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1 THELANCETNEUROLOGY-D Supplementary online data MRI assessments MRI at each site included a volumetric spoiled gradient echo (T1-weighted) sequence with slice partition thickness of 1 5 mm or less with an in-plane resolution of approximately 1 mm ( in plane) in each plane direction (eg, slices with 256x256 matrix with a field of view of the order of 24 cm x 24 cm). Each scan was assessed for motion artefact and quality of acquisition within 1 week of the scan, so that patients could be re-scanned if necessary. Digital MRI datasets were analysed centrally, blind to all patients details. Hippocampal volumes were determined by region growing with histogram constraints in the sagittal projection with manual editing accomplished in the sagittal and coronal projections. 1 Global brain volumes were accomplished using the methods described by Van Leemput et al. 2,3 Ventricular volumes were measured using manual outlining. 4 Rates of global brain atrophy were measured from registered image analysis using the boundary shift integral. 5 MRI reproducibility was examined using geometrical phantoms with anatomic detail (both are geometrical phantoms). In addition at least one normal individual was scanned in each site to assess overall scan quality. Repeat phantom scanning was assessed at least monthly to correct any scanner drift. Flow of patients through the study Figure S1 shows the tests carried out at each visit. Study endpoint was the last point in time at which outcome assessments were made (except for time to diagnosis of AD). Figure S1: Tests done at each visit
2 Results of cognitive Z-score analysis Table S1 shows the results of the individual tests that made up the cognitive Z-score battery for the whole study population (MITT). No significant treatment differences were seen except for verbal fluency categories in favour of placebo. Between-group difference [mean (95% CI)] Delayed Word List Recall 0 22 ( 0 49 to 0 05) NYU Paragraph Recall Test Immediate 0 14 ( 0 14 to 0 41) NYU Paragraph Recall Test Delayed 0 01 ( 0 30 to 0 28) Letter-Number Sequencing 0 05 ( 0 21 to 0 31) Buschke Selective Reminding Test (total free and cued recall) 0 03 ( 1 08 to 1 02) Symbol Digits Modalities Task (number correct) 0 62 ( 1 53 to 0 30) Digit Cancellation Task (times reminded) 0 14 ( 0 39 to 0 10) Maze (time to completion) 1 82 ( 2 04 to 5 68) Verbal Fluency Categories 0 72* ( 1 29 to 0 15) Clock Drawing 0 01 ( 0 12 to 0 14) Total Z-score 0 10 ( 0 63 to 0 44) Between-treatment differences are the difference in the change from baseline between groups. These were calculated using Least Square Means from ANCOVA. For all outcome measures, change from baseline was calculated such that positive change values indicate improvements. *p=0 014, rivastigmine versus placebo from ANCOVA. Following Bonferroni correction for multiple comparisons differences was not significant. All other between-treatment differences were not significant. Table S1: Changes from baseline on the Z-score of cognitive function using a battery of 10 cognitive tests (MITT population)
