as above and mice were euthanized at the end of 6 months of injections. Histochemistry, AP levels and toxicology were performed post mortem. Ten mice were used per group. Additional studies of passive immunization are described in Examples XI and XI below. 10 VII. Comparison of Different Adjuvants This example compares CFA, alum, an oil-in water emulsion and MPL for capacity to stimulate an immune response. A. Materials and Methods 15 1. Study Design One hundred female Hartley strain six-week old guinea pigs, obtained from Elm Hill, were sorted into ten groups to be immunized with AN 1792 or a palmitoylated derivative thereof combined with various adjuvants. Seven groups received injections of AN1792 (33 pg unless otherwise specified) combined witb a) PBS, 20 b) Freund's adjuvant, c) MPL, d) squalene, e) MPUsqualene f) low dose alum, or g) high dose alum (300 pg AN 1792). Two groups received injections of a palmitoylated derivative of ANI 792 (33 pg) combined with a) PBS or b) squalene. A final, tenth group received PBS alone without antigen or additional adjuvant. For the group receiving 69 Freund's adjuvant, the first dose was emulsified with CFA and the remaining four doses with IFA. Antigen was administered at a dose of 33 pg for all groups except the high dose alum group, which received 300 pg of AN 1792. Injections were administered intraperitoneally for CFA/IFA and intramuscularly in the hind limb quadriceps alternately 5 on the right and left side for all other groups. The first three doses were given on a biweekly schedule followed by two doses at a monthly interval). Blood was drawn six to seven days following each immunization, starting after the second dose, for measurement of antibody titers. 10 2. Preparation of Immunogens Two mg Ap42 (California Peptide, Lot ME0339) was added to 0.9 ml of deionized water and the mixture was vortexed to generate a relatively uniform suspension. A 100 pl aliquot of lOX PBS (IX PBS, 0.15 M NaCl, 0.01 M sodium phosphate, pH 7.5) was added. The suspension was vortexed again and incubated 15 overnight at 37*C for use the next day. Unused A 1-42 was stored with desiccant as a lyophilized powder at -20 0 C. A palmitoylated derivative of AN 1792 was prepared by coupling palmitic anhydride, dissolved in dimethyl formamide, to the amino terminal residue of AN 1792 prior to removal of the nascent peptide from the resin by treatment with hydrofluoric acid. 20 To prepare formulation doses with Complete Freund's adjuvant (CFA) (group 2), 33 ig of AN1792 in 200 pl PBS was emulsified 1:1 (vol:vol) with CFA in a final volume of 400 pl for the first immunization. For subsequent immunizations, the antigen was similarly emulsified with Incomplete Freund's adjuvant (IFA). To prepare formulation doses with MPL for groups 5 and 8, lyophilized 25 powder (Ribi ImmunoChem Research, Inc., Hamilton, MT) was added to 0.2% aqueous triethylamine to a final concentration of I mg/ml and vortexed. The mixture was heated to 65 to 70*C for 30 sec to create a slightly opaque uniform suspension of micelles. The solution was freshly prepared for each set of injections. For each injection in group 5, 33 pg of AN1792 in 16.5 il PBS, 50 pg of MPL (50 pl) and 162 pl of PBS were mixed 30 in a borosilicate tube immediately before use. To prepare formulation doses with the low oil-in-water emulsion, AN 1792 in PBS was added to 5% squalene, 0.5% Tween 80, 0.5% Span 85 in PBS to reach a final single dose concentration of 33 pg AN 1792 in 250 p1 (group 6). The mixture was 70 emulsified by passing through a two-chambered hand-held device 15 to 20 times until the emulsion droplets appeared to be about equal in diameter to a 1.0 pim diameter standard latex bead when viewed under a microscope. The resulting suspension was opalescent, milky white. The emulsions were freshly prepared for each series of injections. For 5 group 8, MPL in 0.2% triethylamine was added at a concentration of 50 pg per dose to the squalene and detergent mixture for emulsification as noted above. For the palmitoyl derivative (group 7), 33 pg per dose of palmitoyl-NH-Apl-42 was added to squalene and vortexed. Tween 80 and Span 85 were then added with vortexing. This mixture was added to PBS to reach final concentrations of 5% squalene, 0.5% Tween 80, 0.5% Span 10 85 and the mixture was emulsified as noted above. To prepare. formulation doses with alum (groups 9 and 10), AN 1792 in PBS was added to Alhydrogel (aluminum hydroxide gel, Accurate, Westbury, NY) to reach concentrations of 33 pg (low dose, group 9) or 300 ig (high dose, group 10) AN1792 per 5 mg of alum in a final dose volume of 250 pl. The suspension was gently 15 mixed for 4 hr at RT. 3. Measurement of Antibody Titers Guinea pigs were bled six to seven days following immunization starting after the second immunization for a total of four bleeds. Antibody titers against Ap42 20 were measured by ELISA as described in General Materials and Methods. 4. Tissue Preparation After about 14 weeks, all guinea pigs were euthanized by administering

