Targeting molecules to medicine with mTOR, autophagy and neurodegenerative disorders

Abstract

Neurodegenerative disorders are significantly increasing in incidence as the age of the global population continues to climb with improved life expectancy. At present, more than 30 million individuals throughout the world are impacted by acute and chronic neurodegenerative disorders with limited treatment strategies. The mechanistic target of rapamycin (mTOR), also known as the mammalian target of rapamycin, is a 289 kDa serine/threonine protein kinase that offers exciting possibilities for novel treatment strategies for a host of neurodegenerative diseases that include Alzheimer's disease, Parkinson's disease, Huntington's disease, epilepsy, stroke and trauma. mTOR governs the programmed cell death pathways of apoptosis and autophagy that can determine neuronal stem cell development, precursor cell differentiation, cell senescence, cell survival and ultimate cell fate. Coupled to the cellular biology of mTOR are a number of considerations for the development of novel treatments involving the fine control of mTOR signalling, tumourigenesis, complexity of the apoptosis and autophagy relationship, functional outcome in the nervous system, and the intimately linked pathways of growth factors, phosphoinositide 3‐kinase (PI 3‐K), protein kinase B (Akt), AMP activated protein kinase (AMPK), silent mating type information regulation two homologue one (Saccharomyces cerevisiae) (SIRT1) and others. Effective clinical translation of the cellular signalling mechanisms of mTOR offers provocative avenues for new drug development in the nervous system tempered only by the need to elucidate further the intricacies of the mTOR pathway.

Introduction

Neurodegenerative disorders progressively lead to dysfunction of the nervous system and include more than 600 disease entities 1. Acute and chronic neurodegenerative disorders result in disability and death for greater than 30 million individuals worldwide and the number of individuals afflicted is expected to increase 2. One factor that may be fueling this rise is the improvements in clinical care that have fostered the increased life span of the global population. The age of the global population continues to increase with life expectancy approaching 80 years for individuals 3. In conjunction, there has been a 1 % decrease in the age‐adjusted death rate from the years 2000 through 2011 4. The number of individuals over the age of 65 years also has doubled during the previous 50 years 5. It is expected that the number of elderly individuals in large developing countries such as India and China also will increase from 5 % to 10 % over the next several decades 6, 7.

In tandem with an increase in the life span of the global population has been a rise in non‐communicable diseases (NCDs) 8. According to the World Health Organization, more than 60 % of the 57 million global deaths are caused by NCDs 9. Of the NCDs, the five leading causes of death are cardiac disease, cancer, chronic lower respiratory disease, stroke and traumatic accidents 10. In regards to cardiovascular disease, high cholesterol and hypertension are important risk factors for this disorder with hypertension alone contributing to 13 % of all deaths 11.

Interestingly, cardiovascular disease in combination with hypercholesterolaemia and hypertension can significantly lead to disorders of the nervous system that include cognitive loss and stroke. In relation to dementia, 10 % of the world's population over the age of 65 years is affected with the sporadic form of Alzheimer's disease (AD) 12. In the United States (US) alone, greater than 5 million individuals have AD and another 3.5 million are under treatment at an annual cost of 4 billion US dollars. With the rise in the age of the population, it is expected that the number of individuals with AD will increase to 30 million individuals over the next 15 to 20 years 2, 12, 13. In contrast, familial cases of AD (FAD) affect a significantly smaller proportion of the population. FAD is an autosomal dominant form of a mutated amyloid precursor protein (APP) gene, presents in approximately 200 families worldwide 14, occurs most often prior to age 55 years 15 and results from variable single gene mutations on chromosomes 1, 14 and 21 16. Other neurodegenerative disorders also will place a severe burden on the global population 3, 17. By the year 2030, epilepsy will affect over 50 million people and peripheral neuropathies are estimated to afflict almost 300 million individuals 18. Parkinson's disease (PD), also a progressive disorder and the second most common neurodegenerative disease 19, 20, affects 1 to 4 % of individuals over the age of 60 years in the world and this number of individuals is expected to double by the year 2030. Currently, 50 000 new cases of PD present each year in the US.

Clinical treatments for neurodegenerative disorders have progressed over the years with some promising results. For example, stroke is no longer ranked as the third leading cause of death among cardiac disease, cancer, chronic lower respiratory disease and traumatic accidents. Preventive care has fostered a reduction in disability and death with stroke. Reduction in tobacco consumption, improved control of hypertension and low density lipoprotein cholesterol disorders, heightened public education for the need for rapid treatment of stroke, and focused care on metabolic disorders such as diabetes mellitus (DM) most likely have led to this lower ranking for stroke 3, 21. Treatment with recombinant tissue plasminogen activator has resulted in a reduction in mortality and morbidity in patients presenting with stroke, but this is only applicable to a sub‐group of patients who require a narrow therapeutic window 22, 23. Stroke, similar to other neurodegenerative disorders, continues to remain as a significant cause of death 10 and affects 15 million individuals every year 3. Overall, the availability of treatments that can limit or halt neurodegenerative disorders continues to remain limited.

mTOR components and signalling pathways

One promising avenue to target and advance the development of therapeutic strategies for neurodegenerative disorders is the mechanistic target of rapamycin (mTOR) 8, 24. mTOR also is known as the mammalian target of rapamycin and the FK506‐binding protein 12‐rapamycin complex‐associated protein 1. mTOR controls multiple functions in cells that govern the transcription of genes, protein formation, proliferation and senescence of cells, cellular metabolism and cellular longevity.

Initially, the target of rapamycin (TOR) was observed in Saccharomyces cerevisiae with the genes TOR1 and TOR2 25 . These genes were found to encode two isoforms in yeast, Tor1 and Tor2, through the use of rapamycin‐resistant TOR mutants 26. Rapamycin itself is a macrolide antibiotic 27 originating from Streptomyces hygroscopicus that inhibits TOR and mTOR activity 8. mTOR is a primary component of the protein complexes mTOR complex one (mTORC1) and mTOR complex two (mTORC2) (Figure 1) 12, 19, 28, 29. Rapamycin blocks mTORC1 activity by binding to immunophilin FK‐506‐binding protein 12 (FKBP12) that attaches to the FKBP12‐rapamycin‐binding domain (FRB) at the carboxy (C)‐terminal of mTOR to prevent the phosphorylation of mTOR 30. Overall, mTORC1 is more sensitive to inhibition by rapamycin than mTORC2 31. However, chronic administration of rapamycin can inhibit mTORC2 activity that can arise from the disruption of the assembly of mTORC2 31.