3 Results of other secondary outcome measures Table S2 shows the change from baseline at months 12, 24, 36, and 48 and study endpoint on the other secondary outcome measures for the whole study population (MITT). No significant treatment differences were seen at any of these timepoints on any of these outcome measures. 12 months 24 months 36 months 48 months Endpoint ADAS-cog Rivastigmine 0 4 (4 1) 1 2 (5 7) 2 4 (7 7) 2 7 (8 4) 1 8 (6 4) Placebo 0 3 (4 9) 1 5 (6 1) 2 6 (8 0) 3 1 (9 1) 1 8 (6 6) MMSE Rivastigmine 0 4 (2 3) 0 9 (2 9) 1 4 (3 8) 1 7 (4 2) 1 3 (3 3) Placebo 0 5 (2 6) 1 1 (3 2) 1 6 (4 0) 1 9 (4 4) 1 4 (3 6) NPI-12 Rivastigmine 0 8 (6 4) 1 5 (8 0) 2 1 (8 2) 2 2 (8 4) 2 0 (7 6) Placebo 0 6 (4 8) 1 2 (6 6) 1 9 (7 7) 2 0 (7 6) 1 7 (7 1) BDI Rivastigmine 0 1 (4 9) 0 3 (5 2) 0 3 (5 7) 0 6 (5 9) 0 4 (5 6) Placebo 0 1 (4 7) 0 1 (4 9) 0 0 (5 4) 0 4 (5 5) 0 1 (5 2) ADCS-ADL (18-item) Rivastigmine 0 6 (6 0) 1 9 (7 8) 3 5 (9 5) 4 3 (10 3) 3 3 (8 7) Placebo 0 6 (5 6) 2 2 (7 9) 3 7 (10 1) 4 7 (11 2) 3 0 (8 2) ADCS-ADL (23-item) Rivastigmine 0 8 (8 2) 2 3 (10 1) 4 3 (12 2) 5 4 (13 2) 4 2 (11 3) Placebo 0 6 (7 4) 2 8 (10 0) 4 5 (12 6) 5 8 (14 0) 3 9 (10 6) CDR (global) Rivastigmine 0 0 (0 2) 0 1 (0 4) 0 2 (0 5) 0 1 (0 5) 0 2 (0 4) Placebo 0 1 (0 3) 0 1 (0 3) 0 2 (0 5) 0 1 (0 4) 0 1 (0 4) GDS Rivastigmine 0 1 (0 7) 0 3 (0 8) 0 4 (1 0) 0 5 (1 1) 0 4 (0 9) Placebo 0 2 (0 7) 0 4 (0 8) 0 5 (1 0) 0 5 (1 1) 0 4 (1 0) MMSE=Mini-Mental State Examination; ADAS-cog=Alzheimer s Disease Assessment Scale cognitive subscale; NPI=Neuropsychiatric inventory; BDI=Beck Depression Inventory; ADCS-ADL=Alzheimer s Disease Co-operative Study Activities of Daily Living; CDR=Clinical Dementia Rating; GDS=Global Deterioration Scale. For all outcome measures, change from baseline was calculated such that positive change values indicate improvements. Table S2: Changes from baseline on secondary efficacy measures, MITT population [means (SD)] Subject baseline characteristics (progressors vs non-progressors) Table S3 shows the baseline characteristics of placebo-treated study patients who progressed to AD versus placebo-treated patients who did not progress to AD. Subject baseline characteristics by genotype Table S4 shows subject baseline characteristics by sex and BCHE genotype (pharmacogenetic population only).
4 All randomised patients (MITT) Patients who did not progress to AD Patients who progressed to AD Progressors versus non-progressors n = 510 n = 109 n = 401 Age in years, Mean (SD) 70 6 (7 6) 73 6 (6 6) 69 8 (7 7) p < Gender female, n (%) 262 (51 4) 65 (59 6) 197 (49 1) p = Education in years, Mean (SD) 11 1 (4 1) 10 6 (4 1) 11 2 (4 2) p = CDR, Mean (SD) 1 4 (0 8) 1 9 (0 9) 1 3 (0 7) p = HAM-D total, Mean (SD) 2 7 (2 6) 2 8 (2 9) 2 7 (2 5) p = MHIS, Mean (SD) 0 6 (0 9) 0 6 (0 8) 0 6 (0 9) p = n = 509 n = 108 n = 401 ADAS-cog, Mean (SD) 10 2 (4 9) 14 6 (4 7) 8 96 (4 16) p < n = 509 n = 109 n = 400 MMSE, Mean (SD) 26 9 (2 8) 24 7 (3 7) 27 5 (2 1) p < GDS, Mean (SD) 2 4 (0 5) 2 7 (0 5) 2 3 (0 5) p < n = 508 n = 109 n = 399 NPI, Mean (SD) 2 9 (5 0) 3 7 (4 6) 2 7 (5 1) p = n = 508 n = 109 n = 399 ADCS-ADL, Mean (SD) 58 4 (7 8) 53 2 (8 5) 59 8 (7 0) p < Baseline total hippocampal volume, n = 221 n = 54 n = 167 Mean (SD)* 3 6 (0 7) 3 1 (0 6) 3 7 (0 6) p < APOE ε4 genotype** n = 248 n = 49 n = 199 Carriers, n (%) Non-carriers, n (%) 115 (46 4) 133 (53 6) 29 (59 2) 20 (40 8) 86 (43 2) 113 (56 8) p = BCHE genotype** n = 248 n = 55 n = 193 wt/wt, n (%) K/*, n (%) 159 (64 1) 89 (35 9) 35 (63 6) 20 (36 4) 124 (64 2) 69 (35 8) p = DMC: Diagnosis Monitoring Committee; MMSE: Mini-Mental State Examination; ADAS-cog: Alzheimer s