CO

2 . Cerebrospinal fluid was collected and the brains were removed and three brain 25 regions (hippocampus, cortex and cerebellum) were dissected and used to measure the concentration of total AP protein using ELISA. B. Results 1. Antibody Responses 30 There was a wide range in the potency of the various adjuvants when measured as the antibody response to AN 1792 following immunization. As shown in Fig. 14, when AN 1792 was administered in PBS, no antibody was detected following two or three immunizations and negligible responses were detected following the fourth and 71 fifth doses with geometric mean titers (GMTs) of only about 45. The o/w emulsion induced modest titers following the third dose (GMT 255) that were maintained following the fourth dose (GMT 30 1) and fell with the final dose (GMT 54). There was a clear antigen dose response for AN 1792 bound to alum with 300 pg being more immunogenic 5 at all time points than 33 ptg. At the peak of the antibody response, following the fourth immunization, the difference between the two doses was 43% with GMTs of about 1940 (33 pg) and 3400 (300 pg). The antibody response to 33 pig AN 1792 plus MPL was very similar to that generated with almost a ten-fold higher dose of antigen (300 pg) bound to alum. The addition of MPL to an o/w emulsion decreased the potency of the 10 formulations relative to that with MPL as the sole adjuvant by as much as 75%. A palmitoylated derivative of AN 1792 was completely non-immunogenic when administered in PBS and gave modest titers when presented in an o/w emulsion with GMTs of 340 and 105 for the third and fourth bleeds. The highest antibody titers were generated with Freund's adjuvant with a peak GMT of about 87,000, a value almost 30 15 fold greater than the GMTs of the next two most potent formulations, MPL and high dose AN1792/alum. The most promising adjuvants identified in this study are MPL and alum. Of these two, MPL appears preferable because a 10-fold lower antigen dose was required to generate the same antibody response as obtained with alum. The response can be 20 increased by increasing the dose of antigen and /or adjuvant and by optimizing the immunization schedule. The o/w emulsion was a very weak adjuvant for AN1792 and adding an o/w emulsion to MPL adjuvant diminished the intrinsic adjuvant activity of MPL alone. 25 2. Ap Levels In The Brain At about 14 weeks the guinea pigs were deeply anesthetized, the cerebrospinal fluid (CSF) was drawn and brains were excised from animals in a subset of the groups, those immunized with Freund's adjuvant (group 2), MPL (group 5), alum with a high dose, 300 pg, of AN 1792 (group 10) and the PBS immunized control gropp (group 30 3). To measure the level of Ap peptide, one hemisphere was dissected and homogenates of the hippocampal, cortical, and cerebellar regions were prepared in 5 M guanidine. These were diluted and quantitated by comparison to a series of dilutions of Ap standard protein of known concentrations in an ELISA format. The levels of AD protein in the 72 hippocampus, the cortex and the cerebellum were very similar for all four groups despite the wide range of antibody responses to Ap elicited by these formulations. Mean AD levels of about 25 ng/g tissue were measured in the hippocampus, 21 ng/g in the cortex, and 12 ng/g in the cerebellum. Thus, the presence of a high circulating antibody titer to 5 As for almost three months in some of these animals did not alter the total AD levels in their brains. The levels of Ap in the CSF were also quite similar between the groups. The lack of large effect of AN 1792 immunization on endogenous Ap indicates that the immune response is focused on pathological formations of Ap. 10 VIII. Immune Response to Different Adjuvants in Mice Six-week old female Swiss Webster mice were used for this study with 10 13 animals per group. Immunizations were given on days 0, 14, 28, 60, 90 and 20 administered subcutaneously in a dose volume of 200 pl. PBS was used as the buffer for all formulations. Animals were bleed seven days following each immunization starting 15 after the second dose for analysis of antibody titers by ELISA. The treatment regime of each group is summarized in Table 7. 73 Table 7 Experimental Design Group Na Adjuvant' Dose Antigen Dose (pg) 10 MPL 12.5 pg AN 1792 33 2 10 MPL 25 pg AN1792 --- 33 3 10 MPL 50 jig AN1792 33 4 13 MPL 125 pg AN1792 33 5 13 MPL 50 pg AN1792 ISO 6 13 MPL 50 pg AN1528 33 7 10 PBS AN1792 33 8 10 PBS None 9 10. Squalene 5% AN1792 33 emulsified 10 10 Squalene 5% AN1792 33 admixed I 1 10 Alum 2 mg AN1792 33 12 13 MPL + Alum 50 pg/2 mg AN1792 33 13 10 QS-21 5 pg AN1792 33 14 10 QS-21 10 pg AN1792 33 Is 10 QS-21 25 AN1792 AN1792 33 16 13 QS-21 25 AN1792 AN1792 150 17 13 QS-21 25 AN1792 AN1528 33 18 13 QS-21 + MPL 25 pg/50 pg AN1792 33 19 13 QS-21 + 25 pg/2 mg AN1792 33 Alum Footnotes: 8 Number of mice in each group at the initiation of the experiment. b The adjuvants are noted. The buffer for all these formulations was PBS. For group 8, 5 there was no adjuvant and no antigen. 74 The ELISA titers of antibodies against Ap42 in each group are shown in Table 8 below. Table 8. Geometric Mean Antibody Titers Week of Bleed Treatment Group 2.9 5.0 8.7 12.9 16.7 1 248 1797 2577 6180 4177 2 598 3114 3984 5287 6878 3 1372 5000 7159 12333 12781 4 1278 20791 14368 20097 25631 5 3288 26242 13229 9315 23742 6 61 2536 2301 1442 4504 7 37 395 484 972 2149 8 25 25 25 25 25 9 25 183 744 952 1823 10 25 89 311 513 817 11 29 708 2618 2165 3666 12 198 1458 1079 612 797 13 38 433 566 1080 626 14 104 541 3247 1609 838 15 212 2630 2472 1224 1496 16 183 2616 6680 2085 1631 17 28 201 375 222 1540 18 31699 15544 23095 6412 9059 19 63 243 554 299 441 The table shows that the highest titers were obtained for groups 4, 5 and 18, in which the 5 adjuvants were 125 tg MPL, 50 pig MPL and QS-21 plus MPL. IX. Therapeutic Efficacy of Different Adjuvants A therapeutic efficacy study was conducted in PDAPP transgenic mice with a set of adjuvants suitable for use in humans to determine their ability to potentiate immune responses to AP and to induce the immune-mediated clearance of amyloid 10 deposits in the brain. One hundred eighty male and female, 7.5- to 8.5-month old heterozygous PDAPP transgenic mice were obtained from Charles River Laboratories. The mice were sorted into nine groups containing 15 to 23 animals per group to be immunized with 75 AN1792 or AN1528 combined with various adjuvants. Animals were distributed to match the gender, age, and parentage of the animals within the groups as closely as possible. The adjuvants included alum, MPL, and QS-21, each combined with both antigens, and Freund's adjuvant (FA) combined with only AN 1792. An additional group 5 was immunized with AN 1792 formulated in PBS buffer plus the preservative thimerosal without adjuvant. A ninth group was immunized with PBS alone as a negative control. Preparation of aggregated As peptides: human Ap1-40 (AN1528; California Peptides Inc., Napa, CA; Lot ME0541) and human Ap1-42 (AN1792; California Peptides Inc., Lot ME0439) peptides were freshly solubilized for the 10 preparation of each set of injections from lyophilized powders that had been stored desiccated at -20*C. For this purpose, two mg of peptide were added to 0.9 ml of deionized water and the mixture was vortexed to generate a relatively uniform solution or suspension. AN1528 was soluble at this step, in contrast to AN1792. A 100 pl aliquot of lOX PBS (IX PBS: 0.15 M NaCl, 0.01 M sodium phosphate, pH 7.5) was then added 15 at which point AN 1528 began to precipitate. The suspensions were vortexed again and incubated overnight at 37*C for use the next day. To prepare formulation doses with alum (Groups I and 5), AD peptide in PBS was added to Alhydrogel (two percent aqueous aluminum hydroxide gel, Sargeant, Inc., Clifton, NJ) to reach concentrations of 100 gg As peptide per 1 mg of alum. lOX 20 PBS was added to a final dose volume of 200 pl in IX PBS. The suspension was then gently mixed for approximately 4 hr at RT prior to injection. To prepare formulation doses for with MPL (Groups 2 and 6), lyophilized powder (Ribi ImmunoChem Research, Inc., Hamilton, MT; Lot 67039-E0896B) was added to 0.2% aqueous triethylamine to a final concentration of I mg/ml and vortexed. 25 The mixture was heated to 65 to 70*C for 30 sec to create a slightly opaque uniform suspension of micelles. The solution was stored at 4*C. For each set of injections, 100 pg of peptide per dose in 50 pl PBS, 50 pg of MPL per dose (50 p) and 100 pl of PBS per dose were mixed in a borosilicate tube immediately before use. To prepare formulation doses with QS-21 (Groups 3 and 7), lyophilized 30 powder (Aquila, Framingham, MA; Lot A7018R) was added to PBS, pH 6.6-6.7 to a final concentration of I mg/ml and vortexed. The solution was stored at -20"C. For each set of injections, 100 pg of peptide per dose in 50 pl PBS, 25 pg of QS-21 per dose in 25 76 1 PBS and 125 il of PBS per dose were mixed in a borosilicate tube immediately before use. To prepare formulation doses with Freund's Adjuvant (Group 4), 100 ig of AN1792 in 200 pl PBS was emulsified 1:1 (vol:vol) with Complete Freund's Adjuvant 5 (CFA) in a final volume of 400 l for the first immunization. For subsequent immunizations, the antigen was similarly emulsified with Incomplete Freund's Adjuvant (IFA). For the formulations containing the adjuvants alum, MPL or QS-21, 100 pg per dose of AN 1792 or AN1528 was combined with alum (1 mg per dose) or MPL (50 pg per dose) or QS-21 (25 pg per dose) in a final volume of 200 pl PBS and delivered by 10 subcutaneous inoculation on the back between the shoulder blades. For the group receiving FA, 100 pg of AN1792 was emulsified 1:1 (vol:vol) with Complete Freund's adjuvant (CFA) in a final volume of 400 pl and delivered intraperitoneally for the first immunization, followed by a boost of the same amount of immunogen in Incomplete Freund's adjuvant (IFA) for the subsequent five doses. For the group receiving AN 1792 15 without adjuvant, 10 pg ANI 792 was combined with 5 jig thimerosal in a final volume of 50 il PBS and delivered subcutaneously. The ninth, control group received only 200 pil PBS delivered subcutaneously. Immunizations were given on a biweekly schedule for the first three doses, then on a monthly schedule thereafter on days 0, 16, 28, 56, 85 and 112. Animals were bled six to seven days following each immunization starting after the 20 second dose for the measurement of antibody titers. Animals were euthanized approximately one week after the final dose. Outcomes were measured by ELISA assay of Ap and APP levels in brain and by immunohistochemical evaluation of the presence of amyloid plaques in brain sections. In addition, Ap-specific antibody titers, and Ap dependent proliferative and cytokine responses were determined. 