Figure 1.

mTOR is a significant component of mTORC1 and mTORC2. The mechanistic target of rapamycin (mTOR) is significant for the protein complexes of mTOR complex one (mTORC1) and mTOR complex two (mTORC2). mTORC1 consists of Raptor (regulatory‐associated protein of mTOR), Deptor (DEP domain‐containing mTOR interacting protein), mammalian lethal with Sec13 protein 8 (mLST8/GβL) and the proline rich Akt substrate 40 kDa (PRAS40). mTORC2 is composed of Rictor (rapamycin‐insensitive companion of mTOR), Deptor, the mammalian stress‐activated protein kinase interacting protein (mSIN1), mLST8, and the protein observed with Rictor‐1 (Protor‐1)

The terminal domains of mTOR control catalytic activity, binding and phosphorylation of this protein. The C‐terminal domain has a sequence homology to the catalytic domain of the phosphoinositide 3‐kinase (PI 3‐K) family 32 and contains several phosphorylation sites that regulate mTOR. The C‐terminal domain of mTOR regulates catalytic activity and includes the FAT (FKBP12‐rapamycin‐associated protein (FRAP), ataxia‐telangiectasia (ATM) and the transactivation/transformation domain‐associated protein) domain, the FRB domain, the catalytic PI 3/PI 4‐related kinase domain and the FATC (the FAT‐C‐terminal) domain 25. The FAT domain is adjacent to the FRB domain that promotes the association of mTOR and FKBP12 when bound to rapamycin. Following these domains are the PI 3/PI 4‐related kinase domain and the small FATC domain. The N‐terminal domain of mTOR contains at least a 20 HEAT (huntingtin, elongation factor 3, a subunit of protein phosphatase‐2A and TOR1) repeat that leads to binding with the regulatory proteins Raptor (Regulatory‐associated protein of mTOR) and Rictor (rapamycin‐insensitive companion of mTOR) 33.

mTORC1 is composed of Raptor, the proline rich Akt substrate 40 kDa (PRAS40), Deptor (DEP domain‐containing mTOR interacting protein) and mammalian lethal with Sec13 protein 8, termed mLST8 or G protein β subunit‐like (GβL) (Figure 1) 25. Phosphorylation of Raptor can occur through several pathways. One pathway that allows mTORC1 to bind to constituents involves the protein Ras homologue enriched in brain (Rheb) that phosphorylates the Raptor residue serine⁸⁶³ and other residues that include serine⁸⁵⁹, serine⁸⁵⁵, serine⁸⁷⁷, serine⁶⁹⁶ and threonine⁷⁰⁶ 34. Once active, mTOR also can control Raptor activity that can be blocked by rapamycin 35. As an inhibitor of this system, PRAS40 prevents the binding of mTORC1 to Raptor 36. PRAS40 can inhibit mTORC1 activity by preventing the association of p70 ribosomal S6 kinase (p70S6K) and the eukaryotic initiation factor 4E (eIF4E)‐binding protein one (4EBP1) with Raptor 2, 36. If PRAS40 is phosphorylated by protein kinase B (Akt), PRAS40 disengages from Raptor and is then sequestered in the cytoplasm by the docking protein 14–3‐3 36, 37, 38, 39, 40. This allows activation of mTORC1. Deptor also inhibits mTORC1 activity by binding to the FAT domain of mTOR. If Deptor activity is limited, Akt, mTORC1, and mTORC2 activity are increased 41. mLST8 is a promoter of mTOR kinase activity through p70S6K and 4EBP1 that bind to Raptor 42, controls insulin signalling through the transcription factor FoxO3 43, is necessary for Akt and protein kinase C‐α (PKCα) phosphorylation 43 and is required for Rictor to associate with mTOR 43.

mTORC2 is composed of Rictor, mLST8, Deptor, the mammalian stress‐activated protein kinase interacting protein (mSIN1) and the protein observed with Rictor‐1 (Protor‐1) (Figure 1) 3, 33, 44, 45, 46, 47. The integrity of mSIN1 and prevention of its lysosomal degradation is controlled by the kinase domain of mTOR that phosphorylates mSIN1 48. In addition, Rictor 49 and mSIN1 50 can activate Akt at serine⁴⁷³ and facilitate threonine³⁰⁸ phosphorylation by phosphoinositide‐dependent kinase one (PDK1) to promote cell survival 2, 44, 50. mTORC2 oversees cytoskeleton remodelling through PKCα and cell migration through the Rac guanine nucleotide exchange factors P‐Rex1 and P‐Rex2 and through Rho signalling 51. In regards to Protor‐1, this protein is a Rictor‐binding subunit of mTORC2 that activates serum and glucocorticoid induced protein kinase one (SGK1) 52. mTORC2 also can activate SGK1, a member of the protein kinase A/protein kinase G/protein kinase C (AGC) family of protein kinases 53.

The pathways of PI 3‐K, Akt, and AMP activated protein kinase (AMPK) play a significant role in mTOR signalling (Figure 2). In regards to AMPK, this protein can inhibit mTORC1 activity through activation of the hamartin (tuberous sclerosis 1)/tuberin (tuberous sclerosis 2) (TSC1/TSC2) complex. In contrast, mTORC2 activity is increased during activation of the TSC1/TSC2 complex through the N‐terminal region of TSC2 and the C‐terminal region of Rictor 54. Removal of the TSC1/TSC2 complex leads to the loss of mTORC2 kinase activity in vitro 54. Of note, TSC2 functions as a GTPase‐activating protein (GAP) converting G protein Rheb (Rheb‐GTP) into the inactive GDP‐bound form (Rheb‐GDP). If Rheb‐GTP is active, Rheb‐GTP can then associate with Raptor to control the binding of 4EBP1 to mTORC1 and increase mTORC1 activity 55. AMPK phosphorylates TSC2 to increase the activity of GAP to change Rheb‐GTP into the inactive Rheb‐GDP to block mTORC1 activity 56. AMPK also can increase RTP801 (REDD1/product of the Ddit4 gene) expression during hypoxia to control TSC1/TSC2 activity and suppress mTORC1 activity by releasing TSC2 from its inhibitory binding to protein 14–3‐3 57. AMPK also has a relationship with the sirtuin silent mating type information regulation two homologue one (Saccharomyces cerevisiae) (SIRT1) that can be important for cellular survival and stem cell proliferation 6. AMPK increases nicotinamide phosphoribosyltransferase (NAMPT) activity. This process catalyzes the conversion of nicotinamide to nicotinamide mononucleotide 58, increases nicotinamide adenine dinucleotide (NAD⁺) levels, decreases levels of the SIRT1 inhibitor nicotinamide and leads to SIRT1 transcription 59, 60, 61. As a result of increasing the intracellular NAD⁺ : NADH ratio, AMPK leads to deacetylation of the SIRT1 targets peroxisome proliferator‐activated receptor‐gamma co‐activator one (PGC‐1α) and forkhead transcription factors that include FoxO1 62 and FoxO3a 63. Although SIRT1 may function similar to AMPK as an inhibitor of mTOR to block its activity 64, SIRT1 and AMPK may be protective in combination since they can foster the induction of autophagy that can protect endothelial cells exposed to oxidized low density lipoproteins 65.

