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10
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Carbohydrates and Carbohydrate-Based Therapeutics
in Alzheimer’s Disease
Ana M. Matos, João Barros and Amélia P. Rauter
Universidade de Lisboa, Centro de Química Estrutural, Institute of Molecular Sciences, Faculdade de Ciências,
Department of Chemistry and Biochemistry, Ed. C8, Piso 5, Campo Grande, Lisboa, 1749-016, Portugal
10.1 Introduction
Carbohydrates, the most abundant organic compounds in nature, play unique roles
in health and disease. The complex glycans displayed on the cell surface facing the
extracellular space are the key molecules for cell recognition and adhesion in signaling pathways and in cell–pathogen interactions[1, 2]. Carbohydrates also trigger
immune responses[3–5], and modulate key biological processes in neurodegeneration, namely those related to the O-GlcNAc modification (also known as
O-GlcNAcylation) of serine (Ser) and threonine (Thr) protein residues in the brain,
the dysregulation of which is associated with neurodegenerative diseases [6, 7].
Alzheimer’s disease (AD) is the most common one, affecting 60% of the over 50 million people with dementia in 2020, a number expected to double every two years,
reaching 82
sive disease, resulting from an irreversible degeneration of the brain that causes
cognitive impairment, dementia, and ultimately results in death, as no efficient
therapeutics are known to control the progression of this pathology. This protein
misfolding disease is associated with the formation of soluble Aβ1–42 toxic small
oligomers, derived from abnormal cleavage of β-amyloid precursor protein (APP).
Their aggregation leads to the formation of fibrils, which give rise to extracellular
deposits, the senile plaques[9]. Another AD neuropathological hallmark consists of
intracellular neurofibrillary tangles (NFTs) formation due to altered kinase and
phosphatase activities, leading to hyperphosphorylation of the Tau protein. This is
followed by the aggregation of hyperphosphorylated Tau into paired helical filaments and, finally, into NFTs. The aggregation events and associated aggregation
stress leads to cell apoptosis[9, 10] (Figure10.1).
million in 2030 and 152 million in 2050[8]. AD is a chronic and progres-
293
Carbohydrate-Based Therapeutics, First Edition. Edited by Roberto Adamo and Luigi Lay.
© 2024 WILEY-VCH GmbH. Published 2024 by WILEY-VCH GmbH.

10 Carbohydrates and Carbohydrate-Based Therapeutics in Alzheimer’s Disease
294
Healthy Neuron
Figure10.1 Healthy neuron vs. neuron after degeneration. Source: Adapted from
Demetrius etal.[9].
AD Neuron
Neurofibrillary tangles
(hyperphosphorylated tau)
Amyloid aggregates
Disease progression
Moreover, the cellular prion protein (PrPC), located in the neuronal cell surface,
is a high-affinity binding partner of Aβ oligomers (Aβos) and promotes the activation of Fyn kinase, triggering a cell signaling pathway that culminates in Tau
hyperphosphorylation[11]. Accordingly, Fyn activity increases in AD brain when
C
neurons are exposed to Aβo, via PrP
[12, 13]. Interestingly, prion protein misfolding also promotes prion amyloid formation. Its conformational transition from the
α-helix-rich cellular form into the mainly β-sheet containing counterpart initiates
an “autocatalytic” reaction that leads to the accumulation of amyloid fibrils
Sc
) in the central nervous system (CNS), leading to neurodegeneration. This
(PrP
amyloidogenic process is, among other factors, O-glycosyl dependent and can be
triggered or prevented by changing the sugar residue attached to Ser/Thr in the
PrP core[14].
AD epidemiological data, associated with its devastating nature, unsuccessful
treatment options, and high socio-economic impact are challenging for the
research of new therapeutics. In 2015, a review on carbohydrates and glycomimetics in AD diagnosis and therapeutics was published[15], covering molecules acting on Aβ amyloid events, namely glycosides containing terpenes, phenolics,
peptidomimetics, and metal-ion chelators, free and protected sugars, cyclitols and
glycosaminoglycans (GAGs). Carbohydrate-based molecules targeting the cholinergic system were also reviewed[16], namely the acetylcholinesterase (AChE) and
butyrrylcholinesterase (BChE) inhibitors, aiming to increase levels of the neurotransmitter acetylcholine (ACh) in the brain of AD patients. More recently, carbohydratepeptide conjugates were also reviewed as amyloidogenic aggregation
inhibitors[17].