25 Table 9 shows that the highest antibody titers to ApI-42 were elicited with FA and AN 1792, titers which peaked following the fourth immunization (peak GMT: 75,386) and then declined by 59% after the final, sixth immunization. The peak mean titer elicited by MPL with AN 1792 was 62% lower than that generated with FA (peak GMT: 28,867) and was also reached early in the immunization scheme, after 3 doses, 30 followed by a decline to 28% of the peak value after the sixth immunization. The peak mean titer generated with QS-21 combined with AN1792 (GMT: 1,511) was about 5-fold lower than obtained with MPL. In addition, the kinetics of the response were slower, since an additional immunization was required to reach the peak response. Titers 77 generated by alum-bound AN 1792 were marginally greater than those obtained with QS 21 and the response kinetics were more rapid. For AN 1792 delivered in PBS with thimerosal the frequency and size of titers were barely greater than that for PBS alone. The peak titers generated with MPL and AN 1528 (peak GMT 3099) were about 9-fold 5 lower than those with AN1792. Alum-bound AN1528 was very poorly inuunogenic with low titers generated in only some of the animals. No antibody responses were observed in the control animals immunized with PBS alone. 78 Table 9 Geometric Mean Antibody Titers' Week of Bleed Treatment 3.3 5.0 9.0 13.0 17.0 Alum/ 102 1,081 2,366 1,083 572 AN1792 ( 12 /2 1 )' (17/20) (21/21) (19/21) (18/21) MPL/ 6241 28,867 1,1242 5,665 8,204 AN1792 (21/21) (21/21) (21/21) (20/20) (20/20) QS-21/ 30 227 327 1,511 1,188 AN1792 (1/20) (10/19) (10/19) (17/18) (14/18) CFA/ 10,076 61,279 75,386 41,628 30,574 AN1792 (15/15) (15/15) (15/15) (15/15) (15/15) Alum/ 25 33 39 37 31 AN1528 (0/21) (1/21) (3/20) (1/20) (2/20) MPL/ 184 2,591 1,653 1,156 3,099 AN1528 (15/21) (20/21) (21/21) (20/20) (20/20) QS-21/ 29 221 51 820 2,994 AN1528 (1122) (13/22) (4/22) (20/22) (21122) PBS plus 25 33 39 37 47 Thimerosal (0/16) (2116) (4/16) (3/16) (4/16) PBS 25 25 25 25 25 (0/16) (0/16) (0/15) (0/12) (0/16) Footnotes: a Geometric mean antibody titers measured against A p1-42 b Number of responders per group 79 The results of AN 1792 or AN 1528 treatment with various adjuvants, or thimerosal on cortical amyloid burden in 12-month old mice determined by ELISA are shown in Fig. 15. In PBS control PDAPP mice, the median level of total AP in the cortex at 12 months was 1,817 ng/g. Notably reduced levels of AP were observed in mice 5 treated with AN1792 plus CFA/IFA, AN1792 plus-alum, AN1792 plus MPL and QS-21 plus AN1792. The reduction reached statistical significance (p<0.05) only for AN1792 plus CFA/IFA. However, as shown in Examples I and 111, the effects of immunization in reducing AP levels become substantially greater in 15 month and 18 month old mice. Thus, it is expected that at least the AN 1792 plus alum, AN 1792 plus MPL and AN 1792 10 plus QS-21 compositions will achieve statistical significance in treatment of older mice. By contrast, the AN 1792 plus the preservative thimerosal showed a median level of As about the same as that in the PBS treated mice. Similar results were obtained when cortical levels of Ap42 were compared. The median level of Ap42 in PBS controls was 1624 ng/g. Notably reduced median levels of 403, 1149, 620 and 714 were observed in 15 the mice treated with AN 1792 plus CFA/IFA, AN 1792 plus alum, AN 1792 plus MPL and AN1792 plus QS-21 respectively, with the reduction achieving statistical significance (p=0.05) for the AN1792 CFA/IFA treatment group. The median level in the AN1792 thimerosal treated mice was 1619 ng/g Ap42. A further therapeutic adjuvant/immunogen efficacy study was performed 20 in 9 - 10.5 month old male and female heterozygous PDAPP transgenic mice. The duration of the study was 25 weeks with 29-40 animals per treatment group; therefore the animals were 15 - 16.5 months old at termination.. The treatment groups are identified in Table 10 below. Adjuvant Immunogen Dilution Buffer Administration Group 1: MPL-SE AN1792-GCS (75 pg) PBS SC (250 pl) Group 2: ISA 51 AN1792-GCS (75 ptg) PBS IP (400 pl) ro-up - QS21 AN 1792-GCS (75 pg) PBS SC (250 pl) Group 4: QS21 abbrcv. AN 1792-GCS (75 pg) PBS SC (250 pl) Group 5: PBS ---. ---- SC (250 p) 25 Table 10 abbreviations: MAP - multi-antigenic peptide; TT - tetanus toxoid t-cell epitope (830-844); SQ - subcutaneous; IP - intraperitoneally; PBS - phosphate, buffered saline; ISA-51 is a commercially available adjuvant similar to IFA; GCS is a 80 glycine/citrate/sucrose formulation, MPL-SE is MPL in a stabilized water and oil emulsion. The immunization schedule was identical for all of the treatment groups except for Group 3, the QS2 I/AN 1792 abbreviated schedule group. The mice were 5 injected on weeks 0, 2, 4, 8, 12, 16, 20, 24, with bleeds on weeks 3, 5, 9, 13, 17, 21 and 25. Groups 1, 2, received eight injections and Group 3 received four injections during the 25-week period of the study. Group 4, the QS21/AN1792 abbreviated schedule, received injections on weeks 0, 2, 4, and 8 only. This group was not injected for the remainder of the study, although they were bled on the same bleed schedule as the rest of the study to 10 follow titer decay. Groups 3 and 5, QS21/AN1792 and PBS respectively, served as the positive and negative controls for this study. The titers were determined by the anti-AB antibody titer assay. Group 1, the MPL-SE/ANI 792 group, raised a peak geometric mean titer (GMT) of 17,100 at 9 weeks falling to a GMT of 10,000 at 25 weeks. Initially, the MPL 15 SE titers rose at a somewhat higher rate than the QS21/AN 1792 control group (Group 4). Group 2, the ISA 51/AN1792 group, produced high titers throughout the study reaching a GMT of over 100,000 for the last 9 weeks of the study. Group 3, the QS2I/AN1792 control group, reached its peak titer at 17 weeks with a GMT of 16,000. The titer then fell over the next 8 weeks to finish with a 20 GMT of 8,700. One animal in this group failed to raise a titer over the entire course of the experiment. Group 4, the QS21/AN1792 abbreviated injection schedule group, reached a peak titer of 7,300 at 13 weeks, five weeks after its final injection. The titer then fell to a GMT of 2,100 at the final bleed (25 weeks). As in the control group, one 25 animal failed to raise a detectable titer, while another animal lost all titer by the end of the decay period. Group 5, the PBS alone group, had no titers. To evaluate the cortical A3 levels, total AB and ABI-42 were measured by ELISA. Briefly, one brain hemisphere was dissected for cortical, hippocampal, and cerebellar 30 tissue followed by homogenization in SM guanidine buffer and assayed for brain AB. The cortical total AB and AB42 results are similar. A Mann-Whitney statistical analysis was performed to determine significance between the groups with a p value of 0.05 indicating a significant change in AB. 81 All treatment groups significantly lowered total AB levels as compared to the PBS control group (see Table 11). The MPL-SE/AN1792 group, showed the greatest change in AB, and it is significantly better than the other treatment groups. The QS21/AN1792 abbreviated group, was similar in its overall change of AB to the QS21 5 control group that received all eight injections. The AB levels in the ISA 51/AN1792 group, were similarly lowered compared to the CFA/IFA:MAP(ABI-7) group. Table II Cortical AB levels PBS MPL-SE ISA QS-21 QS-21 (4) MEDIAN 7,335 1,236 3,026 2,389 2,996 (ng/g tissue) RANGE 550- 18,358 70-3,977 23-9,777 210- 11,167 24-16,834 (ng/g tissue) p value - <0.0001 <0.0001 <0.0001 <0.0001 N 38 29 36 34 40 10 In conclusion, MPL-SE, ISA-51 and QS21 adjuvants combined with AN 1792 are effective in inducing a sufficient immune response significantly to retard AB deposition in the cortex. X. Toxicity Analysis 15 Tissues were collected for histopathologic examination at the termination of studies described in Examples 2, 3 and 7. In addition, hematology and clinical chemistry were performed on terminal blood samples from Examples 3 and 7. Most of the major organs were evaluated, including brain, pulmonary, lymphoid, gastrointestinal, liver, kidney, adrenal and gonads. Although sporadic lesions were observed in the study 20 animals, there were no obvious differences, either in tissues affected or lesion severity, between AN 1792 treated and untreated animals. There were no unique histopathological lesions noted in AN-I 528-immunized animals compared to PBS-treated or untreated animals. There were also no differences in the clinical chemistry profile between adjuvant groups and the PBS treated animals in Example 7. Although there were 25 significant increases in several of the hematology parameters between animals treated with AN 1792 and Freund's adjuvant in Example 7 relative to PBS treated animals, these 82 type of effects are expected from Freund's adjuvant treatment and the accompanying peritonitis and do not indicate any adverse effects from AN 1792 treatment. Although not part of the toxicological evaluation, PDAPP mouse brain pathology was extensively examined as part of the efficacy endpoints. No sign of treatment related adverse effect on 5 brain morphology was noted in any of the studies. These results indicate that AN 1792 treatment is well tolerated and at least substantially free of side effects. XI. Therapeutic Treatment with Anti-A P antibodies This examples tests the capacity of various monoclonal and polyclonal 10 antibodies to Ap to inhibit accumulation of AP in the brain of heterozygotic transgenic mice. I. Study Design Sixty male and female, heterozygous PDAPP transgenic mice, 8.5 to 10.5 15 months of age were obtained from Charles River Laboratory. The mice were sorted into six groups to be treated with various antibodies directed to Ap. Animals were distributed to match the gender, age, parentage and source of the animals within the groups as closely as possible. As shown in Table 10, the antibodies included four murine Ap-specific monoclonal antibodies, 2H3 (directed to Ap residues 1-12), 1OD5 (directed to Ap 20 residues 1-16), 266 (directed to Ap residues 13-28 and binds to monomeric but not to aggregated AN1792), 21F12 (directed to AD residues 33-42). A fifth group was treated with an Ap-specific polyclonal antibody fraction (raised by immunization with aggregated AN1792). The negative control group received the diluent, PBS,.alone without antibody. 