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Tsai JJ, Wu T, Leung H, Desudchit T, Tiamkao S, Lim KS, Dash A. Perampanel, an AMPA receptor antagonist: From clinical research to practice in clinical settings. Acta Neurol Scand 2018; 137:378-391. [PMID: 29214650 DOI: 10.1111/ane.12879] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2017] [Indexed: 12/21/2022]
Abstract
Epileptic seizures are refractory to treatment in approximately one-third of patients despite the recent introduction of many newer antiepileptic drugs (AEDs). Development of novel AEDs therefore remains a high priority. Perampanel is a first-in-class non-competitive selective AMPA receptor antagonist with a unique mechanism of action. Clinical efficacy and safety of perampanel as adjunctive treatment for focal seizures with/without secondary generalization (±SG) and primary generalized tonic-clonic (PGTC) seizures have been established in five phase 3 randomized controlled trials (RCTs), and a long-term extension study, and perampanel is approved as monotherapy for focal seizures ±SG in the USA. In patients with focal seizures ±SG, add-on perampanel resulted in median percent reduction in seizure frequency 23.3%-34.5% and ≥50% responder rate 28.5%-37.6%; in PGTC seizures, these results were 76.5% and 64.2%, respectively. Efficacy among adolescents (reduction in seizure frequency 34.8%-35.6%; ≥50% responder rate 40.9%-45.0%) and elderly people (reduction in seizure frequency 12.5%-16.9%; ≥50% responder rate 22.2%-42.9%) is similar to those in adults, and results remain comparable between Asian (reduction in seizure frequency 17.3%-38.0%) and global populations. Perampanel has been extensively studied in real-world clinical practice, with similar efficacy and safety results to the RCTs (≥50% responder rate 12.8%-75.0%; adverse events of somnolence/sedation, dizziness, ataxia, and behavioral changes). Real-world observational studies suggest that perampanel tolerability can be improved by slow titration (2 mg every 2-4 weeks), and bedtime administration can mitigate somnolence and dizziness. Counseling about the potential for behavioral changes and close monitoring are recommended.
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Affiliation(s)
- J.-J. Tsai
- Department of Neurology; National Cheng Kung University Hospital and School of Medicine; National Cheng Kung University; Tainan Taiwan
| | - T. Wu
- Department of Neurology; Chang Gung Memorial Hospital; Chang Gung University; Taoyuan City Taiwan
| | - H. Leung
- Department of Medicine and Therapeutics; Faculty of Medicine; Prince of Wales Hospital; Hong Kong Hong Kong
| | - T. Desudchit
- Department of Paediatrics; King Chulalongkorn Memorial Hospital; Bangkok Thailand
| | - S. Tiamkao
- Integrated Epilepsy Research Group; Department of Medicine; Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - K.-S. Lim
- Division of Neurology; Department of Medicine; Faculty of Medicine; University of Malaya; Kuala Lumpur Malaysia
| | - A. Dash
- Eisai Singapore Pte. Ltd.; Singapore
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Abstract
PURPOSE OF REVIEW Recent advances in our understanding of seizure generation have resulted in modified recommendations for when seizure treatment should be initiated, revisions to our definition of status epilepticus, and new pharmacological and neuromodulatory therapies. The goal of this review is to provide the anesthesiologist with an overview of the advancements they are most likely to encounter while providing clinical care. RECENT FINDINGS There have been recent modifications to seizure definitions and treatment recommendations. These include the idea that treatment with antiepileptic therapy should be initiated after the first unprovoked seizure in individuals who are at high risk for another seizure, and that the idea that status epilepticus should be thought of as a two-phase process, related to an initial phase after which intervention should be started, and a second phase after which time risk of long-term sequelae is increased. Additionally, several new therapies have become available that have novel mechanisms of action, which are more efficacious and have fewer side-effects. SUMMARY As knowledge about mechanisms of seizure generation has improved, there has been a concurrent evolution in our thinking about seizure-related definitions, and indications for initiation of treatment. Several next generation drug therapies with more specific targets have also become available. Taken together, there have been significant improvements in care options.
