Nir Barzilai M.D.Professor of Medicine and GeneticsDirector: Institute for Aging ResearchPI :The Glenn Center for the Biology of Human Aging;The Nathan Shock Centerof Excellence in the Biology of Aging

Albert Einstein College of Medicine

The Biology of Superagers

International workshop on HIV & Aging

What are we afraid of?

2

10000

1000

100

10

1

0

100000

Dea

ths

per 1

00,0

00 p

er y

ear

Heart diseaseCancerStrokeEmphysemaPneumoniaDiabetesAccidentsKidney diseaseAlzheimer’s

Aging itself is the strongest risk factor for all age related diseases

(The Milbank Quarterly, Vol. 80, No. 1, 2002 from 1997 U.S. Vital Statistics)

Genetics and environment of the individual determine which disease occurs first 3

What is the evidence for success in the goal of delaying aging?

• Healthy lifespan has been extended in numerous animal models.

• Relevant drugs have been used in humans. (Metformin, Rapamycin….)

Longevity

4

Age (Days

Surv

ival

Rapamycin extends lifespan in a dose-dependent fashion

98

95

92

Cover of PLoS Biology April 2006Atzmon G, Rincon M, Schechter C, Shuldiner An, Lipton R, Bergman A, Barzilai N: Lipoprotein Genotype and Conserved Pathway for Exceptional Longevity in Humans. PLoS Biol2006 Apr;4(4):e113

~1920Meet the Kahn’s

What do they have?

~90 years later

Genetics of human longevityCan a study design depict the challenges of genetics of aging?

• Only ~1/10,000 individuals is 100 years old(n~620; 95-112; LGP, LonGenity n~3,000)• A homogenous population of Ashkenazi Jews (AJs)• There is a remarkable family history of exceptional longevity in

parents, siblings and offspring of “centenarians”

• Hypothesis: 1) Perfect genome/environment2) Protective genes to assure human’s longevity

Ismail K, Nussbaum L, Sebastiani P, Andersen S, Perls T, Barzilai N, Milman S. J Am GeriatrSoc 2016; 64(8):1583-91

Individuals with exceptional longevity manifest delayed onset of age-associated diseases

Diseases include: Cancer, Cardiovascular disease, Diabetes mellitus, Hypertension , Dementia, Osteoporosis

0

10,000

20,000

60-70 Yo >100 Yo

9

CDC: Medical cost ($) during the last 2 years of life (1993)

Centenarians interaction with the environment(n=477, 75% females)

•Over weight/obese: 48% 44%•Smoking: 60% 30%•Alcohol (daily): 24% 12%•Physical activity: 43% 47%(Moderate: regular walking, bicycling, housework)•Vegetarians: 2.6%

NHANES1Men Women

CentenariansMen Women

•55% 41%•75% 26%•22% 11%•57% 44%

Swapnil Rajpathak and Jill Crandall

‘Environmental’risk

J Am Geriatr Soc. 2011 Aug 3

• Parkinson- 2 mutations in L444P (GAB)• AD-APOE4, UBQLN2 (also ALS)• Other degenerative- SEMA4A, RP1, FZD4, MYO1A, CYP1B1, VSX1, WDR36 • Neoplastic-APC, BRCA1, RET, RNASEL, and STK11• Cardiac (dominant)-ABCC9, ACTN2, ANK2, CACNA1C, JPH2, KCNE2, MYL2, and

TMEM43 • Other dominant- 18 variants for autosomal-dominant diseases and 6 mutations for X-

Chromosomal diseases • Other recessive- 72 variants for recessive traits include four variants that have least

one homozygous• Similar prevalence of common SNPs for age-related disease

Do centenarians simply have perfect genome?WGS of 44 AJs centenarians:

ClinVar database ~15,000 pathogenic variants A total of 227 autosomal and seven X-chromosomal coding SNVs.