Figure 2.

Targeting mTOR for neurodegenerative disorders. The mechanistic target of rapamycin (mTOR) and the signalling pathways of phosphoinositide three‐kinase (PI 3‐K), AMP activated protein kinase (AMPK), protein kinase B (Akt) and the hamartin (tuberous sclerosis 1)/tuberin (tuberous sclerosis 2) (TSC1/TSC2) complex are vital determinants of cell survival in the nervous system. mTOR governs programmed cell death pathways of apoptosis and autophagy that can affect stem cell development and maintenance, growth factors (erythropoietin (EPO), epidermal growth factor (EGF), fibroblast growth factor (FGF), brain derived neurotrophic growth factor (BDNF)), silent mating type information regulation two homologue one (Saccharomyces cerevisiae) (SIRT1), Wnt signalling, and Wnt1 inducible signalling pathway protein one (WISP1). Ultimately, mTOR signalling can impact the onset and progression of multiple disorders in the nervous system that include Alzheimer's disease (AD), Parkinson's disease (PD), Huntington's disease (HD), epilepsy, stroke and trauma

Akt is another component of the the mTOR signalling pathway that can block activity of the TSC1/TSC2 complex that inhibits mTORC1 66, 67, 68, 69. Control of the TSC1/TSC2 complex is primarily mediated though the phosphorylation of TSC2 by Akt. However, extracellular signal‐regulated kinases (ERKs), activating protein p90 ribosomal S6 kinase one (RSK1), glycogen synthase kinase‐3β (GSK‐3β) and, as previously described, AMPK, can modulate the TSC1/TSC2 complex. Akt can phosphorylate TSC2 on several sites that leads to TSC2 destabilization and disruption of TSC2 association with TSC1. Phosphorylation of TSC2 at serine⁹³⁹, serine⁹⁸¹ and threonine¹⁴⁶² results in the binding of TSC2 to cytoplasmic protein 14–3‐3, disengagement of the TSC1/TSC2 complex and activation of Rheb and mTORC1 70. It should be noted that during some instances to promote cell survival, a limited activity of TSC2 and AMPK 71 is required since complete knockdown of TSC2 can result in cellular injury 72.

mTOR pathways of apoptosis and autophagy

Critical for mTOR to affect the onset and progression of neurodegenerative disorders is the ability of the mTOR pathway to alter programmed cell death through apoptosis and autophagy (Figure 2). Apoptosis has two distinct phases that consist of an early phase that involves the loss of plasma membrane phosphatidylserine (PS) asymmetry and a subsequent phase that leads to genomic DNA degradation 73, 74, 75. Apoptosis is the result of a series of cascade activation of nucleases and proteases that involve caspases 59, 76. Membrane PS externalization activates inflammatory cells to engulf and remove injured cells 77, 78, 79, 80. If this process is blocked since the loss of PS asymmetry can be reversible 7, 81, 82, loss of functional cells expressing membrane PS residues can be prevented. If PS asymmetry is not reversed, genomic DNA degradation can result 73, 74, 77, 78, 83, 84, 85. The destruction of cellular DNA is usually not considered to be a reversible process 86, 87, 88, 89.

Under most conditions, mTOR activation prevents apoptotic cell death in the nervous system 19, 47. If mTOR activity is lost, this leads to apoptotic neuronal cell death 90 and aggravation of oxidative stress pathways 91. mTOR activation can protect against neuronal injury during ischaemic preconditioning 92, permanent cerebral ischaemia 93, loss of neurite outgrowth 94, cervical spinal cord injury 95, memory loss 96 and β‐amyloid (Aβ) toxicity 39, 72, 97, 98, 99. Components of the mTOR pathway, such as p70S6K, promote progenitor cell neovascularization in ischaemic tissue 100, block cortical ischaemic injury 101, 102, provide growth factor neuronal cell protection during apoptosis 37, 39 and block apoptosis during oxidative stress exposure 103, 104.

Protection against apoptotic cell injury with mTOR is closely associated with trophic factor activity 105. The growth factors epidermal growth factor (EGF) and fibroblast growth factor (FGF) in mice are protective of stem cells and neurons 106, 107, 108, 109, 110. EGF and FGF also rely upon mTOR to maintain the proliferation of neural stem and progenitor cells 111. Through PI 3‐K, Akt and mTOR, EGF prevents cell injury during metabolic stress 112 and restores memory function 113. Brain derived neurotrophic factor (BDNF) also relies upon mTOR activation for memory consolidation 114. Erythropoietin (EPO) uses mTOR signalling to prevent apoptotic cell death in the nervous system 115, 116. Through mTOR, EPO prevents cerebral microglial injury 117, Aβ toxicity 97, sepsis‐associated encephalopathy 118, cerebral microglial injury 117, oxidative stress injury 37, 119, 120 and retinal progenitor cell loss 121.

EPO can oversee mTOR signalling through several downstream pathways that include PRAS40 function to increase neuronal cell survival 37. EPO works with other proliferative pathways with mTOR, such as Wnt signalling, to prevent caspase activation and apoptosis 97. Wnt signalling involves cysteine‐rich glycosylated proteins that oversee cell development and survival 122, 123. EPO requires Wnt signalling to block ‘pro‐apoptotic’ forkhead transcription factor activity that can result in cell death 124, 125. A downstream target in the Wnt pathway also linked to mTOR is the Wnt1 inducible signalling pathway protein one (WISP1) 3, 19, a member of the six secreted extracellular matrix associated CCN family of proteins 126, 127. WISP1 activates mTOR, inhibits PRAS40 39 and limits TSC2 activity 72 to increase microglial cell survival during oxidative stress and Aβ toxicity. WISP1 fosters nuclear trafficking and activity of SIRT1 that results in neuronal protection 128 and blocks apoptotic injury 78, 129, 130. WISP1 also regulates the post‐translational phosphorylation of AMPK 64, 131, 132, 133. WISP1 modulates AMPK activation by differentially decreasing phosphorylation of TSC2 at serine¹³⁸⁷, a target of AMPK, and increasing phosphorylation of TSC2 at threone¹⁴⁶², a target of Akt 72. As a result, WISP1 provides a minimal but not excessive level of TSC2 and AMPK activity to promote cellular survival during toxic insults 72. Interestingly, the ability of EPO to control neuroinflammation also is linked to AMPK activity 134. EPO appears to require a specific level of AMPK activity to alleviate detrimental effects of oxidative stress 135.