25 The monoclonal antibodies were injected at a dose of about 10 mg/kg (assuming that the mice weighed 50 g). Injections were administered intraperitoneally every seven days on average to maintain anti-AP titers above 1000. Although lower titers were measured for mAb 266 since it does not bind well to the aggregated AN 1792 used as the capture antigen in the assay, the same dosing schedule was maintained fof this 30 group. The group receiving monoclonal antibody 2H3 was discontinued within the first three weeks since the antibody was cleared too rapidly in vivo. Animals were bled prior to each dosing for the measurement of antibody titers. Treatment was continued over a 83 six-month period for a total of 196 days. Animals were euthanized one week after the final dose. Table 12 EXPERIMENTAL DESIGN Treatment N' Treatment Antibody Antibody Group Antibody - Isotype Specificity 1 9 none NAb NA (PBS alone) I 2 10 Polyclonal ApI-42 mixed 3 0 mAb'2H3 Apl-12 IgGl 4 8 mAb10D5 ApI-16 IgGl 5 6 mAb266 Ap13-28 IgGI 6 8 mAb21F12 Ap33-42 IgG2a 5 Footnotes a. Number of mice in group at termination of the experiment. All groups started with 10 animals per group. b. NA: not applicable c. mAb: monoclonal antibody 10 2. Materials and Methods a. Preparation of the Antibodies The anti-Ap polyclonal antibody was prepared from blood collected from two groups of animals. The first group consisted of 100 female Swiss Webster mice, 6 to 15 8 weeks of age. They were immunized on days 0, 15, and 29 with 100 pg of AN 1792 combined with CFAIFA. A fourth injection was given on day 36 with one-half the dose of AN 1792. Animals were exsanguinated upon sacrifice at day 42, serum was prepared and the sera were pooled to create a total of 64 ml. The second group consisted of 24 female mice isogenic with the PDAPP mice but nontransgenic for the human APP gene, 6 20 to 9 weeks of age. They were immunized on days 0, 14, 28 and 56 with 100 pg of AN 1792 combined with CFAIFA. These animals were also exsanguinated upon sacrifice at day 63, serum was prepared and pooled for a total of 14 ml. The two lots of sera were pooled. The antibody fraction was purified using two sequential rounds of 84 precipitation with 50% saturated ammonium sulfate. The final precipitate was dialyzed against PBS and tested for endotoxin. The level of endotoxin was less than 1 EU/mg. The anti-Ap monoclonal antibodies were prepared from ascites fluid. The fluid was first delipidated by the addition of concentrated sodium dextran sulfate to ice 5 cold ascites fluid by stirring on ice to a reach a final concentration of 0.238%. Concentrated CaC 2 was then added with stirring to reach a final concentration of 64mM. This solution was centrifuged at 10,000 x g and the pellet was discarded. The supernatant was stirred on ice with an equal volume of saturated ammonium sulfate added dropwise. The solution was centrifuged again at 10,000 x g and the supernatant was discarded. The 10 pellet was resuspended and dialyzed against 20 mM Tris-HCl , 0.4 M NaCl, pH 7.5. This fraction was applied to a Pharmacia FPLC Sepharose Q Column and eluted with a reverse gradient from 0.4 M to 0.275 M NaCl in 20 mM Tris-HCl, pH 7.5. The antibody peak was identified by absorbance at 280 nm and appropriate fractions were pooled. The purified antibody preparation was characterized by measuring 15 the protein concentration using the BCA method and the purity using SDS-PAGE. The pool was also tested for endotoxin. The level of endotoxin was less than 1 EU/mg. titers, titers less than 100 were arbitrarily assigned a titer value of 25. 3. As and APP Levels in the Brain: 20 Following about six months of treatment with the various anti-Ap antibody preparations, brains were removed from the animals following saline perfusion. One hemisphere was prepared for immunohistochemical analysis and the second was used for the quantitation of As and APP levels. To measure the concentrations of various forms of beta amyloid peptide and amyloid precursor protein (APP), the hemisphere was 25 dissected and homogenates of the hippocampal, cortical, and cerebellar regions were prepared in SM guanidine. These were serially diluted and the level of amyloid peptide or APP was quantitated by comparison to a series of dilutions of standards of As peptide or APP of known concentrations in an ELISA format. The levels of total As and of A1-42 measured by ELISA in homogenates 30 of the cortex, and the hippocampus and the level of total Ap in the cerebellum are shown in Tables 1, 12, and 13, respectively. The median concentration of total Ap for the control group, inoculated with PBS, was 3.6-fold higher in the hippocampus than in the cortex (median of 63,389 ng/g hippocampal tissue compared to 17,818 ng/g for the 85 cortex). The median level in the cerebellum of the control group (30.6 ng/g tissue) was more than 2,000-fold lower than in the hippocampus. These levels are similar to those that we have previously reported for heterozygous PDAPP transgenic mice of this age (Johnson-Wood et al., 1997). 5 For the cortex, one treatment group had a median AP level, measured as AP0I-42, which differed significantly from that of the control group (p < 0.05), those animals receiving the polyclonal anti-AD antibody as shown in Table 13. The median level of AP 1-42 was reduced by 65%, compared to the control for this treatment group. The median levels of AP1-42 were also significantly reduced by 55% compared to the 10 control in one additional treatment group, those animals dosed with the mAb IOD5 (p = 0.0433). 86 t- - C4 > C r' rn ZA? CL <+ + + 10 40r, "Kr C 721 7' 710 _ 0 0 4 C4 I-C. co -( 00 0 I? IT C. l .'4I 0 cu c.) 00 ccI E 70 -n I V. - CCo tMI 4) E C 6 a 87) In the hippocampus, the median percent reduction of total AD associated with treatment with polyclonal anti-Ap antibody (50%, p = 0.0055) was not as great as that observed in the cortex (65%) (Table 14). However, the absolute magnitude of the 5 reduction was almost 3-fold greater in the hippocampus than in the cortex, a net reduction of 31,683 ng/g tissue in the hippocampus versus 11,658 ng/g tissue in the cortex. When measured as the level of the more amyloidogenic form of Ap, Ap 1-42, rather than as total AP, the reduction achieved with the polyclonal antibody was significant (p'= 0.0025). The median levels in groups treated with the mAbs I ODS and 266 were reduced by 33% 10 and 21%, respectively. 88 r- C' zr 00 W)N >1 + - + + ' + N " - o 2: % c c - - 00 N- 00 Ln+ + + + < ;100 en %n I0 000 01n IC D oo CNo 'l- 10% 22 ca 0.e~I C< (00 1: 00 r-1 I " < ~ r' 00) "0) 01 ~ NN I m :3 40 Z) r- 10 :0 C 0- - (NJ 014)o ca.1 <1<~ Z ~E .00 :, l 0 ___r ___ =_ _ >j~ 1 6 8aC9Q. c Total As was also measured in the cerebellum (Table 15). Those groups dosed with the polyclonal anti-Ap and the 266 antibody showed significant reductions of the levels of total AP (43% and 46%, p = 0.0033 and p = 0.0184, respectively) and that group 5 treated with IOD5 had a near significant reduction (29%, p =0.0675). 90 Table 15 CEREBELLUM Treatment Na Medians Means Group Total AD Total A ELISA P % ELS P ELISA value value value Change PBS9 30.64 NA NA 40.00+/-31.89c Polyclonal 10 17.61 0.0033 -43 18.15+/-4.36 anti-Ap42 mAb IOD5 8 21.68 0.0675 -29 27.29+/-19.43 mAb 266 6 16.59 0.0184 -46 19.59+/-6.59 mAb 21F12 8 29.80 >0.9999 -3 32.88+1-9.90 Footnotes: a. Number of animals per group at the end of the experiment 5 b. nglg tissue c. Mann Whitney analysis d. NA: not applicable e. Standard Deviation 10 APP concentration was also determined by ELISA in the cortex and cerebellum from antibody-treated and control, PBS-treated mice. Two different APP assays were utilized. The first, designated APP-a/FL, recognizes both APP-alpha (a, the secreted form of APP which has been cleaved within the Ap sequence), and full-length forms (FL) of APP, while the second recognizes only APP-a. In contrast to the treatment-associated 15 diminution of Ap in a subset of treatment groups, the levels of APP were virtually unchanged in all of the treated compared to the control animals. These results indicate that the immunizations with AD antibodies deplete AD without depleting APP. 91 In summary, AP levels were significantly reduced in the cortex, hippocampus and cerebellum in animals treated with the polyclonal antibody raised against AN 1792. To a lesser extent monoclonal antibodies to the amino terminal region of AP 1-42, specifically amino acids 1-16 and 13-28 also showed significant treatment effects. 5 4. Histochemical Analyses: The morphology of AB-immunoreactive plaques in subsets of brains from mice in the PBS, polyclonal AB42, 21F 12, 266 and 10D5 treatment groups was qualitatively compared to that of previous studies in which standard immunization procedures with AB42 10 were followed. The largest alteration in both the extent and appearance of amyloid plaques occurred in the animals immunized with the polyclonal AB42 antibody. The reduction of amyloid load, eroded plaque morphology and cell-associated AB immunoreactivity closely resembled effects produced by the standard immunization procedure. These observations 15 support the ELISA results in which significant reductions in both total AB and AB42 were achieved by administration of the polyclonal AB42 antibody. In similar qualitative evaluations, amyloid plaques in the IOD5 group were also reduced in number and appearance, with some evidence of cell-associated AB immunoreactivity. Relative to control-treated animals, the polyclonal Ig fraction against AB 20 and one of the monoclonal antibodies (10D5) reduced plaque burden by 93% and 81%, respectively (p<0.005). 21F12 appeared to have a relatively modest effect on plaque burden. Micrographs of brain after treatment with pabABI- 4 2 show diffuse deposits and absence of many of the larger compacted plaques in the pabAB 4 2 treated group relative to control treated animals. 25 5. Measurement of Antibody Titers: A subset of three randomly chosen mice from each group were bled just prior to each intraperitoneal inoculation, for a total of 30 bleeds. Antibody titers were measured as 30 AP 1-42-binding antibody using a sandwich ELISA with plastic multi-well plates coated with Ap142 as described in detail in the General Materials and Methods. Mean titers for each bleed are shown in Figures 16-18 for the polyclonal antibody and the monoclonals IODS and 21F12, respectively. Titers averaged about 1000 over this time period for the polyclonal 92 antibody preparation and were slightly above this level for the 10D5- and 21F 12-treated animals. 6. Lymphoproliferative Responses: 5 Ap-dependent lymphoproliferation was measured using spleen cells harvested eight days following the final antibody infusion. Freshly harvested cells, 105 per well, were cultured for 5 days in the presence of Apl-40 at a concentration of 5 piM for stimulation. As a positive control, additional cells were cultured with the T cell mitogen, PHA, and, as a negative control, cells were cultured without added peptide. 10 Splenocytes from aged PDAPP mice passively immunized with various anti Ap antibodies were stimulated in vitro with AN1792 and proliferative and cytokine responses were measured. The purpose of these assays was to determine if passive immunization facilitated antigen presentation, and thus priming of T cell responses specific for AN1792. No AN 1792-specific proliferative or cytokine responses were observed in mice passively 15 immunized with the anti-Ap antibodies. XII: FURTHER STUDY OF PASSIVE IMMUNIZATION In a second study, treatment with IOD5 was repeated and two additional anti AB antibodies were tested, monoclonals 3D6 (ABI.5) and 16C II (AB 3 3