Freudenberg-Hua Y et al. Mol Genet Genomic Med. 2014 Sep;2(5):438-12

Frequency trends of favorable longevity Genotypes/Allele (All validted or have phenotype/function)

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5

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15

20

25

30

55-64 64-74 75-84 85-94 95-104

Favo

rabl

e ge

noty

pe/A

llele

(%)

Age

•Lower plasma APOC3 levels•Favorable lipid profile

•High adiponectin levels•Favorable lipid profile•HOMA

•High TSH levels•Offspring

•Lower plasma CETP levels•Associated with high HDL, large lipoprotein sizes•Protects from diabetes and CVD•Validated

Effects of Anacetrapib in Patients with Atherosclerotic Vascular Disease

© N Eng J Med 2017

Diminished GH/IGF-1 action improves longevity across nature

Ghr-/-, lit/lit, GHA, Wt, bGH

Ponies live longer than thoroughbreds

Small dogs live longer than large dogs

IGF-1R+/-females, but not males, live longer

Longer lifespan in daf-2 mutants Longevity

Adjusted Odds Ratio

Breast cancer (pre-menopausal)

0.1 1 2

Higher IGF-1 and risk of cancer:prospective observational studies

Renehan et al. Lancet 2004

Lung cancer Chen et al. J Exp Clin Can Res 2009

Rinaldi et al. Int J Cancer 2010 Colorectal cancer

Rowlands et al. Int J Cancer 2009 Prostate cancer

Cao et al. Int J Cancer 2015 Prostate cancer

Lung cancer Cao et al. PLoSOne 2012

The Endogenous Hormones and Breast Cancer Collaborative Group, Lancet Oncology 2010

Renehan et al. Lancet 2004 Prostate cancer

Van Bunderen et al. JCEM 2010 All non-fatal cancer

Breast cancer

Adjusted Hazard Ratio

Cancer mortality

0.1 1 2

All-cause mortality

Higher IGF-1 and risk of mortality

Saydah et al. Am J Epidemiol 2007(NHANES III)Van Bunderen et al. JCEM 2010 (LASA)

Kaplan et al. JCEM 2007Svensson et al. JCEM 2012 (M) CVD mortality

Burgers et al. JCEM 2011Svensson et al. JCEM 2012 (Mr-OS Sweden)

Saydah et al. Am J Epidemiol 2007Van Bunderen et al. JCEM 2010Burgers et al. JCEM 2011

Saydah et al. Am J Epidemiol 2007Burgers et al. JCEM 2011Svensson et al. JCEM 2012 (Mr-OS Sweden)

Kaplan et al. JCEM 2017 (CHS)

: SNPs in centenarians

: SNPs related to IR and growth retardation

L1 L2CR

31 1367

IGF1R domain structure and coding variants

Tyrosine protein kinase

transmembraneFibronectin , type III

Furin -like cysteine rich

EGF recept Lsignal peptide Tyrosine protein kinase

transmembraneFibronectin , type III

Furin -like cysteine rich

Ligand bindingsignal peptide

Genotyping IGF1R Mutations in the full groups (n=700) revealed 9 centenarians vs. 1 control (~2%) harbor nonsynonymous mutations (p<0.02) and carriers have higher IGF-I ((p<0.04) and tend to be shorter

Suh, et al. Proc Natl Acad Sci U S A. 2008 105(9):3438-42.

Yousin Suh, PhD

A. AJ (female and male of control and centenarian),

B. Older Order Amish males.

C. French Caucasian males,

D. white male of the CHS study

Prevalence of d3-GHR homozygotes with age groups

Sci Adv. 2017 Jun 16;3(6):e1602025

Kaplan-Maier survival curves between d3-GHR in dominant model(Wild Type (WT) vs. homozygote +heterozygotedeletion d3-GHR).

WT

WT

Proliferation

Functional studies on transformed lymphocytes of d3-GHR homozygotes

Activation

d3-GHR homozygotes were 1 inch taller and had lower IGF-1 levels.