Yet, growth factor protection in the nervous system may sometimes necessitate inhibition of mTOR activity with the promotion of autophagy. Cortical neurons can be protected by BDNF through the induction of autophagy and the inhibition of mTOR during oxygen deprivation 136. In other scenarios, glial cell‐derived neurotrophic factor (GDNF) and nerve growth factor (NGF) protect against photo‐oxidative stress with inhibition of mTOR activity 137. The concentrations of growth factors also may affect mTOR signalling and apoptotic cell death. For example, elevated concentrations of EPO can lead to cellular damage and lessen the activity of mTOR 138.

Given that under some scenarios, trophic factors require limited mTOR activity to promote cell survival suggests that the programmed cell death pathway of autophagy also has a critical role for cell survival in the nervous system 2. Autophagy recycles components of the cell cytoplasm to eliminate non‐functional organelles for disposal and tissue remodelling 17, 139, 140, 141. Macroautophagy is the autophagy classification most often responsible for the recycling of organelles 12, 19, 142. This process consists of the sequestration of cytoplasmic proteins and organelles into autophagosomes that combine with lysosomes for degradation and recycling 7, 141, 143, 144, 145.

There exist at least 33 autophagic related genes (Atg) that have been identified in yeast with TOR and can affect metabolic disorders, cardiovascular disease, cancer and neurodegenerative disease 139, 140, 141, 146, 147, 148, 149, 150, 151. Atg1, Atg13 (also known as Apg13), and Atg17 are tied to the PI 3‐K, Akt and TOR pathways. Either the Atg1 complex in yeast or the UNC‐51 like kinase one (ULK1) complex in mammals requires activation for the induction of autophagy 140, 152. Atg13 as well as Atg17 can determine Atg1 activity 153. Phosphorylation of Atg13 through TOR dependent pathways releases Atg13 from Atg1 and reduces Atg1 activity 154. In contrast, de‐phosphorylation of Atg13 that can occur during starvation and reduced mTOR activity results in the activation of Atg1 and the induction of autophagy. In mammals, several ULK isoforms exist 147. The homologues of Atg1 are UNC‐51 like kinase one (ULK1) and ULK2 19. Mammalian Atg13 binds to ULK1, ULK2 and FIP200 (focal adhesion kinase family interacting protein of 200 kDa) to activate ULKs, promote the phosphorylation of FIP200 by ULKs and results in the induction of autophagy 155. mTOR activity blocks the induction of autophagy by phosphorylating Atg13 and ULKs to inhibit the ULK‐Atg13‐FIP200 complex 155.

In the nervous system, induction of autophagy with the inhibition of mTOR activity can be neuroprotective 156. mTOR blockade with the induction of autophagy increases cell survival in neonatal models of ischaemia 157 and during excitotoxicity 158. Inhibition of mTOR signalling with autophagy activation results in neural tissue protection and functional improvement in models of spinal cord injury 159. Autophagy is protective during prion protein disease 160 and in models of Huntington's disease (HD) 25, 161. Consumption of a high calorie diet has been observed to inhibit autophagy and facilitate hippocampal neuronal loss in mice 162. In experimental models of AD, disease progression and duration appears to be associated with dysfunctional autophagic processes as well as inhibition of mTOR activity 148. In contrast, reduction in Aβ production and improved memory function in animal models of AD has been associated with autophagy activation 163. Vascular cells that may protect during periods of cerebral ischaemia also are lost if autophagy is blocked 164.

Autophagy is impacted not only by mTOR but also by SIRT1. SIRT1 increases lifespan in higher organisms and offers protection against oxidative stress in neuronal cells 165. SIRT1 promotes cell survival in the nervous system through the blockade of mammalian forkhead transcription factor activity, such as FoxOs 59, 166, 167, 168, 169. SIRT1 also can work in conjunction with FoxOs to protect neurons. Mammalian forkhead transcription factors can bind to the SIRT1 promoter region that contains a cluster of five putative core binding repeat motifs (IRS‐1) and a forkhead‐like consensus‐binding site (FKHD‐L) 125. FoxO proteins, such as FoxO1, can subsequently regulate SIRT1 transcription and increase SIRT1 expression 170. Expression of FoxO1 can lead to induction of autophagy and the clearance of toxic mutant Huntingtin (mHtt) protein neurons in experimental models of full length mutant mHtt transgenic mice 171. In regards to the relationship of mTOR with SIRT1, SIRT1 is protective 172 in embryonic stem cells and has an inverse relationship with mTOR 6. SIRT1 can inhibit mTOR pathways and promote autophagy to protect human embryonic stem cells against oxidative stress 173. SIRT1 inhibits mTOR signalling to promote neuronal growth 174 and can oversee cellular metabolism during caloric restriction 175. In endothelial cells exposed to oxidized low density lipoproteins that can lead to atherosclerosis, SIRT1 up‐regulation in combination with AMPK activity results in autophagy that is necessary for cell protection 65.

In some cases, limitations in the induction of autophagy may be required to promote cell survival in the nervous system. A reduction in autophagy combined with the activation of mTOR in animal models of traumatic spinal cord injury leads to improvement in function and increased survival of motor neurons 95. During ischaemic stroke in rodents, inhibition of autophagy reduces infarct size and protects cerebral neurons 176. Blockade of autophagy and activation of mTOR protects dopaminergic neurons during oxidative stress exposure 91. In tri‐cultures of neurons, astrocytes and microglia that are exposed to inflammatory stressors and Aβ, cell injury increases during the induction of autophagy 177. Other studies suggest that autophagy is not always beneficial for cell survival. Autophagy can impair endothelial progenitor cells, lead to mitochondrial oxidative stress and prevent new blood vessel formation during elevated glucose exposure 144. Trophic factors, such as EPO, promote protection against hypoxia and oxidative stress in retinal progenitor cells by limiting the induction of autophagy 121. EPO can limit excessive autophagy that precedes apoptosis during experimental neonatal necrotizing enterocolitis 178 and can prevent neonatal brain damage in the developing rodent during hyperoxia exposure and oxygen toxicity by blocking autophagy 179. In Purkinje neurons, insulin growth factor‐1 prevents neuronal injury by preventing the induction of autophagy 180.