..

2 ). Control groups 20 received either PBS or an irrelevant isotype-matched antibody (TM2a). The mice were older (11.5-12 month old heterozygotes) than in the previous study, otherwise the experimental design was the same. Once again, after six months of treatment, IOD5 reduced plaque burden by greater than 80% relative to either the PBS or isotype-matched antibody controls (p=0.003). One of the other antibodies against AB, 3D6, was equally effective, producing an 25 86% reduction (p=0.003). In contrast, the third antibody against the peptide, 16C 11, failed to have any effect on plaque burden. Similar findings were obtained with AB 42 ELISA measurements. These results demonstrate that an antibody response against AB peptide, in the absence of T cell immunity, is sufficient to decrease amyloid deposition in PDAPP mice, but that not all anti-AB antibodies are efficacious. Antibodies directed to epitopes comprising 30 amino acids 1-5 or 3-7 of As are particularly efficacious. In summary, we have shown that passively administered antibodies against AB reduced the extent of plaque deposition in a mouse model of Alzheimer's disease. When held 93 at modest serum concentrations (25-70 pg/ml), the antibodies gained access to the CNS at levels sufficient to decorate B-amyloid plaques. Antibody entry into the CNS was not due to abnormal leakage of the blood-brain barrier since there was no increase in vascular permeability as measured by Evans Blue in PDAPP mice. In addition, the concentration of 5 antibody in the brain parenchyma of aged PDAPP mice was the same as in non-transgenic mice, representing 0.1% of the antibody concentration in serum (regardless of isotype). XIII: MONITORING OF ANTIBODY BINDING To determine whether antibodies against AB could be acting directly within 10 the CNS, brains taken from saline-perfused mice at the end of the Example XII, were examined for the presence of the peripherally-administered antibodies. Unfixed cryostat brain sections were exposed to a fluorescent reagent against mouse immunoglobulin (goat anti-mouse IgG-Cy3). Plaques within brains of the IOD5 and 3D6 groups were strongly decorated with antibody, while there was no staining in the 16C II group. To reveal the full 15 extent of plaque deposition, serial sections of each brain were first immunoreacted with an anti-AB antibody, and then with the secondary reagent. 10D5 and 3D6, following peripheral administration, gained access to most plaques within the CNS. The plaque burden was greatly reduced in these treatment groups compared to the 16C II group. These data indicate that peripherally administered antibodies can enter the CNS where they can directly trigger 20 amyloid clearance. It is likely that 16C 11 also had access to the plaques but was unable to bind. 94 XIV: EX VIVO SCREENING ASSAY FOR ACTIVITY OF AN ANTIBODY AGAINST AMYLOID DEPOSITS To examine the effect of antibodies on plaque clearance, we established an ex vivo assay in which primary microglial cells were cultured with unfixed cryostat sections of 5 either PDAPP mouse or human AD brains. Microglial cells were obtained from the cerebral cortices of neonate DBA/2N mice (1-3 days). The cortices were mechanically dissociated in HBSS- (Hanks' Balanced Salt Solution, Sigma) with 50 pg/ml DNase I (Sigma). The dissociated cells were filtered with a 100 pm cell strainer (Falcon), and centrifuged at 1000 rpm for 5 minutes. The pellet was resuspended in growth medium (high glucose DMEM, 10 1O%FBS, 25ng/ml rmGM-CSF), and the cells were plated at a density of 2 brains per T-75 plastic culture flask. After 7-9 days, the flasks were rotated on an orbital shaker at 200 rpm for 2h at 37'C. The cell suspension was centrifuged at 1000rpm and suspended in the assay medium. 10-pm cryostat sections of PDAPP mouse or human AD brains (post-mortem 15 interval < 3hr) were thaw mounted onto poly-lysine coated round glass coverslips and placed in wells of 24-well tissue culture plates. The coverslips were washed twice with assay medium consisting of H-SFM (Hybridoma-serum free medium, Gibco BRL) with 1% FBS, glutamine, penicillin/streptomycin, and Sng/ml rmGM-CSF (R&D). Control or anti-AB antibodies were added at a 2x concentration (5 pg/ml final) for 1 hour. The microglial cells 20 were then seeded at a density of 0.8x 106 cells/ml assay medium. The cultures were maintained in a humidified incubator (37"C, 5%CO 2 ) for 24hr or more. At the end of the incubation, the cultures were fixed with 4% paraformaldehyde and permeabilized with 0.1% Triton-XOO. The sections were stained with biotinylated 3D6 followed by a streptavidin / Cy3 conjugate (Jackson ImmunoResearch). The exogenous microglial cells were visualized 25 by a nuclear stain (DAPI). The cultures were observed with an inverted fluorescent microscope (Nikon, TE300) and photomicrographs were taken with a SPOT digital camera using SPOT software (Diagnostic instruments). For Western blot analysis, the cultures were extracted in 8M urea, diluted 1:1 in reducing tricine sample buffer and loaded onto a 16% tricine gel (Novex). After transfer onto immobilon, blots were exposed to 5 pg/ml of the 30 pabAB42 followed by an HRP-conjugated anti-mouse antibody, and developed with ECL (Amersham) When the assay was performed with PDAPP brain sections in the presence of 16C1 I (one of the antibodies against AB that was not efficacious in vivo), B-amyloid plaques remained intact and no phagocytosis was observed. In contrast, when adjacent sections were 95 cultured in the presence of 10D5, the amyloid deposits were largely gone and the microglial cells showed numerous phagocytic vesicles containing A.B. Identical results were obtained with AD'brain sections; 10D5 induced phagocytosis of AD plaques, while 16C II was ineffective. In addition, the assay provided comparable results when performed with either 5 mouse or human microglial cells, and with mouse, rabbit, or primate antibodies against AB. Table 16 shows whether binding and/or phagocytosis was obtained for several different antibody binding specificities. It can be seen that antibodies binding to epitopes within aa 1-7 both bind and clear amyloid deposits, whereas antibodies binding to epitopes within amino acids 4-10 bind without clearing amyloid deposits. Antibodies binding to 10 epitopes C-terminal to residue 10 neither bind nor clear amyloid deposits. 96 Table 16: Analysis of Epitope Specificity Antibody Staining Phagocytosis epitope isotype N-Term mab 3D6 1-5 IgG2b + + 10D5 3-6 IgG1 + + 22C8 3-7 IgG2a 4 + 6E10 5-10 IgG1 + 14A8 4-10 rat IgG1 + 13-28 18G11 10-18 rat igGI - 266 16-24 igG1 - 22D12 18-21 IgG2b - C-Term 2G3 -40 IgG1 - 16C11 -40/-42 IgG1 - 21F12 -42 IgG2a - Immune serum rabbit (CFA) 1-6 + + mouse (CFA) 3-7 + + mouse (QS-21) 3-7 + + monkey (QS-21) 1-5 + + mouse (MAPI-7) + + Table 17 shows results obtained with several antibodies against A13, 5 comparing their abilities to induce phagocytosis in the ex vivo assay and to reduce in vivo plaque burden in passive transfer studies. Although 16C1 I and 21F12 bound to aggregated synthetic AB peptide with high avidity, these antibodies were unable to react with B-amyloid plaques in unfixed brain sections, could not trigger phagocytosis in the ex vivo assay, and were not efficacious in vivo. 101D5, 3D6, and the polyclonal antibody against AB were active 10 by all three measures. The 22C8 antibody binds more strongly to an analog form of natural 97 AB in which aspartic acid at positions I and 7 is replaced with iso-aspartic acid. These results show that efficacy in vivo is due to direct antibody mediated clearance of the plaques within the CNS, and that the ex vivo assay is predictive of in vivo efficacy. The same assay has been used to test clearing of an antibody against a 5 fragment of synuclein referred to as NAC. Synuclein has been shown to be an amyloid plaque-associated protein. An antibody to NAC was contacted with a brain tissue sample containing amyloid plaques, an microglial cells, as before. Rabbit serum was used as a control. Subsequent monitoring showed a marked reduction in the number and size of plaques indicative of clearing activity of the antibody. 10 Table 17 The ex vivo assay as predictor of in vivo efficacy. Antibody Isotype Avidity for Binding to Ex vivo In vivo aggregated B-amyloid efficacy efficacy A1l (pM) plaques monoclonal 3D6 IgG2b 470 + + + IODS IgGI 43 + + + 16C11 IgGI 90 - 21F12 lgG2a 500 - TM2a IgGI - polyclonal 1-42 mix 600 + + + Confocal microscopy was used to confirm that AB was internalized during the course of the ex vivo assay. In the presence of control antibodies, the exogenous microglial 15 cells remained in a confocal plane above the tissue, there were no phagocytic vesicles containing AD, and the plaques remained intact within the section. In the presence of 10DS, nearly all plaque material was contained in vesicles within the exogenous microglial cells. To determine the fate of the internalized peptide, IOD5 treated cultures were extracted with 8M urea at various time-points, and examined by Western blot analysis. At the one hour time 20 point, when no phagocytosis had yet occurred, reaction with a polyclonal antibody against AB revealed a strong 4 kD band (corresponding to the AB peptide). AB imunuoreactivity 98 decreased at day I and was absent by day 3. Thus, antibody-mediated phagocytosis of AB leads to its degradation. To determine if phagocytosis in the ex vivo assay was Fc-mediated, F(ab')2 fragments of the anti-A.B antibody 3D6 were prepared. Although the F(ab')2 fragments 5 retained their full ability to react with plaques, they were unable to trigger phagocytosis by microglial cells. In addition, phagocytosis with the whole antibody could be blocked by a reagent against murine Fc receptors (anti-CD16/32). These data indicate that in vivo clearance of AB occurs through Fc-receptor mediated phagocytosis. 10 XV: PASSAGE OF ANTIBODIES THROUGH BLOOD BRAIN BARRIER This example determines the concentration of antibody delivered to the brain following intravenous injection into a peripheral tissue of either normal or PDAPP mice. PDAPP or control normal mice were perfused with 0.9% NaCI. Brain regions (hippocampus or cortex) were dissected and rapidly frozen. Brain were homogenized in 0.1% triton + 15 protease inhibitors. Immunoglobulin was detected in the extracts by ELISA. Fab'2 Goat Anti-mouse IgG were coated onto an RIA plate as capture reagent. The serum or the brain extracts were incubated for lhr. The isotypes were detected with anti-mouse IgGl-HRP or IgG2a-HRP or IgG2b-HRP (Caltag). Antibodies, regardless of isotype, were present in the CNS at a concentration that is 1:1000 that found in the blood. For example, when the 20 concentration of IgGI was three times that of IgG2a in the blood, it was three times IgG2a in the brain as well, both being present at 0.1% of their respective levels in the blood. This result was observed in both transgenic and nontransgenic mice - so the PDAPP does not have a uniquely leak blood brain barrier. 25 XVI: THERAPEUTIC EFFICACY OF AN AB PEPTIDE IN MAP CONFIGURATION A therapeutic adjuvant/immnunogen efficacy study was performed in 9 - 10.5 month old male and female heterozygous PDAPP transgenic mice to test the efficacy of a fusion protein comprising ABI-7 in tetrameric MAP configuration as described above. The duration of the study was 25 weeks with 29 - 40 animals per treatment group; therefore the 30 animals were 15 - 16.5 months old at termination. The methodology used in this study is the same as that in the therapeutic study of different adjuvants in Example VIII above. . The treatment groups are identified in Table 18 below. 99 Table 18 Adjuvant Immunogen Dilution Buffer Administration Group 1: CFAIFA MAP(AB 1-7:TT) (100 I±g) PBS IP(400pi) Group 2: QS21 AN1792-GCS (75 pg) PBS SC (250 pi) Group 3: PBS -- --- SC (250 ii 5 Table abbreviations: MAP - multi-antigenic peptide; TT - tetanus toxoid t-cell epitope (830-844); SC - subcutaneous; IP - intraperitoneally; PBS - phosphate buffered saline; GCS is a glycine/citrate/sucrose formulation. The immunization schedule was identical for all of the treatment groups. The 10 mice were injected on weeks 0, 2, 4, 8, 12, 16, 20, 24, with bleeds on week 3, 5, 9, 13, 17, 21 and 25. Groups 1, 2, 3, 4, and 6 received eight injections Groups 2 and 3, QS21/AN 1792 and PBS respectively, served as the positive and negative controls for this study. The titers were determined by the anti-AB antibody titer assay. Group 1, CFA/FA:MAP(AB1-7:TT) group, had low titer levels. The peak 15 GMT reached was only 1,200 at 13 weeks, falling to a GMT of 600 by week 25. There were 3 of the 30 mice that did not raise any titer and another 7 mice that did not exceed a titer of 400 by the end of the study. Group 2, the QS21/AN1792 control group, reached its peak titer at 17 weeks with a GMT of 16,000. The titer then fell over the next 8 weeks to finish with a GMT of 20 8,700. One animal in this group failed to raise a titer over the entire course of the experiment. Group 3, the PBS alone group, had no titers. Both treatment groups showed a significant lowing in cortical AB levels as compared to the PBS control group (see Table 19). The CFA/IFA:MAP(ABI-7) group, significantly 25 lowered AB as compared to the PBS control group in spite of the relatively low titers of anti AB antibodies. 100 Table 19 Cortical AB levels PBS MAP QS-21 MEDIAN 7,335 3,692 2,389 (ng/g tissue) RANGE 550- 18,358 240-10,782 210-11,167 (ng/g tissue) p value - 0.0003 < 0.0001 N 38 30 34 5 In conclusion, the AB 1-7MAP immunogen is effective in inducing a sufficient immune response significantly to retard A3 deposition in the cortex. 10 XVII. EPITOPE MAPPING OF IMMUNOGENIC RESPONSE TO AP IN MONKEYS This example analyzes the response of a primate to immunization with AN1792 (i.e., A1-42). Eleven groups of monkeys (4/sex/group) were immunized with 15 AN1792 (75 or 300 pg/dose) in combination with QS-21 adjuvant (50 or 100 pg/dose) or 5% sterile dextrose in water (D5W, control group). All animals received IM injections on one of three injection schedules as shown in Table 20 for a total of 4, 5 or 8 doses. Serum samples (from 4 monkeys/sex/group) collected on Day 175 of the study and CSF samples (from 3 monkeys/sex/group) collected on Day 176 of the study (at the 6 month necropsy) were 20 evaluated for their ability to bind to AP1-40 peptide and APP. 101 Table 20: Group Assignments and Dose Levels Group Schedulea # Monkeys AN1792 Dose QS-21 Dose Dose Route No. (M/F) (pg/dose) (pg/dose) b 1 4/4 0 0 IM 2 1 4/4 Vehiclec 50 IM 3 1 4/4 Vehicle 100 IM 4 1 4/4 75 50 IM 5 1 4/4 300 50 IM 6 1 4/4 75 100 IM 7 1 4/4 300 100 IM 8 2 4/4 75 100 IM 9 2 4/4 300 100 IM 10 3 4/4 75 100 IM 11 3 414 300 100 IM a. Schedule 1, Dose Days 1, 15, 29, 57, 85, 113, 141, 169; Schedule 2, Dose Days 1, 29, 57, 113. 169; Schedule 3, Dose Days 1, 43, 85, 169 5 b. D5W injection control group c. Vehicle consists of the glycine/citrate/sucrose buffer which is the excipient for AN1792. The exact array of linear peptides recognized by the antibodies in the serum samples from animals immunized with AN1792 was determined by an ELISA that measured 10 the binding of these antibodies to overlapping peptides that covered the entire Apl-42 sequence. Biotinylated peptides with partial sequences of AN 1792 were obtained from Chiron Technologies as 10 amino acid peptides with an overlap of 9 residues and a step of one residue per peptide (synthesis No. 5366, No. 5331 and No. 5814). The first 32 peptides (from the eight amino acid position upstream of the N-terminal of AN 1792 down to the 15 twenty-fourth amino acid of AN1792) are biotinylated on the C-terminal with a linker of GGK. The last 10 peptides (repeating the thirty-second peptide fromthe previous series) are biotinylated on the N-terminal with a linker consisting of EGEG (SEQ ID NO: 76). The lyophilized biotinylated peptides were dissolved at a concentration of 5 mM in DMSO. These peptide stocks were diluted to 5 pM in TTBS (0.05% Tween 20,25 mM Tris HCl, 137 mM NaCl, 5.1 20 mM KCI, pH= 7 .5). 100 p1 aliquots of this 5 pM solution were added in duplicate to streptavidin pre-coated 96-well plates (Pierce). Plates were incubated for one hour at room temperature, then washed four times with TTBS. Serum samples were diluted in specimen diluent without azide to normalize titers, and 100 p1 was added per well. These plates were incubated one hour at room temperature and then washed four times with TTBS. HR.P 102.

