From Bitopic Inhibitors to Multitarget Drugs for the Future Treatment of Alzheimer's Disease

Dementia is one of the main causes of the disease burden in developed regions. According to the World Health Organization (WHO), it will become the world's second leading cause of death by the middle of the century, overtaking cancer. This will have a dramatic impact on medical care, and have important social and economic implications, unless more effective preventive procedures or treatments become available. Alzheimer's disease (AD) is the most common cause of dementia, accounting for approximately 50-75% of all dementias worldwide, followed by vascular dementia, mixed dementia, and Lewy body dementia. Currently, acetylcholinesterase (AChE) inhibitors, such as donepezil, rivastigmine and galantamine are used to treat mild to moderate AD. An alternative therapy for severe AD is memantine, an antagonist of the NMDA-subtype of glutamate receptors. However, these drugs provide only temporary symptom improvement, and do not alter disease progression, except temporarily in some patients. In recent years different approaches have been developed to provide a more effective treatment for AD. These approached include the discovery of emerging targets and new drugs aiming at a single target, but given the complexity of the disease, different targets may need to be engaged simultaneously. New strategies have explored bitopic inhibitors, for example a single drug that acts on different sites of the acetylcholinesterase enzyme to produce at least two different activities, and multitarget drugs that act on multiple therapeutic targets. In this review, we explore the journey from a bitopic inhibitor strategy to multitarget drugs for the future treatment of AD.