Conditions that lead to detrimental effects with the induction of autophagy may be the result of a fine balance required between apoptotic and autophagic pathways. Under some experimental conditions in neuronal cell line models, EPO suppresses apoptotic cell injury through the increased activity of AMPK and limited autophagy activity 181. In addition, WISP1 has been shown to prevent neuronal cell death through the modulation of both apoptotic and autophagic pathways 182.

mTOR oversight of stem cells in the nervous system

One mechanism that mTOR may influence disease progression in the nervous system is through stem cell development and maintenance (Figure 2) 8. Trophic factors that rely upon mTOR can direct stem cell development. EPO regulates Wnt signalling to maintain the survival of mesenchymal stem cells 183. EPO uses mTOR to control bone homeostasis with osteoblastogenesis and osteoclastogenesis 184. For the growth factors insulin 185 or EPO 119, mTOR activity is necessary for neuronal precursor cell differentiation to ensue.

Without mTORC1, neural stem cells succumb to reduced lineage expansion, lack of differentiation and reduced neuronal production 186. Furthermore, the degree of activity of mTOR can lead to the modification of stem cell differentiation. Blockade of mTOR activity can result in stem cell differentiation into astrocytic cells 111. Inhibition of both Akt and mTORC1 can result in reduced neuronal stem cell self‐renewal and earlier neuronal and astroglial differentiation 187.

mTOR activity is necessary for the onset and progression of neurogenesis. mTOR controls the expression of RTP801/REDD1 during neuronal maturation. During development, levels of RTP801/REDD1 in newborn and mature neurons become diminished and mTOR activity is increased to promote the maturation of neurons 188. Neuronal phenotype also is controlled by mTOR. mTOR activity is required for the expression of the neuronal phenotype of post mortem neuronal precursors 119. In addition, mTOR activity appears necessary for the maintenance of neuronal stem cells during ageing. mTOR signalling in the aged brain is reduced and is accompanied by a reduced proliferation of active neural stem cells 189. mTOR in conjunction with Akt has been shown to prevent mesenchymal stem cell ageing 190. Non‐neuronal neighbouring cells also can influence the growth of neuronal stem cells. Endothelial cells can foster mTOR activity and lead to the expansion of long term glioblastoma stem‐like cells 191.

mTOR and neurodegenerative disorders

Alzheimer's disease

mTOR has a critical role during cognitive function and memory 12 and affects genetic pathways that lead to cognitive loss 113. In models of vascular dementia, recovery of memory and learning are dependent upon the up‐regulation of mTOR and eIF4E 96. During periods of cerebral ischaemia in rodents, increased expression of mTOR is associated with hippocampal neuron preservation and memory improvement 92. In models of experimental autoimmune encephalomyelitis (EAE) for multiple sclerosis, cognitive deficits are associated with impaired myelin growth in the parahippocampal cortex that can be reversed with mTOR activation 192. Memory formation with mTOR also may require metabotropic glutamate receptor (mGluR) signalling 193. Environmental enrichment for improvements in learning and memory relies upon long term potentiation with mGluR5 activation and sustained phosphorylation of the mTOR pathway p70S6K 194. Loss of mTOR signalling can impair long term potentiation and synaptic plasticity in animal models of AD that can be restored by mTOR activation 195. Loss of Akt, mTOR and p70S6K activity also can injure newborn neurons and limit dendritic density formation during Aβ exposure 196. mTOR activation can control dendritic protein synthesis in hippocampal neurons 197 and the formation of long term memory in the amygdala 198.

However, under conditions that require autophagy induction for enhanced neuronal survival, limitations in the activation of mTOR have been shown to be more fruitful. In murine models of AD, autophagic clearance of cortical Aβ that also involves reduced production of this protein can afford protection against memory impairment though the inhibition of mTOR signalling 163. Similar studies in cells also show that Aβ clearance requires induction of autophagy with mTOR inhibition, processes that may be associated with memory improvement in disorders such as AD 199. In animal models of caloric restriction, learning and memory were significantly improved under conditions that promoted the induction of autophagy with a decrease in mTOR signalling 162.

The role of mTOR and its signalling pathways in memory formation highlights the potential for targeting mTOR for the treatment of cognitive disorders, such as AD (Figure 2). Early studies have observed that a decrease in mTOR activity is present in peripheral lymphocytes of patients with AD and this loss of mTOR appears to correlate with the progression of the disease 200. Loss of mTOR activity also may result in neuronal atrophy in AD. Absence of the retinoblastoma‐1 (RB1) inducible coiled‐coil one (RB1CC1) tumour suppressor is present in the brains of patients with AD and may be linked to neuronal loss. RB1CC1 maintains mTOR signalling and appears to be necessary for neurite growth, since reduced expression of RB1CC1 leads to loss of mTOR activity, neuronal apoptosis and neuronal atrophy 201. Reduction in Aβ accumulation in AD also may require mTOR activity. Increased Rheb GTPase activity that is known to increase mTORC1 activity can reduce β‐site amyloid precursor protein (APP)‐cleaving enzyme one (β‐secretase, BACE1) activity to limit Aβ accumulation in AD 202. Aβ exposure independently can reduce mTOR activity 203 and may lead to apoptotic neuronal death through the loss of activity in the Akt and mTOR axis 39, 72, 97, 98, 99, 199. In longitudinal studies, mTOR signalling is reduced in aged models of AD with the progression of Aβ accumulation 148, suggesting that the loss of mTOR activity may ultimately lead to Aβ toxicity and cognitive loss. In a number of scenarios, protection against Aβ toxicity requires the activation of the mTOR pathway 97, 98, 99, 196, 203.