In this chapter, we focus on the investigation carried out to uncover the role of
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carbohydrates in AD and approaches toward carbohydrate-based therapeutics.
Dysregulation of O-GlcNAcylation in intracellular proteins is associated with neurodegenerative diseases, including AD, for which O-GlcNAc cycling is considered a
therapeutic target against the formation of amyloid plaques and NFTs . Patients
with AD have O-GlcNAc levels 50% lower than normal individuals, and efforts
toward the discovery of efficient carbohydrate-based therapeutics to control these
levels by inhibition of the O-GlcNAc hydrolase enzyme, O-GlcNAcase (OGA), are
here reviewed. Synthesis and bioactivity of the most promising classes of inhibitors
are presented, namely carbohydrate-based thiazolines, 2-acetamido-2-deoxy-glucono-1,5-lactone O-(phenylcarbamoyl)oxime (PUGNAc), and GlcNAc statins.
The role of GalNAc in neurodegeneration is also revised herein, highlighting
reports that show the importance of GalNAc levels in APP to control Aβ production
and the significance of GalNAc residues in chondroitin sulfate proteoglycans (PGs)
that play a role in regulating the trophic microenvironment of neurons. Moreover,
GalNAc containing oligosaccharides and chitosan (CTS) oligosaccharides have neurodegenerative effects and are also covered in this chapter.
AD is a multifactorial disease, with the cholinergic system of AD patients being
severely affected and represent a therapeutic target. ACh is a major neurotransmitter in the brain and AD patients have low levels of ACh, emerging the inhibition of
cholinesterases (ChEs), enzymes that split ACh into choline and acetate, as a promising option to treat AD. The drugs rivastigmine, galantamine, and donepezil are
clinically in use and act as ChE inhibitors. However, they are not efficient to control
disease progression and have side effects, such as convulsions, severe nausea, stomach cramps, vomiting, irregular breathing, confusion, muscle cramps, and muscle
weakness, among others[18, 19]. New directions in anticholinesterase drug development are encouraging and the latest findings on carbohydrate-based ChE inhibitors are also covered.
Finally, our latest discoveries on carbohydrate-based inhibitors of Fyn kinase, Aβ
aggregation, Aβ and prion binding, and of the oxidative stress-induced neurotoxicity are also disclosed. This chapter ends by giving an overview about carbohydrate–
protein interactions as potential targets for AD drug discovery.
29510.2 O-GlcNAc Transferase (OGT) and O-GlcNAc Hydrolase (OGA) in Neurodegeneration
10.2 O-GlcNAc Transferase (OGT) and O-GlcNAc
Hydrolase (OGA) in Neurodegeneration
The modification of the hydroxy group of Ser and Thr residues to install an O-(2acetamido-β--glucopyranosyl, O-GlcNAc) functionality (a process termed
O-GlcNAcylation) is an essential mechanism that takes place in cell cycle and metabolic processes on nuclear, cytoplasmic, and mitochondrial proteins. It is achieved
enzymatically by O-GlcNAc transferase (OGT), which transfers O-GlcNAc from uri-
dine diphosphate (UDP)-GlcNAc donor to Ser and Thr residues, while the enzymatic hydrolysis to remove the glycan and unveil the free hydroxy group is carried
out by OGA (Figure10.2), a member of the glycoside hydrolase family 84(GH84)of

10 Carbohydrates and Carbohydrate-Based Therapeutics in Alzheimer’s Disease
296
Glucose
EXTRACELLULAR MEDIUM
CYTOPLASM
Hexosamine
biosynthesis pathway
HO O
GLUT
UDP
UDP-
GIcNAc
Protein Protein
(Ser/Thr)
OGT
OGA
Figure10.2 Illustration of O-GlcNAc modification of proteins via O-GlcNAc transferase
(OGT) and the hydrolase O-GlcNAcase (OGA).
the CAZy classification system[20]. The O-GlcNAc modification is particularly
abundant in the brain controlling a number of processes, including memory formation[21], and seems to be essential for the normal function of the mammalian nervous system [22–24]. Dysregulation of O-GlcNAcylation is associated with
neurodegenerative diseases. As the O-GlcNAcylation of proteins is regulated by the
intracellular glucose metabolism, which is reduced in the brain of AD patients, their
O-GlcNAc levels are nearly 50% lower than in control brains[25, 26].
The role of O-GlcNAcylation in neurodegeneration has been extensively
reviewed[6]. The expression and activities of OGT and OGA in the brain are agedependent and more than four thousand O-GlcNAc protein targets have been identified as playing critical roles in many cellular processes[6, 27]. In the mammalian
brain, O-GlcNAc modification of Tau, which is naturally O-GlcNAcylated [28],
decreases its phosphorylation and toxicity, suggesting a neuroprotective role of
brain O-GlcNAcylation for AD treatment[6].
10.2.1 O-GlcNAc Cycling as a Therapeutic Target Against
Alzheimer’s Amyloid Plaques and Neurofibrillary Tangles
Approximately 2–5% of all glucose entering the cell is channeled into the hexosamine biosynthetic pathway to generate UDP-GlcNAc [6] (Figure 10.2). Because

