Intranasal Glulisine in Amnestic Mild Cognitive Impairment and Probable Mild Alzheimer's Disease

Disruption of central nervous system (CNS) insulin signaling has been increasingly associated
with Alzheimer's Disease pathogenesis, and consequently this disease has been referred to as
a type III diabetes of the brain. Clinical trials of intranasal insulin in AD have
demonstrated therapeutic effects of intranasal (IN) insulin in memory-impaired adults in
terms of memory recall without significantly altering serum insulin or glucose levels. In
this study, the investigators are investigating the chronic effects of the rapid acting
insulin, glulisine, administered intranasally (IN) 20 IU two times daily in adults with
amnestic-mild cognitive impairment (a-MCI) and mild Alzheimer's disease (AD). The
investigation will enroll n=90 subjects and follow them over a 6 month period.

This study has the following objectives:

1. Primary:

a. To measure the chronic effects of IN insulin glulisine on cognition and function in
subjects with aMCI and probable mild AD over a 6 month period.

2. Secondary:

1. To measure the effect of IN insulin glulisine on mood in subjects with aMCI and
mild AD over a 6 month period.

2. To measure the safety and efficacy of IN glulisine in aMCI and mild AD subjects
with non-insulin dependent diabetes over a 6 month period.

3. Exploratory:

1. To measure the effect of IN delivery of insulin glulisine on parieto-temporal and
posterior cingulate/precuneus glucose metabolism in subjects with aMCI and mild AD
over a 6 month period.

2. To measure the chronic effect of IN delivery of insulin glulisine on AD-specific
cerebrospinal (CSF) biomarkers (Abeta42, tau, and phospho-tau) in subjects with
aMCI and mild AD over a 6 month period.

Inclusion Criteria:

Subject is/has

- clinical and research diagnosis of amnestic-MCI OR probable mild AD in accordance with
National Institute of Neurological and Communicative Disorders and Stroke and the
Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) criteria

- Montreal Cognitive Assessment (MoCA) score 18-27

- Hachinski Ischemia Score <4

- 50-90 years of age

- Females at least 2 years post-menopausal or surgically sterile

- Proficiency in speaking, reading and understanding English

- Dedicated family member /caregiver, who will be able to attend all visits and report
on subject's status

- (and family member/caregiver) provided fully informed written consent prior to
participation. In the event that subject is legally unable to provide informed written
consent due to deterioration in cognitive abilities, fully informed written consent
must be provided by a legally authorized representative

- If AD, a brain computed tomography (CT) or magnetic resonance imaging (MRI) in the
initial diagnostic workup or subsequent care that is compatible with the diagnosis of
probable AD

Exclusion Criteria:

Subject has/have/is

- medical history and/or clinically determined evidence of other central nervous system
(CNS) disorders including, but not limited to brain tumor, active subdural hematoma,
seizure disorder, multiple sclerosis, dementia with Lewy bodies, vascular dementia,
corticobasal syndrome, progressive supranuclear palsy, Parkinson's disease, multiple
system atrophy, frontotemporal dementia, normal pressure hydrocephalus, Huntington's
disease, or Jakob-Creutzfeldt disease presenting as dementia

- medical history and/or clinically determined disorders: current B12 deficiency,
chronic sinusitis, any untreated thyroid disease, significant head trauma and history
of difficulty with smell and/or taste prior to AD diagnosis

- history of any of the following: moderate to severe pulmonary disease, poorly
controlled congestive heart failure, significant cardiovascular and/or cerebrovascular
events within previous 6 months, condition known to affect absorption, distribution,
metabolism, or excretion of drugs such as any hepatic, renal or gastrointestinal
disease or any other clinically relevant abnormality that inclusion would pose a
safety risk to the subject as determined by investigator

- previous nasal and/or oto-pharyngeal surgery and severe deviated septum and/or other
anomalies

- history of any psychiatric illness, with the exception of major depressive and anxiety
disorder (according to Diagnostic and Statistical Manual of Mental Disorders, version
5, Text Revision (DSM-IV TR)) currently in remission or stable with treatment for > 2
yrs, or any other psychiatric condition that inclusion would pose a safety risk to the
subject as determined by investigator

- currently taking any medications, herbals and food supplements that are
medically/clinically contraindicated as determined by investigator in order to comply
with procedural testing of cognitive function as well as ensure study safety. See list
of prohibited medications and compounds

- undergone a recent change (<1mo) in their prescribed acetylcholinesterase inhibitor
(e.g. donepezil, rivastigmine, galantamine) or memantine.

- undergone a recent change (<1mo) in their selective serotonin re-uptake inhibitor
(SSRI) or anti-depressant medication

- current or recent drug or alcohol abuse or dependence as defined by DSM-IV TR

- laboratory results that are medically relevant, in which inclusion would pose a safety
risk to the subject as determined by investigator

- participated in any other research study at least 3 mos prior to this study

- an insulin allergy