Given the role mTOR holds in memory formation and the fine balance that may be necessary for mTOR activity to promote cognitive function, it is not surprising to observe that excessive activation of mTOR also may function as a pathological mechanism for cognitive loss and the progression of AD 204. Down‐stream components of mTOR that include active p70S6K can co‐localize with hyper‐phosphorylated tau deposition in the brains of patients with AD, indicating that p70S6K may assist with the accumulation of hyper‐phosphorylated tau 205. SIRT1 can prevent neuronal degeneration during Aβ exposure and involve the down‐regulation of mTOR and p70S6K 174 while suppression of mTOR expression can reduce Aβ deposition 206. In related studies that pertain to cognitive loss and metabolic dysfunction, high levels of mTOR activity can result in elevated protein expression of acetylcholinesterase (AChE) in central neurons 207 that may impair memory formation. Treatment with temsirolimus, an inhibitor of mTOR and approved by the US Federal Drug Administration (FDA) for the treatment of renal cell carcinoma, can improve spatial learning in animal models of AD and promote the clearance of Aβ 208. Temsirolimus treatment in mutant tau mouse models also can stimulate macroautophagy, inhibit Akt, mTOR, and p70S6K signalling, decrease abnormal tau accumulation and improve motor deficits 209. Interestingly, some studies illustrate that reductions in Aβ deposition can be achieved with autophagy that is not dependent upon mTOR, suggesting that memory dysfunction in disorders such as AD may not be tied to high levels of mTOR. Blockade of acetyl‐coA cholesterol acyltransferase one (ACAT1) has recently been shown to decrease amyloidopathy in experimental models of AD through induction of autophagy in microglia with the sequestration of Aβ that is independent of mTOR signalling 210.

Parkinson's disease and Huntington's disease

PD is a movement disorder that leads to resting tremor, rigidity and bradykinesia. It is characterized by the loss of dopaminergic neurons in the substantia nigra. Recent work suggests that during disease progression in PD, mTOR signalling is altered 211. For the treatment of PD, mTOR activation can offer protection against this neurodegenerative disorder (Figure 2). In cell culture with dopaminergic cells, activation of mTOR and p70S6K or down‐regulation of 4EBP1 can offer protection against oxidative stress 212. Persistent activation of 4EBP1 by leucine‐rich repeat kinase two (LRRK2), a site for dominant mutations in PD, has been reported to alter protein translation and result in the loss of dopaminergic neurons 213. Yet, over‐expression of 4EBP1 in other experimental studies that include the degeneration of dopaminergic neurons in Drosophila indicates that 4EBP1 may suppress pathologic experimental phenotypes of PD 214. In addition to mTOR, activation of the Akt pathway with mTOR can block methamphetamine neurotoxicity in dopaminergic neurons 215. Experimental PD toxic mimetics have been shown to suppress mTOR and p70S6K activity 216. Over‐expression of wild‐type mTOR or constitutively active p70S6K can prevent neuronal cell death in the presence of PD toxins 216.

Modulation of autophagy through mTOR also represents another mechanism to address the treatment of PD and progression of neurodegenerative disorders 2. In some studies, inhibition of autophagy with mTOR activation has been shown to prevent dopaminergic neuronal injury during oxidative stress exposure 91, suggesting that autophagy may be detrimental to dopamine neurons. Yet, a number of studies that address α‐synuclein toxicity in PD support the premise that induction of autophagy degrades and eliminates α‐synuclein to protect dopaminergic neurons 20, 217. In models of α‐synucleinopathy, defects in autophagic pathways can result in neurodegeneration 218. Mutation of α‐synuclein and accumulation of wild‐type α‐synuclein in dopaminergic neurons have been associated with the onset and progression of PD 219. Pathways such as those that involve mTOR inhibition or modulation of FoxO proteins 125 can prevent nigral neuron cell death in the presence of human α‐synuclein accumulation by reducing the amount of α‐synuclein and promoting the accumulation of autophagic vacuoles containing lipofuscin 220. The growth factor EPO has been shown to protect against dopaminergic neurotoxicity through induction of autophagy and mTOR inhibition 181. Autophagy also may protect neurons in PD through the maintenance of mitochondrial homeostasis 160, 221 and may not require mTOR inhibition 222.

Similar to PD, autophagy and the modulation of mTOR activity may offer promising therapeutic strategies to treat other disorders that involve toxic intracellular aggregates such as the mutant aggregates that occur in HD (Figure 2). HD is the result of mutations resulting in the polyglutamine tract expansion of CAG in the huntingtin (Htt) gene. mTOR is one of several proteins that can interact with mHtt and affect the course of HD 223. Blockade of mTOR activity can result in the induction of autophagy and the removal of proteins with long polyglutamine or polyalanine expansions 224. Other pathways, such as FoxO proteins, also can increase clearance of mHtt through autophagic pathways 171. mHtt can increase the activity of mTORC1. Enhanced mTORC1 activity has been shown to accelerate the onset of the loss of motor coordination and premature death in murine models of HD 225. Yet, inhibition of mTORC1 alone may not be sufficient to alter autophagy or mHtt accumulation. Some studies suggest that combined inhibition of mTORC1 and mTORC2 is required for autophagy and the reduction of mHtt accumulation 226. In addition, work in mouse models of HD indicate that prevention of motor performance decline may be more associated with decreasing the activity of p70S6K that improves muscle function rather than changes in cerebral mHtt accumulation and neuronal protection 227. Induction of macroautophagy that is independent of mTOR signalling to remove cellular aggregates also may play a role in HD 222. Complete elimination of mTOR activity during HD may not be beneficial and a careful modulation of this pathway may be required for optimal clinical efficacy. In HD patients and in rodent models of HD, the expression of Rhes, an mTOR activator in the striatum, is reduced 228. Activation of mTORC1 protects against striatal atrophy, impaired dopamine signalling, mitochondrial dysfunction and results in the induction of autophagy 228.

Epilepsy

In regards to disorders such as epilepsy and tuberous sclerosis complex (TSC), a disorder that leads to epilepsy in more than 80% of patients 229, activation of mTOR signalling is associated with epileptic pathology (Figure 2) 25, 230. Limiting cerebral mTOR activity has been advocated for the treatment of these disorders 231, 232. In models of pilocarpine‐induced status epilepticus, animals develop both seizures and aggressive behaviour. Aggressive behaviour precedes seizure development and both are controlled with the inhibition of mTOR activity 233. Inhibition of mTOR also prevents the development of absence seizures in animal models 234. In hypoxia‐induced neonatal seizures in rodents, mTORC1 activity has been observed to spike within 3 weeks following birth and to be associated with the induction of seizures 235. Models of status epilepticus suggest that the components of autophagy are also altered during seizure activity with increase activation of mTOR 236.