Disease Assessment Scale cognitive subscale; ADCS-ADL: Alzheimer s Disease Co-operative Study Activities of Daily Living; CDR: Clinical Dementia Rating; GDS: Global Deterioration Scale; HAM-D: Hamilton rating scale for depression; MHIS: Modified Hachinski Ischemic Scale. *Based on a subpopulation of subjects who agreed to MRI testing (n = 440, classical ITT). Hippocampal volumes were adjusted for whole brain volume and are expressed as (total hippocampal volume x 1000)/whole brain volume. **Based on a subpopulation of subjects who agreed to pharmacogenetic testing at baseline (APOE: n = 500; BCHE: n = 490). p-values derived from Chi-squared test (for categorical variables) and t-test (Satterthwaite s approximation, for continuous variables). Subjects who developed other types of dementia are included in the group of subjects who did not progress to AD. Table S3: Baseline characteristics of placebo-treated study subjects (MITT subject population)
5 Female BCHE wt/wt Female BCHE-K Male BCHE wt/wt Male BCHE-K Rivastigmine Placebo Rivastigmine Placebo Rivastigmine Placebo Rivastigmine Placebo n = 101 n = 80 n = 32 n = 40 n = 74 n = 79 n = 35 n = 49 Age 71 1 (7 7) 71 5 (7 3) 70 2 (7 9) 71 5 (7 0) 70 7 (6 8) 71 7 (6 6) 71 4 (7 2) 70 2 (8 6) Years of education 10 2 (3 7) 9 8 (4 1) 9 5 (3 6) 9 7 (3 8) 12 6 (5 3) 12 4 (4 6) 12 4 (3 9) 12 2 (4 0) CDR 1 5 (0 7) 1 6 (0 7) 1 6 (0 9) 1 4 (0 8) 1 5 (0 9) 1 3 (0 7) 1 6 (0 9) 1 4 (0 8) n = 100 n = 80 n = 32 n = 39 n = 74 n = 79 n = 49 n = 35 MMSE 26 4 (3 1) 25 7 (3 7) 26 2 (3 3) 25 8 (3 3) 27 4 (2 2) 27 0 (2 2) 27 1 (2 7) 27 3 (2 6) GDS 2 4 (0 6) 2 5 (0 6) 2 4 (0 6) 2 4 (0 6) 2 3 (0 6) 2 3 (0 5) 2 3 (0 5) 2 2 (0 6) n = 100 n = 80 n = 32 n = 39 n = 74 n = 78 n = 49 n = 35 NPI 3 5 (4 5) 3 7 (5 9) 3 8 (5 1) 3 5 (5 1) 5 5 (8 3) 3 6 (5 3) 2 6 (4 4) 4 3 (6 0) n = 43 n = 43 n = 17 n = 21 n = 43 n = 36 n = 17 n = 21 Total hippocampal volume* 3 8 (0 8) 3 6 (0 7) 3 8 (0 9) 3 7 (0 8) 3 6 (0 7) 3 6 (0 7) 4 1 (0 9) 3 6 (0 5) MMSE=Mini-Mental State Examination; CDR=Clinical Dementia Rating; GDS=Global Deterioration Scale; NPI=Neuropsychiatric inventory. *Based on a subpopulation of subjects who agreed to MRI testing (classical ITT). Hippocampal volumes were adjusted for whole brain volume and are expressed as (total hippocampal volume x 1000)/whole brain volume. Table S4: Patients baseline characteristics by sex and BCHE genotype [mean (SD)]
6 References 1 Styner MA, Charles HC, Park J, Gerig G. Multi-site validation of image analysis methods assessing intra and inter-site variability. In: Sonka M, Fitzpatrick JM (eds). Medical imaging 2002: image processing. Proceedings of SPIE, vol May, Bellingham, WA: SPIE Press, 2002: Van Leemput K, Maes F, Vandermeulen D, Colchester A, Suetens P. Automated segmentation of multiple sclerosis lesions by model outlier detection. IEEE Trans Med Imag 2000; 20: Van Leemput K, Maes F, Vandermeulen D, Suetens P. Automated model-based tissue classification of mr images of the brain. IEEE Trans Med Imag 1999; 18: Schott JM, Price SL, Frost C, Whitwell JL, Rossor MN, Fox NC. Measuring atrophy in Alzheimer disease: a serial MRI study over 6 and 12 months. Neurology 2005; 65: Fox NC, Freeborough PA. Brain atrophy progression measured from registered serial MRI: Validation and application to Alzheimer s disease. J Magn Reson Imaging 1997; 7:
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