conjugated goat anti-human antibody (Jackson ImmunoResearch) was diluted 1:10,000 in specimen diluent without azide and 100 il was added per well. The plates were again incubated and washed. To develop the color reaction, TMB (Pierce), was added at 100 Pl per well and incubated for 15 min prior to the addition of 30 pl of 2 N H 2

SO

4 to stop the reaction. 5 The optical density was measured at 450 nm on a Vmax or Spectramax colorimetric plate reader. Immunization with AN 1792 resulted in the production of antibodies in 100% of the animals in all of the dose groups by Day 175. Mean titers in the groups ranged from 14596 - 56084. There was a trend for titers to be higher within an immunization schedule in 10 the presence of higher antigen and/or higher adjuvant concentration, but no statistically significant differences could be demonstrated due to the high variability in individual animal responses to the immunizations. Sera which were positive for antibodies to AN 1792 were also positive for antibodies to AD-40. Mean titers in the groups ranged from 36867 - 165991, and as for anti 15 AN1792 titers, showed no statistically significant differences between groups at Day 175. Binding to AN 1792 showed a highly positive correlation (Spearman r = 0.8671) with binding to As1-40. Of the 48 monkeys immunized on various schedules with AN 1792, 33 yielded CSF samples of adequate volume and quality for analysis. Thirty-two (97%) of these 20 monkeys had positive titers to AN1792. Titers ranged from 2-246, with a mean of 49.44 t 21.34. CSF anti-AN1792 levels were 0.18 ± 0.11% of what was measured in the serum and demonstrated a highly positive correlation (Spearman r = 0.7840) with serum titers. No differences were seen across groups or between sexes in the percentage of antibody in the CSF. The level of antibody in the CSF is consistent with the passive transfer of peripherally 25 generated antibody across the blood-brain-barrier into the central nervous system. Testing of a subset of anti-AN 1792 positive CSF samples demonstrated that, like the antibody in serum samples, antibody in the CSF cross-reacts with Apl-40. Titers to APl-40 showed a high correlation (Spearman r = 0.9634) to their respective AN1792 titers. Testing of a subset of CSF samples with the highest titers to AN1792 showed no binding to 30 APP, as for the serum antibodies. When sera from Day 175 was tested against a series of overlapping I 0-mer peptides, antibodies from all of the monkeys bound to the peptide whose sequence covered 103 amino acids 1-10 of the AN1792 peptide (amino acids 653-672 of APP). In some animals, this was the only peptide to which binding could be measured (see Fig. 19). In other animals, other reactivities could be measured, but in all cases the reactivity to the N-terminal peptide sequence was the predominant one. The additional 5 reactivities fell into two groups. First and most common, was the binding to peptides centering around the N-terminal 1-10 AN1792 peptide (Figure 20). Binding of this type was directed to the peptides covering amino acids -1--8, -1-9, and 2-11 of the AN 1792 peptide. These reactivities, combined with that to the 1-10 peptide, represent the overwhelming majority of reactivity in all animals. Epitope mapping of individual animals -over time 10 indicates that the antibody reactivity to the 1-10 peptide proceeds the spread to the adjacent peptides . This demonstrates a strong biasing of the immune response to the N-terminus of the AN 1792 peptide with its free terminal aspartic acid residue. The second minor detectable activity in some animals was binding to peptides located C-terminally to the major area and centered around peptides covering amino acids 7-16, 11-20 and 16-25 of the AN1792 15 peptide . These reactivities were seen in only 10-30% of the monkeys. Variability in response between different animals (e.g., whether amino acids 1-10 were the exclusive or predominant reactive epitope) did not correlate with antigen/adjuvant dose, dosing schedule, or antibody titer, and is probably a reflection of each individual animal's genetic make-up. 20 XVIII. PREVENTION AND TREATMENT OF HUMAN SUBJECTS A single-dose phase I trial is performed to determine safety in humans. A therapeutic agent is administered in increasing dosages to different patients starting from 25 about 0.01 the level of presumed efficacy, and increasing by a factor of three until a level of about 10 times the effective mouse dosage is reached. A phase 11 trial is performed to determine therapeutic efficacy. Patients with early to mid Alzheimer's Disease defined using Alzheimer's disease and Related Disorders Association (ADRDA) criteria for probable AD are selected. Suitable patients score in the 30 12-26 range on the Mini-Mental State Exam (MMSE). Other selection criteria are that patients are likely to survive the duration of the study and lack complicating issues such as use of concomitant medications that may interfere. Baseline evaluations of patient function are made using classic psychometric measures, such as the MMSE, and the ADAS, which is a comprehensive scale for evaluating patients with Alzheimer's Disease status and function. 104 These psychometric scales provide a measure of progression of the Alzheimer's condition. Suitable qualitative life scales can also be used to monitor treatment. Disease progression can also be monitored by MRI. Blood profiles of patients can also be monitored including assays of immunogen-specific antibodies and T-cells responses. 5 Following baseline measures, patients begin receiving treatment. They are randomized and treated with either therapeutic agent or placebo in a blinded fashion. Patients are monitored at least every six months. Efficacy is determined by a significant reduction in progression of a treatment group relative to a placebo group. A second phase II trial is performed to evaluate conversion of patients from 10 non-Alzheimer's Disease early memory loss, sometimes referred to as age-associated memory impairment (AAMI) or mild cognitive impairment (MCI), to probable Alzheimer's disease as defined as by ADRDA criteria. Patients with high risk for conversion to Alzheimer's Disease are selected from a non-clinical population by screening reference populations for early signs of memory loss or other difficulties associated with pre-Alzheimer's symptomatology, a 15 family history of Alzheimer's Disease, genetic risk factors, age, sex, and other features found to predict high-risk for Alzheimer's Disease. Baseline scores on suitable metrics including the MMSE and the ADAS together with other metrics designed to evaluate a more normal population are collected. These patient populations are divided into suitable groups with placebo comparison against dosing alternatives with the agent. These patient populations are 20 followed at intervals of about six months, and the endpoint for each patient is whether or not he or she converts to probable Alzheimer's Disease as defined by ADRDA criteria at the end of the observation. XIX. General Materials and Methods 25 1. Measurement of Antibody Titers Mice were bled by making a small nick in the tail vein and collecting about 200 p1 of blood into a microfuge tube. Guinea pigs were bled by first shaving the back hock area and then using an 18 gauge needle to nick the metatarsal vein and collecting the blood into microfuge tubes. Blood was allowed to clot for one hr at room temperature (RT), 30 vortexed, then centrifuged at 14,000 x g for 10 min to separate the clot from the serum. Serum was then transferred to a clean microfuge tube and stored at 4*C until titered. Antibody titers were measured by ELISA. 96-well microtiter plates (Costar EIA plates) were coated with 100 pl of a solution containing either 10 pg/ml either Aj342 or 105 SAPP or other antigens as noted in each of the individual reports in Well Coating Buffer (0.1 M sodium phosphate, pH 8.5, 0.1% sodium azide) and held overnight at RT. The wells were aspirated and sera were added to the wells starting at a 1/100 dilution in Specimen Diluent (0.014 M sodium phosphate, pH 7.4, 0.15 M NaCl, 0.6% bovine serum albumin, 0.05% 5 thimerosal). Seven serial dilutions of the samples were made directly in the plates in three fold steps to reach a final dilution of 1/218,700. The dilutions were incubated in the coated plate wells for one hr at RT. The plates were then washed four times with PBS containing 0.05% Tween 20. The second antibody, a goat anti-mouse Ig conjugated to horseradish peroxidase (obtained from Boehringer Mannheim), was added to the wells as 100 1 d of a 10 1/3000 dilution in Specimen Diluent and incubated for one hr at RT. Plates were again washed four times in PBS, Tween 20. To develop the chromogen, 100 pl of Slow TMB (3,3',5,5'-tetramethyl benzidine obtained from Pierce Chemicals) was added to each well and incubated for 15 min at RT. The reaction was stopped by the addition of 25 pl of 2 M