Experimental mouse models of TSC that delete the TSC2 gene from mouse Purkinje cells develop increases in Purkinje cell size with eventual apoptotic cell death of these cells, indicating that mTORC1 increased activity in the absence of TSC2 oversight leads to cerebellar disease pathology 237 and eventual epilepsy 33. In comparison, TSC patients were found to have significant Purkinje cell loss as well 237. Furthermore, in astrocytes of TSC patients in the mesial temporal lobe, a region that can lead to mesial temporal lobe epilepsy, mTOR signalling with p70S6K was found to have increased activity 238. Glutamine may be one method to control p70S6K activity and reduce the risk of seizures as indicated in studies with TSC2 knockout mice 239. For the clinical treatment of epilepsy, lamotrigine, an approved Food and Drug Administration (FDA) anti‐epileptic agent, leads to the induction of autophagy that may be associated with limitation in mTOR activity to reduce seizure frequency 151. The FDA has approved the use of everolimus (RAD‐001), an analogue of rapamycin and an inhibitor of mTOR, for the treatment of subependymal giant cell astrocytoma. In TSC, everolimus limits giant cell astrocytoma cell growth 240, 241. Seizure frequency was reduced in approximately 60 % of the patients studied, but some patients experienced increased seizure frequency with the drug 241. In addition, toxic side effects were present that included respiratory infections, stomatitis and leukopenia 241. Additional work has reported that everolimus in patients with TSC and refractory epilepsy reduced seizure frequency by a median reduction of 73 % in 17 of 20 patients examined 242.

Stroke and trauma

mTOR and its signalling pathways markedly influence acute neurodegenerative disorders, such as stroke and trauma (Figure 2) 3, 69. Following traumatic rodent spinal cord injury, reduced motor neuron death and enhanced forelimb function occur with treatments that increase Akt and mTOR activity with a reduction in autophagy 95. mTOR activation fosters axonal growth following injury in the peripheral nervous system, but proper target innervation may require fine control of mTOR activity 243. During ischaemic pre‐conditioning in animal models of stroke, mTOR activation can lead to neuronal cell protection. During remote ischaemic preconditioning in the hippocampus prior to global brain ischaemia, mTOR activation prevents neuronal injury and leads to improvements in memory function 92. In models of ischaemic post‐conditioning, activation of the Akt/mTOR pathway reduce long term cerebral focal ischaemic damage and neurological disability 244. During ischaemic‐reperfusion injury, Golgi phosphoprotein‐3 and mTOR were found to be necessary for the reduction in stroke volume 245. Middle cerebral artery infarction in rodent models is also reduced with activation of mTOR signalling that includes mTOR and p70S6K 102. During oxygen‐glucose deprivation in neuronal cells, induction of EPO expression prevents cell death through activation of Akt and mTOR pathways 120, 246. Non‐coding micro RNAs (miRNAs) may offer treatment options for stroke that require mTOR activation 141, 247. A cohort of circulating miRNAs related to PI 3‐K, Akt and mTOR were found to be associated with a greater degree of neuronal cell protection in adult rodent females 248. Exercise following injury in the spinal cord may lead to improved neuronal plasticity though miRNA expression and activation of p70S6K 249.

Non‐neuronal cells also may play a critical role in treating acute neurodegenerative disorders through mTOR. Activation of mTOR is necessary to maintain the integrity of cerebral microglia that can be reparative 117, 250, 251. mTOR signalling with a reduction in PRAS40 activity in neuronal cell lines and microglia during oxidative stress can prevent apoptotic cell death 37, 39. Interestingly, mice with a PRAS40 gene knockout that were subjected to cerebral ischaemia were observed to suffer increased infarctions, but lacked significant p70S6K activity, suggesting that a specific level of mTOR may be required for cortical protection 40. Over‐expression of PRAS40 in this model resulted in a potential feed‐back pathway that resulted in a reduction in cerebral ischaemic injury with phosphorylation and increased activity of Akt and mTOR 40. mTORC1 and mTORC2 also have been demonstrated to be necessary in astrocytes for glutamate transporter subtype two (GLT‐1) expression that would promote glutamate uptake during brain ischaemia and limit ischaemic injury 252. During cerebral ischaemia, leucine‐rich repeat in Flightless‐1 interaction protein one (Lrrfip1) has recently been shown to be up‐regulated as a neuroprotective mechanism to increase mTOR activity in astrocytes and enhance GLT‐1 activity 101.

Similar to chronic neurodegenerative disorders, mTOR activation with a reduction in autophagy is not consistently protective in the nervous system 69, 127. The induction of autophagy and mTOR inhibition is necessary with histamine H₃‐receptor antagonism during stroke to result in neuronal cell protection 253. Excitotoxicity in hippocampal neurons is also prevented with activation of autophagy and mTOR inhibition 158. During oxygen‐glucose deprivation in human umbilical vein endothelial cells, mTOR inhibition and induction of autophagy protect vascular cells from injury 164. Application of rapamycin blocks mTORC1 and mTORC2 activation and leads to increased cortical neuronal survival 254. During ischaemic brain tolerance studies, rapamycin can promote autophagy induction, reduce brain damage and result in improved neurological scores that are associated with TSC1 activity 255. In murine models of spinal cord injury, inhibition of mTOR and activation of autophagy lead to reduced neuronal tissue damage and improved locomotor function 159.

Future perspectives

Neurodegenerative disorders impact a significant proportion of the global population and are increasing in incidence as a result of the extended lifespan enjoyed by individuals throughout the world. Currently, acute and chronic neurodegenerative diseases impact more than 30 million individuals globally, but treatments to prevent death or disability for these disorders are limited. mTOR, a 289‐kDa serine/threonine protein kinase, offers stimulating possibilities to provide novel treatment strategies for multiple neurodegenerative disorders that include AD, PD, HD, epilepsy, stroke and trauma. In particular, strategies that can modulate mTOR activity with lamotrigine for the treatment of epilepsy and everolimus for the treatment of subependymal giant cell astrocytoma are already in play and approved by the FDA.

Yet, a number of considerations must be addressed for the development of efficacious and safe strategies that employ mTOR signalling. First, mTOR has an important role in stem cell development and proliferation that may be critical for reparative processes in the nervous system, but close modulation of mTOR pathways is required to optimize clinical utility. Neuronal stem cell production and proliferation are closely dependent upon mTOR activity 8, 186, 188, 189, 190. Loss of mTOR activity can lead to impaired stem cell self‐renewal. In addition, ageing appears to deplete mTOR stores that results in the loss of neural stem cells. Maintaining the activation of mTOR under these conditions could assist with the repair of injured tissue as well as assist with treatments for cognitive loss. Yet, some levels of mTOR activity can promote the differentiation of stem cells into non‐neuronal cells that may be an undesired clinical outcome and could further tissue injury.