O-GlcNAcylation depends on the availability of UDP-GlcNAc, and in turn, intracel-
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lular UDP-GlcNAc level determines OGT activity, O-GlcNAcylation is considered a
valuable intracellular sensor of glucose metabolism that can be directly regulated in
a glucose-responsive manner[29].
Positron Emission Tomography (PET) studies [30], supported by experiments
with transgenic mice[31, 32] have shown that brain glucose metabolism declines
with age and is more impaired in AD patients. Glucose metabolism impairment
may lead to lower UDP-GlcNAc levels and consequently lower O-GlcNAcylation,
resulting in impaired GlcNAc cycling. But how does O-GlcNAcylation affect the
main pathological hallmarks of AD, i.e. formation of extracellular Aβ amyloid
plaques and intracellular NFT that is accompanied by synaptic loss and dementia?
The APP is an O-GlcNAc-modified protein processed by three different proteases,
namely the α-, the β-, and the γ-secretase. APP cleavage by α-secretase in the extracellular domain is non-amyloidogenic, generating a soluble fragment sAPPα and a
membrane-bound C-terminal fragment (APP-CTFα) (Figure 10.3). The latter is
cleaved by γ-secretase in the transmembrane region to afford the non- amyloidogenic
fragment p3 and the β-amyloid precursor protein intracellular domain (AICD). APP
β-secretase (BACE1) cleavage generates the soluble sAPPβ fragment and the
membrane-bound fragment APP-CTFβ, which is also cleaved by γ-secretase generating amyloid-β peptide monomers (Aβ1–40 and Aβ1–42), together with the
AICD[6, 33]. This abnormal cleavage of APP is an important event leading to the
overproduction and aggregation of Aβ species. Approximately, 90% of all Aβ fragments generated are Aβ1–40 and a smaller fraction corresponds to the toxic amyloidogenic, Aβ1–42, observed in amyloid plaques in the brain. Therefore, among the
29710.2 O-GlcNAc Transferase (OGT) and O-GlcNAc Hydrolase (OGA) in Neurodegeneration
O
γ-Secretase
p3
AICD
Non-amyloidogenic processing
sAPPα
CTFα
UDP
UDP-GIcNAc
α-Secretase
OGT
O-GlcNAcylation
O
APP
sAPPβ
BACE-1
CTFβ
Amyloidogenic processing
Aβ Monomers
γ-Secretase
EXTRACELLULAR
AICD
Figure10.3 Illustration of amyloidogenic and non-amyloidogenic cleavage of APP.
Source: Adapted from Wani etal.[6].
MEDIUM
CYTOPLASM

10 Carbohydrates and Carbohydrate-Based Therapeutics in Alzheimer’s Disease
COOH
HO
R
GIcNAcstatin
Streptozotocin
298
products generated by the amyloidogenic (initially cleaved by the BACE1) and nonamyloidogenic (initially cleaved by α-secretase) pathways, only the amyloidogenic
products are thought to lead to AD pathology[34].
Interestingly, it was demonstrated that by increasing O-GlcNAcylation, either
through pharmacological or genetic interventions, processing by α-secretase is also
increased, resulting in enhanced neuroprotective sAPPα levels and decreased Aβ
formation. In addition, hyper O-GlcNAcylation, produced in a 5XFAD Aβ mouse
model treated with the OGA inhibitor 1,2-dideoxy-2′-propyl-α--glucopyranoso-
2
[2,1-d]-Δ
′-thiazoline (NButGT Figure10.4), decreased Aβ1–40 and Aβ1–42levels,
reduced Aβ plaque formation, and improved cognition[26]. These findings suggest
that O-GlcNAc cycling is indeed a target for the identification of therapeutics for AD.
After the discovery that human brain Tau is O-GlcNAcylated, scientists have
focused on finding a link with neurodegeneration, as Tau hyperphosphorylation
leads to the formation of NFT [28]. Hence, the relationship between protein
O-GlcNAcylation and phosphorylation is key for the investigation of the molecular
mechanism leading to brain tauopathies, including AD[35]. Liu etal.[36] found
that decreased O-GlcNAc levels and increased Tau phosphorylation occur in mice
brain obtained from mice sacrificed after injection into the left ventricle of the brain
of 6-diazo-5-oxonorleucine (DON), an inhibitor of glutamine:fructose-6-P, the ratelimiting enzyme of hexosamine biosynthesis pathway. The analysis of human brain
HO
HO
HO
HO
OH
O
S
HO
OH
OH
N
CH
2CH2CH3
NButGT
O
N
O
N
NHAc NHAc
PUGNAc
N
NHCOCH(CH
H
N
O
3)2
R
2
HO
Thiamet-G R
MK 8719 R
HO
HO
Figure10.4 Structure of selected OGA inhibitors.
HO
OH
HO
Nagstatin
OH
HO
1
O
N
= OH, R2 = H
1
1
N
O
NHCON
S
2
N
OH
N
H
CH
3
N
O