Milman et al. Aging Cell 2014

Number of survivors is 2x greater

Groups defined based on the median IGF-1 level of 96 ng/mL

Role of IGF-1 in survival in individuals with exceptional longevity

Low IGF-1 is associated with better cognition in females with exceptional longevity

Perice L, Barzilai N, Verghese J, Weiss EF, Holtzer R, Cohen P, Milman S. Aging (Albany NY) 2016

p<0.01

Females Males

Adjusted odds of cognitive impairment in females

Model OR (95% CI)IGF-1 Tertile 1 vs. 2 & 3

p-value

Adjusted for age 0.39 (0.19-0.83) 0.01

Adjusted for age, DM, HTN, CVD, cancer

0.42 (0.19-0.97) 0.04

Adjusted for age, depression, education, tobacco use, alcohol use, IGFBP-3

0.24 (0.06-0.98) 0.047

Perice L, Barzilai N, Verghese J, Weiss EF, Holtzer R, Cohen P, Milman S. Aging (Albany NY) 2016

Muscle Mass and Function

Skeletal muscle mass and functional assessment IGF-I Tertile 1 IGF-I Tertiles 2 and 3 p-value

Females

Sarcopenia (n=72), % 18.2 28.0 0.56

Failed chair rise test (n=51), % 81.0 80.0 0.93

Weak grip strength (n=52), % 50.0 43.3 0.63

Slow gait (n=40), % 47.1 52.2 0.75

Males

Sarcopenia (n=15), % 21.4 11.5 0.65

Failed chair rise test (n=24), % 75.0 54.6 0.60

Weak grip strength (n=24), % 66.7 33.3 0.21

Slow gait (n=19), % 57.1 33.3 0.38

Perice L, Barzilai N, Verghese J, Weiss EF, Holtzer R, Cohen P, Milman S. Aging (Albany NY) 2016

What can we do about it?

Survival to 24mo with IGF-1R mAb treatment

Control + IP Saline

IP IGF-1R Antibody

CB6F1 FemalesControl + IP

SalineIP IGF-1R Antibody

CB6F1 Males

Age (months)80 85 90 95 100

Perc

ent S

urvi

val (

%)

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50

60

70

80

90

100

Control MalesmAb Males

Age (months)18 19 20 21 22 23 24

Perc

ent S

urvi

val (

%)

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50

60

70

80

90

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Control FemalesmAb Females

P=0.88 P=0.14

IGF-1 receptor antibody delays agingin a sex specific manner

How do we move to humans?

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Why TAME?

• (Proof of concept) To show that multiple morbidities of aging can be targeted by metformin• (FDA regulation) To obtain a new indication for the delay of age-related morbidities.•(Template for pharmaceuticals) To provide a paradigm for studying next-generation drugs targeting multiple morbidities of aging•(Shake the neutra-cuiticals…) To apply the discoveries of geroscience as powerful new tools for achieving primary prevention of multiple diseases

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Summary•Genomic studies in centenarians suggest severalmechanisms for exceptional longevity.•Consider determining protective/resiliencemechanisms that are protecting from age-relateddiseases.•GH/IGF-1 pathway seems relevant to humanslongevity.•There are strategies with translational potential usingtools already in clinical use (TAME, IGF-1R)•Every thing above is probably true for managing HIVand aging

Glucose homeostasiswith aging

Derek Huffman Ph.DGil Atzmon Ph.D.Yousin Suh Ph.d (lab)Sofiya Milman MDHassy Cohen MD (USC)Hongqian Liang Ph.DKai Mao Ph.DPasha Aponets Ph.DMarielisa Rincon MD

Other CollaboratorsJim Kirkalnd (Mayo Clinic)Dan Promislow (U Wash.)Anne L.S. Chang (Stanford)Amir Lerman (Mayo Clinic)Tom Pearls (BU)Paola Sabastiani (BU)Sree Nair (Mayo Clinic)John Greally MD PhD (Einstein)Alan Shuldiner M.D. (UMD)Francis Collins MD (NIH)Gad Rennert (Technion)Sigal Fishman MD (Tel Aviv)Norman Fleischer M.D (Einstein)Harry Shamoon M.D. (Einstein)Alan Permutt MD (WashU)Karl skorecki MD (Technion)Diddahally Govindaraju (BU)Ben Glazer MD (Hadassah)Zohar Nir PhD (Negev)Josephe Attardi Ph.D. (Cal Tech)Cynthia Kenyon PhDAnn Brunett PhD