H

2

SO

4 . The color intensity was then read on a Molecular Devices Vmax at (450 nm - 650 15 nm). Titers were defined as the reciprocal of the dilution of serum giving one half the maximum OD. Maximal OD was generally taken from an initial 1/100 dilution, except in cases with very high titers, in which case a higher initial dilution was necessary to establish the maximal OD. If the 50% point fell between two dilutions, a linear extrapolation was 20 made to calculate the final titer. To calculate geometric mean antibody titers, titers less than 100 were arbitrarily assigned a titer value of 25. 2. Lymphocyte proliferation assay Mice were anesthetized with isoflurane. Spleens were removed and rinsed 25 twice with 5 ml PBS containing 10% heat-inactivated fetal bovine serum (PBS-FBS) and then homogenized in a 500 Centricon unit (Dako A/S, Denmark) in 1.5 ml PBS-FBS for 10 sec at 100 rpm in a Medimachine (Dako) followed by filtration through a 100 micron pore size nylon mesh. Splenocytes were washed once with 15 ml PBS-FBS, then pelleted by centrifugation at 200 x g for 5 min. Red blood cells were lysed by resuspending the pellet in 30 5 mL buffer containing 0.15 M NH4Cl, 1 M KHCO3, 0.1 M NaEDTA, pH 7.4 for five min at RT. Leukocytes were then washed as above. Freshly isolated spleen cells (105 cells per well) were cultured in triplicate sets in 96-well U-bottomed tissue culture-treated microtiter plates (Corning, Cambridge, MA) in RPMI 1640 medium (JRH Biosciences, Lenexa, KS) 106 supplemented with 2.05 mM L glutamine, 1% Penicillin/Streptomycin, and 10% heat inactivated FBS, for 96 hr at 37*C. Various Ap peptides, Apl-16, Apl-40, Apl-42 or AP40 1 reverse sequence protein were also added at doses ranging from 5 to 0.18 micromolar in four steps. Cells in control wells were cultured with Concanavalin A (Con A) (Sigma, cat. # 5 C-5275, at I microgram/ml) without added protein. Cells were pulsed for the final 24 hr with 3H-thymidine (1 ptCi/well obtained from Amersham Corp., Arlington Heights IL). Cells were then harvested onto UniFilter plates and counted in a Top Count Microplate Scintillation Counter (Packard Instruments, Downers Grove, IL). Results are expressed as counts per minute (cpm) of radioactivity incorporated into insoluble macromolecules. 10 4. Brain Tissue Preparation After euthanasia, the brains were removed and one hemisphere was prepared for immunohistochemical analysis, while three brain regions (hippocampus, cortex and cerebellum) were dissected from the other hemisphere and used to measure the concentration 15 of various As proteins and APP forms using specific ELISAs (Johnson-Wood et al., supra). Tissues destined for ELISAs were homogenized in 10 volumes of ice-cold guanidine buffer (5.0 M guanidine-HCI, 50 mM Tris-HCI, pH 8.0). The homogenates were mixed by gentle agitation using an Adams Nutator (Fisher) for three to four hr at RT, then stored at -20*C prior to quantitation of ADp and APP. Previous experiments had shown that 20 the analytes were stable under this storage condition, and that synthetic Ap protein (Bachem) could be quantitatively recovered. when spiked into homogenates of control brain tissue from mouse littermates (Johnson-Wood et al., supra). 25 5. Measurement of Ap Levels The brain homogenates were diluted 1:10 with ice cold Casein Diluent (0.25% casein, PBS, 0.05% sodium azide, 20 pg/ml aprotinin, 5 mM EDTA pH 8.0, 10 pg/mil leupeptin) and then centrifuged at 16,000 x g for 20 min at 4* C. The synthetic Ap protein standards (1-42 amino acids) and the APP standards were prepared to include 0.5 M . 30 guanidine and 0.1% bovine serum albumin (BSA) in the final composition. The "total" Ap sandwich ELISA utilizes monoclonal antibody monoclonal antibody 266, specific for amino acids 13-28 of Ap (Seubert, et al.), as the capture antibody, and biotinylated monoclonal antibody 3D6, specific for amino acids 1-5 of AD (Johnson-Wood, et al), as the reporter 107 antibody. The 3D6 monoclonal antibody does not recognize secreted APP or full-length APP, but detects only AP species with an amino-terminal aspartic acid. This assay has a lower limit of sensitivity of -50 ng/ml (1I nM) and shows no cross-reactivity to the endogenous murine AP protein at concentrations up to I ng/ml (Johnson-Wood et al., supra). 5 The ApI-42 specific sandwich ELISA employs mAO 21F12, specific for amino acids 33-42 of AP (Johnson-Wood, et al.), as the capture antibody. Biotinylated mA p 3D6 is also the reporter antibody in this assay which has a lower limit of sensitivity of about 125 tig/ml (28 pM, Johnson-Wood et al.). For the AP ELISAs, 100 pl of either mAO 266 (at 10 pig/ml) or mAp 21F12 at (5 pg/ml) was coated into the wells of 96-well immunoassay 10 plates (Costar) by overnight incubation at RT. The solution was removed by aspiration and the wells were blocked by the addition of 200 pl of 0.25% human serum albumin in PBS buffer for at least I hr at RT. Blocking solution was removed and the plates were stored desiccated at 4*C until used. The plates were rehydrated with Wash Buffer [Tris-buffered saline (0.15 M NaCl, 0.01 M Tris-HCI, pH 7.5), plus 0.05% Tween 20] prior to use. The 15 samples and standards were added in triplicate aliquots of 100 pt per well and then incubated overnight at 40 C. The plates were washed at least three times with Wash Buffer between each step of the assay. The biotinylated mAp 3D6, diluted to 0.5 pg/ml in Casein Assay Buffer (0.25% casein, PBS, 0.05% Tween 20, pH 7.4), was added and incubated in the wells for 1 hr at RT. An avidin-horseradish peroxidase conjugate, (Avidin-HRP obtained from 20 Vector, Burlingame, CA), diluted 1:4000 in Casein Assay Buffer, was added to the wells for 1 hr at RT. The colorimetric substrate, Slow TMB-ELISA (Pierce), was added and allowed to react for 15 minutes at RT, after which the enzymatic reaction was stopped by the addition of 25 VI 2 N H2S04. The reaction product was quantified using a Molecular Devices Vmax measuring the difference in absorbance at 450 nm and 650 nm. 25 6. Measurement of APP Levels Two different APP assays were utilized. The first, designated APP-Ct/FL, recognizes both APP-alpha (a) and full-length (FL) forms of APP. The second assay is specific for APP-a. The APP-a /FL assay recognizes secreted APP including the first 12 30 amino acids of A0. Since the reporter antibody (2H3) is not specific to the a-clip-site, occurring between amino acids 612-613 of APP695 (Esch et al., Science 248, 1122-1124 (1990)); this assay also recognizes full length APP (APP-FL). Preliminary experiments using 108 immobilized APP antibodies to the cytoplasmic tail of APP-FL to deplete brain homogenates of APP-FL suggest that approximately 30-40% of the APP-c /FL APP is FL (data not shown). The capture antibody for both the APP-a/FL and APP-a assays is mAb 8E5, raised against amino acids 444 to 592 of the APP695 form (Games et al., supra). The reporter mAb 5 for the APP-a/FL assay is mAb 2H3, specific for amino acids 597-608 of APP695 (Johnson Wood et al., supra) and the reporter antibody for the APP-a assay is a biotinylated derivative of mAb 16H9, raised to amino acids 605 to 611 of APP. The lower limit of sensitivity of the APP-caFL assay is about I1 ng/ml (150 pM) (Johnson-Wood et al.) and that of the APP-a specific assay is 22 ng/ml (0.3 nM). For both APP assays, mAb 8E5 was coated onto the 10 wells of 96-well EIA plates as described above for mAb 266. Purified, recombinant secreted APP-a was used as the reference standard for the APP-a assay and the APP-a/FL assay (Esch et al., supra). The brain homogenate samples in 5 M guanidine were diluted 1:10 in ELISA Specimen Diluent (0.0 14 M phosphate buffer, pH 7.4, 0.6% bovine serum albumin, 0.05% thimerosal, 0.5 M NaCl, 0.1% NP40). They were then diluted 1:4 in Specimen 15 Diluent containing 0.5 M guanidine. Diluted homogenates were then centrifuged at 16,000 x g for 15 seconds at RT. The APP standards and samples were added to the plate in duplicate aliquots and incubated for 1.5 hr at RT. The biotinylated reporter antibody 2H3 or 16H9 was incubated with samples for I hr at RT. Streptavidin-alkaline phosphatase (Boehringer Mannheim), diluted 1:1000 in specimen diluent, was incubated in the wells for I hr at RT. 20 The fluorescent substrate 4-methyl-umbellipheryl-phosphate was added for a 30-min RT incubation and the plates were read on a Cytofluor tm 2350 fluorimeter (Millipore) at 365 nm excitation and 450 nm emission. 7. Immunohistochemistry 25 Brains were fixed for three days at 40C in 4% paraformaldehyde in PBS and then stored from one to seven days at 4*C in 1% paraformaldehyde, PBS until sectioned. Forty-micron-thick coronal sections were cut on a vibratome at RT and stored in cryoprotectant (30% glycerol, 30% ethylene glycol in phosphate buffer) at -20 0 C prior to immunohistochemical processing. For each brain, six sections at the level of the dorsal 30 hippocampus, each separated by consecutive 240 pm intervals, were incubated ovemight with one of the following antibodies: (1) a biotinylated anti-Ap (mAb, 3D6, specific for human AP) diluted to a concentration of 2 ptg/ml in PBS and 1% horse serum; or (2) a biotinylated mAb specific for human APP, 8E5, diluted to a concentration of 3 ig/ml in PBS 109 and 1.0% horse serum; or (3) a mAb specific for glial fibrillary acidic protein (GFAP; Sigma Chemical Co.) diluted 1:500 with 0.25% Triton X- 100 and 1% horse serum, in Tris-buffered saline, pH 7.4 (TBS); or (4) a mAb specific for CD1 I b, MAC-I antigen, (Chemicon International) diluted 1:100 with 0.25% Triton X-100 and 1% rabbit serum in TBS; or (5) a 5 mAb specific for MHC II antigen, (Pharmingen) diluted 1:100 with 0.25% Triton X-100 and 1% rabbit serum in TBS; or (6) a rat mAb specific for CD 43 (Pharmingen) diluted 1:100 with 1% rabbit serum in PBS or (7) a rat mAb specific for CD 45RA (Pharmingen) diluted 1:100 with 1% rabbit serum in PBS; or (8) a rat monoclonal AP specific for CD 45RB (Pharmingen) diluted 1:100 with 1% rabbit serum in PBS; or (9) a rat monoclonal AP 10 specific for CD 45 (Pharmingen) diluted 1:100 with 1% rabbit serum in PBS; or (10) a biotinylated polyclonal hamster As specific for CD3e (Pharmingen) diluted 1:100 with 1% rabbit serum in PBS or (11) a rat mAb specific for CD3 (Serotec) diluted 1:200 with 1% rabbit serum in PBS; or with (12) a solution of PBS lacking a primary antibody containing 1% normal horse serum. 15 Sections reacted with antibody solutions listed in 1,2 and 6-12 above were pretreated with 1.0% Triton X-100, 0.4% hydrogen peroxide in PBS for 20 min at RT to block endogenous peroxidase. They were next incubated overnight at 4"C with primary antibody. Sections reacted with 3D6 or 8E5 or CD3e mAbs were then reacted for one hr at RT with a horseradish peroxidase-avidin-biotin-complex with kit components "A" and "B" 20 diluted 1:75 in PBS (Vector Elite Standard Kit, Vector Labs, Burlingame, CA.). Sections reacted with antibodies specific for CD 45RA, CD 45RB, CD 45, CD3 and the PBS solution devoid of primary antibody were incubated for I hour at RT with biotinylated anti-rat IgG (Vector) diluted 1:75 in PBS or biotinylated anti-mouse IgG (Vector) diluted 1:75 in PBS, respectively. Sections were then reacted for one hr at RT with a horseradish peroxidase 25 avidin-biotin-complex with kit components "A" and "B" diluted 1:75 in PBS (Vector Elite Standard Kit, Vector Labs, Burlingame, CA.). Sections were developed in 0.01% hydrogen peroxide, 0.05% 3,3' diaminobenzidine (DAB) at RT. Sections destined for incubation with the GFAP-, MAC-1 AND MHC II-specific antibodies were pretreated with 0.6% hydrogen peroxide at RT to 30 block endogenous peroxidase then incubated overnight with the primary antibody at 4 0 C. Sections reacted with the GFAP antibody were incubated for 1 hr at RT with biotinylated anti-mouse IgG made in horse (Vector Laboratories; Vectastain Elite ABC Kit) diluted 1:200 with TBS. The sections were next reacted for one hr with an avidin-biotin-peroxidase 110 complex (Vector Laboratories; Vectastain Elite ABC Kit) diluted 1:1000 with TBS. Sections incubated with the MAC-I-or MHC 11-specific monoclonal antibody as the primary antibody were subsequently reacted for 1 hr at RT with biotinylated anti-rat IgG made in rabbit diluted 1:200 with TBS, followed by incubation for one hr with avidin-biotin-peroxidase complex 5 diluted 1:1000 with TBS. Sections incubated with GFAP-, MAC-i- and MHC II-specific antibodies were then visualized by treatment at RT with 0.05% DAB, 0.0 1% hydrogen peroxide, 0.04% nickel chloride, TBS for 4 and 1 min, respectively. Immunolabeled sections were mounted on glass slides (VWR, Superfrost slides), air dried overnight, dipped in Propar (Anatech) and overlaid with coverslips using 10 Permount (Fisher) as the mounting medium. To counterstain AP plaques, a subset of the GFAP-positive sections were mounted on Superfrost slides and incubated in aqueous 1% Thioflavin S (Sigma) for 7 min following immunohistochemical processing. Sections were then dehydrated and cleared in Propar, then overlaid with coverslips mounted with Permount. 15 8. Image Analysis A Videometric 150 Image Analysis System (Oncor, Inc., Gaithersburg, MD) linked to a Nikon Microphot-FX microscope through a CCD video camera and a Sony Trinitron monitor was used for quantification of the immunoreactive slides. The image of the 20 section was stored in a video buffer and a color-and saturation-based threshold was determined to select and calculate the total pixel area occupied by the immunolabeled structures. For each section, the hippocampus was manually outlined and the total pixel area occupied by the hippocampus was calculated. The percent amyloid burden was measured as: (the fraction of the hippocampal area containing AP deposits immunoreactive with mAb 25 3D6) x 100. Similarly, the percent neuritic burden was measured as: (the fraction of the hippocampal area containing dystrophic neurites reactive with monoclonal antibody 8E5) xO0. The C-Imaging System (Compix, Inc., Cranberry Township, PA) operating the Simple 32 Software Application program was linked to a Nikon Microphot-FX microscope through an Optronics camera and used to quantitate the percentage of the retrospenial cortex occupied 30 by GFAP-positive astrocytes and MAC-I-and MHC II-positive microglia. The image of the immunoreacted section was stored in a video buffer and a monochrome-based threshold was determined to select and calculate the total pixel area occupied by immunolabeled cells. For each section, the retrosplenial cortex (RSC) was manually outlined and the total pixel area 111 occupied by the RSC was calculated. The percent astrocytosis was defined as: (the fraction of RSC occupied by GFAP-reactive astrocytes) X 100. Similarly, percent microgliosis was defined as: (the fraction of the RSC occupied by MAC-1- or MHC II-reactive microglia) X 100. For all image analyses, six sections at the level of the dorsal hippocampus, each 5 separated by consecutive 240 im intervals, were quantitated for each animal. In all cases, the treatment status of the animals was unknown to the observer. Although the foregoing invention has been described in detail for purposes of clarity of understanding, it will be obvious that certain modifications may be practiced within the scope of the appended claims. All publications and patent documents cited herein are 10 hereby incorporated by reference in their entirety for all purposes to the same extent as if each were so individually denoted. From the foregoing it will be apparent that the invention provides for a number of uses. For example, the invention provides for the use of any of the antibodies to AP described above in the treatment, prophylaxis or diagnosis of amyloidogenic disease, or 15 in the manufacture of a medicament or diagnostic composition for use in the safne. Likewise, the invention provides for the use of any of the epitopic fragments of Ap described above for the treatment or prophylaxis of amyloidogenic disease or in the manufacture of a medicament for use in the same. 112 10 C00 0 0) o ol:I 0 000 r- 0 0000C -3 a~ CD L C C o InLnc 001000 0)L 03 000 n 0 n r- 00crC .0 -W .0.0W al a C C - v X