10.2 O-GlcNAc Transferase (OGT) and O-GlcNAc Hydrolase (OGA) in Neurodegeneration
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tissue showed that hyperphosphorylated Tau has up to four-fold lower O-GlcNAc
levels. Interestingly, the reduction of protein O-GlcNAcylation in AD and other
Tau-driven pathologies seems to vary in brain regions, as reported by Frenkel–Pinter
etal.[37]. They found an increase in O-GlcNAcylation in the hippocampus of AD
patients, suggesting that this complex disorder involves lesions in various brain
regions, which should be separately investigated for a comprehensive study of AD
etiology. Nonetheless, the research carried out so far supports that targeting
O-GlcNAcylation represents one of the most promising therapeutic opportunities to
control AD neurodegeneration by decreasing Tau hyperphosphorylation and by
recovering brain dysmetabolism, leading to reduced brain damage and improved
cognition[29].
10.2.2 OGA Inhibitors
The structure of some of the most studied OGA inhibitors is depicted in Figure10.4.
These carbohydrate-based compounds contain either a thiazoline ring, such as
NButGT, Thiamet-G, and MK8719, or an imidazole ring fused to the carbohydrate
moiety as GlcNAcstatins, which structure was inspired by that of nagstatin.
PUGNAc, one of the first OGA inhibitors discovered, shows a different structure as
the sugar is linked to a carbamate functionality. Around 2000, PUGNAc and streptozotocin (STZ) were used to increase cellular O-GlcNAc levels for the study of
related cellular processes, but STZ is a poor OGA inhibitor and is highly toxic to
pancreatic β-cells, being used to induce type 1 diabetes in animals[38].
Human O-GlcNAcase (hOGA) is expressed in two isoforms. The larger variant
OGA, localized in the nucleus and cytosol, is more active than the other isoform,
expressed only during embryo formation[27]. The crucial role of OGA for maintaining or decreasing O-GlcNAc levels in the brain is, indeed, key for brain neurodegeneration, encouraging the development of OGA inhibitors. In 2005, Vocadlo and
coworkers were able to elucidate, for the first time, the catalytic mechanism of
hOGA[39]. They described a two-step mechanism involving the nucleophilic participation of the 2-acetamido group, with the formation of an oxazole or oxazolinium intermediate. Later on, in 2016, Vocadlo’s group, supported by the experimental
work carried out with thiazoline inhibitors (see Section10.2.2.3), proposed that the
intermediate is an oxazoline rather than an oxazolinium ion (Figure10.5a)[40]. A
molecule of water attacks the anomeric center of the intermediate, breaking the
oxazole ring and leading to the hemiacetal with retention of configuration. In 2017,
the crystal structures of hOGA and its substrates were determined[41], providing
important information for further investigation of the mechanism of hOGA.
Recently, Xiong and Xu confirmed the existence of the oxazoline intermediate by
studying the whole catalytic process with hOGA using a Quantum Mechanics/
Molecular Mechanics approach[42]. Based on the calculated free energy profiles,
they showed that the intramolecular cyclization by the 2-acetamido group leading
to an intermediate bicyclic oxazolinium ion (I1) is the rate-limiting step, and their
simulations further suggest the formation of the oxazoline ring intermediate I2,
299

(a)
(b)
10 Carbohydrates and Carbohydrate-Based Therapeutics in Alzheimer’s Disease
300
Figure10.5 Mechanism for hOGA inhibition. (a) Mechanism proposed by Macauley
etal.[39] and Cekic etal.[40] (b) Energy profiles (Kcal mol
(2020)[41] for the formation of the oxazoline intermediate by proton transfer of the
oxazolinium intermediate to the residue D
as deduced by computational simulations.
174
−1
) adapted from Xiong and Xu
resulting from proton transfer from the 2-acetamido group to residue D174
(Figure 10.5b). A relatively small barrier was found to connect EI1 and EI2
1
(5.43 kcal mol
in SCC-DFTB/MM and 1.93 kcal mol1 in DFT calculations), which
might contribute to accelerating the overall reaction rate.
The authors also made mutagenesis simulations of D174A and D175A, which
indicate that these catalytic residues mainly affect the observed reaction rate by
affecting the stability of the intermediate[42]. These results seem to be in full agreement with the experimental results of Vocadlo’s group, who developed aminothiazoline inhibitors (see Section 10.2.2.3). Their potency is strongly pK
-dependent,
a
leading to picomolar binding. The authors described them as genuine transition
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