Support: AFAR, NIH:E-NSC, R01, P01 (genes), P01 (metabolic), K08, Ellison Medical Foundation, LWPES, DRTC, Glenn Foundation, Aviva and Sammy Ofer

LGP/LonGenity :Gil Atzmon Ph.D.Yousin Suh Phd (lab)Sofiya Milman MDBill Greiner R.N. Jill Crandall MD Hassy Cohen MD (USC)Richard Lipton M.D (EAS)Joe Verghese MDRoee Holtzer PhDTina GaoWanda Guzman (Res. Coord.)Erica WeissLeah SuttonKhadija Isamil MSJenny Deluty MSVafa Tabatabaie MDKenny Ye PhD

Thanks you!

AMPK

PI3K

Akt

ACC

AMP

p66shc

IRS-1IRS-2

Metformin

Rapamycin

Ras

Protein SynthesisAutophagyStress DefenseInflammation

Erk1/2

Healthspan andLongevity

Resveratrol

NAD+

NADH

Cellular Survival

CytokineReceptor

ATP

SIRT1 mTOR

ATG13 p70S6K

4EBP1

Bax p53 FOXO

1

2

3

NF-kB

AdiponectinReceptorINSR IGF-1R

PAI-1TNFaIL-6 Adiponectin

Insulin

Metformin

IGF-1

Oxidative stressSenolytic

Metformin as a tool to target multiple pathways of aging

Barzilai N et al Metformin as a Tool to Target Aging. Cell Metab. 2016 Jun 14;23(6):1060 32

Metformin is generic, cheap and safe (no one gets hurt!)

• Biology of Aging: Metformin has age-delaying effects on nematodes and mice.

• Intervention in non-type 2 diabetes mellitus (T2DM): Metformin delays T2DM (DPP).

• Intervention: Metformin delays CVD (UKPDS) in T2DM.

• Association: Metformin is associated with less cancer in patients with T2DM.

• Early support exists that metformin may delay cognitive decline and AD, even in noon-T2DM.

• Phase 4: lower mortality in patients with T2DM on metformin compared with non-diabetics.

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TAME: Targeting Aging with MEtformin

Cancer site SRR (95%CI) Number of studies

Breast 0.88 (0.75-1.03) 13

Colon 0.80 (0.64-1.00) 12

Prostate 1.06 (0.80-1.41) 12

Pancreas 0.75 (0.49-1.15) 11

Liver 0.47 (0.28-0.79) 9

Lung 0.82 (0.67-0.99) 5

Summary risk estimates for specific cancer types

Gandini, et al. Cancer Prev Res 2014;7:867-8534

Metformin was associated with reduced mortality in T2DM compared with non-diabetics

Bannister et al., Diabetes, Obesity and Metabolism 2014 35

St Sauver JL et al. Risk of developing multimorbidity across all ages in a historical cohort study. BMJ Open 2015; 5:e006413

Multi-morbidity Incidence: Rochester Epidemiology Project

On Metformin

TAME

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How are we going to achieve TAME goals?

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Age 65-80 and Gait Speed <1m/sec

Time to occurrence of composite of major age-related disease:MI, stroke, CHF, cancer, MCI/dementia, or death.

InclusionCriteria

Primary outcome

Double blind placebo-controlled trial

TAME Study Design

n=3000

*Courtesy of Tamara Harris

Health ABC event rates for chronic conditions grouped by history

Projected Event Rates -ABC

9.3%/yrAccumulation rate

Courtesy of Mike Miller

Age 65-80 and Gait Speed <1m/secInclusionCriteria

Double blind placebo-controlled trial

TAME Study Design

n=3000

PrimaryOutcome

SecondaryOutcome

TertiaryOutcomes

Time to occurrence of composite of major age-related disease:MI, stroke, CHF, cancer, MCI/dementia, or death.

Time to occurrence of composite functional outcome: Major decline in mobility or cognitive function, onset of severe ADL limitation or death.Supporting analyses: Continuous measures of physical performance, cognitive performance, and quality of life.