As a second consideration, mTOR signalling has the potential to promote tumourigenesis, an outcome that must be avoided when considering repair and regeneration in the nervous system. The role of mTOR during tumour growth is complex and involves not only the level of mTOR activation, but also the association of mTOR with other proliferative pathways that either can foster tumour growth or function to block metastatic disease. Considering that mTOR is a proliferative agent, mTOR activity is usually restricted for the treatment of cancer. mTOR activity can result in neurofibromatosis type 1, TSC, Lhermitte‐Duclos disease and glioblastoma multiforme 19. The FDA has approved ‘rapalogues’ that inhibit mTOR to treat tumours associated with TSC, renal cancer and neuroendocrine pancreatic tumours 25, 68. Recent work also suggests that mTOR activity in neurons may foster high grade glioma proliferation in neural and oligodendroglial precursor cells 256, 257. mTOR signalling can promote cancer stem cell growth 258 and has been correlated with chemotherapy resistance of breast cancer cells with stem cell characteristics 259. In regards to the association of mTOR with other proliferative mechanisms, growth factors that rely upon mTOR signalling, such as EPO, may lead to cancer 260, 261, 262 and blood–brain barrier injury 263 during prolonged treatment regimens. Down‐stream signalling pathways of EPO, such as Wnt and WISP1, also can lead to unchecked cellular growth. Wnt signalling may result in glioma proliferation 264, 265, metastatic disease 266, 267, 268, 269 and malignant melanoma 270. Variants of WISP1 can promote distant metastatic disease 271. However, in potential association with mTOR, non‐variant WISP1 expression can block tumour cell invasion, motility and metastatic disease 272. Under these conditions, mTOR may limit the excessive cell growth that is promoted by Wnt signalling. mTOR activation has been shown to maintain cell senescence and prevent tumour cell growth that is promoted by Wnt 273.

The role of mTOR in programmed cell death pathways also is a challenge for the development of new treatment options. Under many conditions, mTOR activation is protective against apoptotic pathways for both early membrane PS externalization and later DNA degradation. Through these pathways, mTOR can regulate immune cell activity and prevent the removal of functional cells that may be marked for disposal by nervous system microglia 72, 97, 210, 230, 250, 274. Acute and chronic injury in the nervous system can be ameliorated through activation of mTOR signalling pathways. Yet, pathways tied to mTOR, such as EPO, WISP1 and SIRT1, can require a controlled level of mTOR activity to protect neurons through inhibition of apoptosis in conjunction with autophagic pathways 39, 97, 117, 174, 175, 275. For disorders in the nervous system, toxic cellular and extracellular accumulations that can involve AD, PD and HD may require the induction of autophagy to halt progression of these disorders 7, 136, 162, 209. These circumstances may argue for the inhibition of mTOR activity to promote autophagic pathways. However, it is sometimes unclear which particular components of the mTOR pathway are required for clinical success. Some work suggests that combined inhibition of mTORC1 and mTORC2 is required for autophagy for the treatment of disorders, such as HD 226. mTORC1 and mTORC2 also may be necessary in astrocytes for GLT‐1 expression that would promote glutamate uptake during brain ischaemia and limit ischaemic injury 252. In addition, autophagy is not consistently protective 144, 178, 179, 180. In some cases, induction of autophagy may proceed independently of mTOR 210, suggesting that the development of treatment strategies for progressive neurodegeneration may require careful control of mTOR activity and the induction of autophagy. Alternatively, severely limiting mTOR activity in disorders such as AD, PD and HD to promote autophagy may yield unexpected detrimental effects that involve new or progressive cognitive dysfunction. Loss of mTOR signalling can impair long term potentiation, synaptic plasticity, dendritic density and memory formation 92, 96, 113.

Consideration also must be given for the role mTOR holds within the PI 3‐K, Akt and mTOR axis. In many scenarios of nervous system dysfunction, mTOR does not function independently and new clinical strategies may need to seek modulation of family pathways linked to mTOR. For example, mTOR in conjunction with PI 3‐K and Akt are necessary for growth factors, such as EGF and EPO, to maintain memory function and prevent cellular injury 37, 97, 112, 113, 117. mTOR in combination with Akt is necessary to prevent mesenchymal stem cell ageing 190. Loss of Akt and mTOR signalling can injure newborn neurons and limit dendritic density formation 196. During either trauma or ischaemia to the brain, both Akt and mTOR may be required to preserve neuronal survival and restore neurological function 120, 244, 245. Autophagy also is tied to combined signalling with PI 3‐K, Akt, and mTOR 140. In a similar fashion, nervous system tumours may require therapies that adequately address the PI 3‐K, Akt and mTOR axis. Tumours of the nervous system can develop resistance to agents that inhibit mTOR signalling 276, since these cancers may have an abnormal increased basal activity of PI 3‐K, Akt and mTOR 277. Inhibition of only the mTOR pathway without controlling the activity of PI 3‐K or Akt can lead to a poor clinical response and ineffective blockade of cell tumour cell proliferation 277. Other studies indicate that blockade of mTORC1 can result in the feedback activation of PI 3‐K, Akt and Ras‐mitogen activated protein kinase (MAPK) signalling that can lead to further neoplastic growth 278, 279. Treatments with current strategies that block mTOR, such as rapamycin or its derivative compounds, also have additional limitations with toxicity that include oral and respiratory infections, stomatitis, hypertriglyceridaemia, hypercholesterolaemia, leukopenia and immunosuppression 241, 280, 281. mTOR offers great promise and exciting avenues for drug development for disorders of the nervous system, but future focus will need to target several critical considerations for the generation of rewarding clinical outcomes.

Competing Interests

The author has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares support from American Diabetes Association, American Heart Association, NIH NIEHS, NIH NIA, NIH NINDS and NIH ARRA for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years and no other relationships or activities that could appear to have influenced the submitted work.

This research was supported by the following grants to Kenneth Maiese: American Diabetes Association, American Heart Association, NIH NIEHS, NIH NIA, NIH NINDS and NIH ARRA.

Maiese, K. (2016) Targeting molecules to medicine with mTOR, autophagy and neurodegenerative disorders. Br J Clin Pharmacol, 82: 1245–1266. doi: 10.1111/bcp.12804.