-

W , 1 v -, 101E I 1 .0.0.f0E o 0 Q a r 0 E Evvv C- L -i a 7 in yC wD 0 -X - *d E CE 00* ! 0 E X X X. gi 0 Elv i A <0 CD C3C 0 0 C - a c3Ln a c3 c3 c- 0 'W - W 0 . 0 0 SE,-- E v vv 0 C) 00 C)- C') CD CD wAU 0j C)0C 3mc 0) 3 00 . n cin to w' 0. r X a - ~ ~ C n 0 C3 C-------------------- - - C- r C3 C3 0 El C31~ 0 0 C3 C3 C CD 113:

Claims (23)

1. An A$ fragment linked to a carrier peptide for use in inducing an immune response against As and thereby preventing or treating a disease associated with amyloid deposits of As in the brain of a patient, wherein the A$ fragment consists of: s i) AP 1-7 having the amino acid sequence DAEFRHD ii) As3-7 having the amino acid sequence EFRHD, or iii) a multimer of i) or ii).

2. An AP fragment linked to a carrier peptide according to claim 1, wherein the AP fragment consists of AI1-7 or A33-7. 10

3. An AP fragment linked to a carrier peptide of claim 1 or claim 2, wherein a cysteine residue is added to the As fragment.

4. An AP fragment linked to a carrier peptide according to any one of claims 1 3, wherein the carrier peptide is linked to the C-terminus of the AP fragment.

5. An A$ fragment linked to a carrier peptide according to any one of claims 1 is 3, wherein the carrier peptide is linked to the N-terminus of the As fragment.

6. An AP fragment linked to a carrier peptide according to any one of claims 1 5, wherein the carrier peptide is a peptide that enhances transport across tissues.

7. An AP fragment linked to a carrier peptide according to any one of claims 1 6, wherein the carrier peptide enhances the immune response against AP 1-7 or Ap3 -7. 20

8. An AP fragment linked to a carrier peptide of claim 7, wherein the carrier peptide is: a serum albumin; keyhole limpet hemocyanin; an immunoglobulin molecule; 25 thyroglobulin; ovalbumin; a toxoid from a pathogenic bacteria; a universal T-cell epitope; a cytokine; or 30 a chemokine.

9. An AP fragment linked to a carrier peptide of claim 8, wherein the carrier peptide is tetanus toxoid, diphtheria toxoid, E. coli toxoid, cholera or H. pylori toxoid or an attenuated toxoid derivative. 115

10. An AP fragment linked to a carrier peptide according to claim 9, wherein the carrier peptide includes a universal T-cell epitope which is: Influenza Hemagluttinin: HA 307 . 3 1 9 (PKYVKQNTLKLAT); PADRE (AKXVAAWTLKAAA); 5 Malaria CS: T3 epitope (EKKIAKMEKASSVFNV); Hepatitis B surface antigen: HBsAgi 9 - 28 (FFLLTRILTI); Heat Shock Protein 65: hsp65 153 171 (DQSIGDLIAEAMDKVGNEG); bacille Calmette-Guerin (QVHFQPLPPAVVKL); Tetanus toxoid: TT 8 3 0 - 84 4 (QYIKANSKFIGITEL); 1o Tetanus toxoid: TT 9 4 7 - 9 6 7 (FNNFTVSFWLRVPKVSASHLE); or HIV gpl20 TI (KQIINMWQEVGKAMYA).

11. An As fragment linked to a carrier peptide according to any one of claims 1-10, wherein the As fragment is linked to the carrier peptide by chemical crosslinking.

12. An As fragment linked to a carrier peptide according to any one of claims is 1-10, wherein the As fragment is expressed as a fusion protein with the carrier peptide.

13. A pharmaceutical composition comprising an As fragment linked to a carrier peptide according to any one of claims 1-12 and one or more pharmaceutically acceptable components.

14. A pharmaceutical composition according to claim 13, comprising a 20 pharmaceutically acceptable carrier.

15. A pharmaceutical composition according to claim 13 or claim 14, comprising a pharmaceutically acceptable adjuvant.

16. A pharmaceutical composition according to claim 15, wherein the adjuvant is for administration concurrently with the Ap fragment linked to a carrier peptide. 25

17. A pharmaceutical composition according to claim 16, wherein the AP fragment linked to a carrier peptide is coupled to the adjuvant.

18. A pharmaceutical composition according to claim 17, wherein the adjuvant is for administration before or after the As fragment linked to a carrier peptide.

19. A pharmaceutical composition according to any one of claims 13-18, wherein 30 the AP fragment linked to a carrier peptide is presented by a virus or a bacterium.

20. A pharmaceutical composition according to any one of claims 13-19, which is adapted to provide a dosage of the AP fragment linked to a carrier peptide of greater than 10 micrograms. 116

21. Use of an AP fragment linked to a carrier peptide according to any one of claims 1 to 12 in the manufacture of a medicament to induce an immune response against As and thereby prevent or treat a disease associated with amyloid deposits of As in the brain of a patient. 5

22. An AP fragment linked to a carrier peptide of any one of claims 1-12 or the use of claim 21, wherein the disease is Alzheimer's disease.

23. An A3 fragment linked to a carrier peptide or the use of claim 22 wherein the patient is: asymptomatic; and/or 10 has inherited risk factors indication susceptibility to Alzheimer's disease; or has no known risk factors of Alzheimer's disease. Dated 14 December, 2011 Janssen Alzheimer Immunotherapy is Patent Attorneys for the Applicant/Nominated Person SPRUSON & FERGUSON