Rate of accumulation of 15 age-related chronic conditions:* To provide convergent evidence of broad age-related effects. Supporting analyses: Effects on common acute health conditions (fractures, pneumonia), and geriatric syndromes (frailty, anemia, falls and fall injuries).

*Primary outcome + cardiac arrhythmia, chronic kidney disease, chronic obstructive pulmonary disease, T2DM, depression, hypertension, osteoarthritis, osteoporosis, and surgical treatment of peripheral artery disease.

TAME sites, site directors and relevant experience Site PI Relevant NIH studies

Johns Hopkins Jessica Yeh, Larry Appel PREMIER, TONE, DASH, DPPOS

U Alabama Beth Lewis ACCORD, Look AHEAD, SPRINT

Albert Einstein Jill Crandall, Nir Barzilai DPPOS, GRADE, T-Trial

Northwestern Mary McDermott LIFE, ENRGISE, PROPEL, BRAVO

U Connecticut George Kuchel MOBILIZE, SAES

U Florida Marco Pahor, Steve Anton T-Trial, LIFE, WISE, ALLHAT

U Tennessee Karen Johnson SPRINT, Look AHEAD, WHI

U Miami Hermes Florez, Ana Palacio DPPOS, GRADE

U Minnesota Karen Margolis ACCORD, ASPREE, WHI, WISE

Yale University Thomas Gill T-Trial, LIFE, SILVER-AMI

U Pittsburgh Anne Newman, Jane Cauley WHI, T-Trial, LIFE, SWAN

Brown University Rena Wing, Charles Eaton Look AHEAD, DPP, WHI, SNAP

MedStar Vanita Aroda DPPOS, GRADE, D2d

Wake Forest(Admin/DCC)

Steve Kritchevsky, Mark Espeland Look AHEAD, ACCORD, WHI,TONE, PEPI, ACAPS, PLAC-2

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• To prove that aging can be targeted• To change health-span of individuals• To lead to development of better drugs

and their combination. • To effect healthcare system and its costs

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TAME has a potential:

• Steve Austad• Caroline Blaum• Morgan Canon• Harvey Cohen• Eileen Crimmins• Richard Faragher• Jon Gelfond• Jamie Justice• Tamara Harris• George Kuchel• Brian Kennedy

• Jim Kirkland• Sofiya Milman• Anne Newman• John Newman• Michael Pollak• Walter Rocca• Felipe Sierra• Stephanie Studenski• Ella Temprosa• Joe Verghese• Jeannie Wei

Contributed to development •Luigi Ferucci•Marcel Salive•Jay Olshansky•David Sinclair•Rafa deCabo•Stephanie Lederman•Evan Hadley•Chhanda Dutta•Mark Collins

44Efforts so far are sponsored by AFAR

Targeting Aging with MEtformin (TAME) Executive team: Kritchevsky, Crandall, Espeland, Barzilai

Hypothesis (Aging as mechanism for diseases):

Aging in humans can be targeted to delay many age-related diseases and other phenotypes of aging.

Metformin is currently the best tool to evaluate in this novel framework. Its generic (cheap), safe, and billions of years use.

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TAME: Targeting Aging with MEtformin

Power Projections: Composite Incidence of New Disease Family

TreatmentEffect

7.5%/year 8.5%/year 9%/year

22.5% 0.92 0.95 0.96

*Based on simulated actuarial tables, N=200,000

Adjusted Odds Ratio/Hazard Ratio

CHF

0.1 1 2

DM Type 2/IGT

Higher IGF-1 and risk of disease:prospective observational studies

Vasan et al. Ann Int Med 2003(Framingham Heart Study)

CVDAndreassen et al. Eur J of Endo 2009

Andreassen et al. Eur J of Endo 2009 CHF

Ricketts et al. Int J Mol Epidemiol Genet 2011(EPIC-Norfolk)

CAD

Osteoporotic fracturesYamaguchi et al. Calcif Tissue Int 2006

Green et al. J of Alzheimer’s Disease 2014 Dementia

Rajpathak et al. Diabetes 2012 (F)Sandhu et al. Lancet 2002