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Affiliation(s)
- Lia D Ernst
- aDepartment of Neurology, Oregon Health & Science University bEpilepsy Center of Excellence, VA Portland Healthcare System cDepartment of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
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Rybka S, Obniska J, Żmudzki P, Koczurkiewicz P, Wójcik-Pszczoła K, Pękala E, Bryła A, Rapacz A. Synthesis and Determination of Lipophilicity, Anticonvulsant Activity, and Preliminary Safety of 3-Substituted and 3-Unsubstituted N-[(4-Arylpiperazin-1-yl)alkyl]pyrrolidine-2,5-dione Derivatives. ChemMedChem 2017; 12:1848-1856. [PMID: 29045762 DOI: 10.1002/cmdc.201700539] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 10/14/2017] [Indexed: 01/30/2023]
Abstract
A new series of 1,3-substituted pyrrolidine-2,5-dione derivatives as potential anticonvulsant agents are described. Initial pharmacological screening of these compounds was performed by using acute models of seizures (MES and scPTZ tests) in mice after intraperitoneal administration. Quantitative pharmacological research revealed that the most promising compounds were N-[{4-(3-trifluoromethylphenyl)piperazin-1-yl}propyl]-3-benzhydrylpyrrolidine-2,5-dione monohydrochloride (11) with a ED50 value of 75.9 mg kg-1 (MES test) and N-[{4-(3,4-dichlorophenyl)piperazin-1-yl}ethyl]-3-methylpyrrolidine-2,5-dione monohydrochloride (18) with ED50 =88.2 mg kg-1 (MES test) and ED50 =65.7 kg mg-1 (scPTZ test). These compounds displayed a more beneficial protective index than well-known antiepileptic drugs. A plausible mechanism of action of compounds 11 and 18 [molecule 11 blocked the sodium channel (site 2) and 18 blocked both the sodium (site 2) and L-type calcium channels] and their preliminary safety in vitro were evaluated. Besides, the lipophilicity of all synthesized compounds was determined by using UPLC-MS.
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Affiliation(s)
- Sabina Rybka
- Department of Medicinal Chemistry, Faculty of Pharmacy, Jagiellonian University, Medical College, 9 Medyczna Street, 30-688, Kraków, Poland
| | - Jolanta Obniska
- Department of Medicinal Chemistry, Faculty of Pharmacy, Jagiellonian University, Medical College, 9 Medyczna Street, 30-688, Kraków, Poland
| | - Paweł Żmudzki
- Department of Medicinal Chemistry, Faculty of Pharmacy, Jagiellonian University, Medical College, 9 Medyczna Street, 30-688, Kraków, Poland
| | - Paulina Koczurkiewicz
- Department of Pharmaceutical Biochemistry, Faculty of Pharmacy, Jagiellonian University, Medical College, 9 Medyczna Street, 30-688, Kraków, Poland
| | - Katarzyna Wójcik-Pszczoła
- Department of Pharmaceutical Biochemistry, Faculty of Pharmacy, Jagiellonian University, Medical College, 9 Medyczna Street, 30-688, Kraków, Poland
| | - Elżbieta Pękala
- Department of Pharmaceutical Biochemistry, Faculty of Pharmacy, Jagiellonian University, Medical College, 9 Medyczna Street, 30-688, Kraków, Poland
| | - Adrian Bryła
- Department of Pharmacodynamics, Faculty of Pharmacy, Jagiellonian University, Medical College, 9 Medyczna Street, 30-688, Kraków, Poland
| | - Anna Rapacz
- Department of Pharmacodynamics, Faculty of Pharmacy, Jagiellonian University, Medical College, 9 Medyczna Street, 30-688, Kraków, Poland
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Vavers E, Svalbe B, Lauberte L, Stonans I, Misane I, Dambrova M, Zvejniece L. The activity of selective sigma-1 receptor ligands in seizure models in vivo. Behav Brain Res 2017; 328:13-18. [PMID: 28389336 DOI: 10.1016/j.bbr.2017.04.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/06/2017] [Accepted: 04/03/2017] [Indexed: 12/12/2022]
Abstract
Sigma-1 receptor (Sig1R) is a ligand-regulated protein which, since its discovery, has been widely studied as a novel target to treat neurological disorders, including seizures. However, the roles and mechanisms of Sig1R in the regulation of seizures are not fully understood. The aim of the present study was to test and compare effects of often used selective Sig1R ligands in models of experimentally induced seizures. The anti-seizure activities and interactions of selective Sig1R agonist PRE-084, selective Sig1R antagonist NE-100 and novel positive allosteric Sig1R modulator E1R were evaluated in pentylenetetrazol (PTZ) and (+)-bicuculline (BIC)-induced seizure models in mice. Sig1R antagonist NE-100 at a dose of 25mg/kg demonstrated pro-convulsive activity on PTZ-induced seizures. Agonist PRE-084 did not change the thresholds of chemoconvulsant-induced seizures. Positive allosteric modulator E1R at a dose of 50mg/kg showed anti-convulsive effects on PTZ- and BIC-induced clonic and tonic seizures. The anti-seizure activity of E1R was blocked by NE-100. Surprisingly, NE-100 at a dose of 50mg/kg induced convulsions, but E1R significantly alleviated the convulsive behaviour induced by NE-100. In conclusion, the selective Sig1R antagonist NE-100 induced seizures that could be partially attenuated by positive allosteric Sig1R modulator. Our results confirm that Sig1R could be a novel molecular target for new anti-convulsive drugs.
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Affiliation(s)
- Edijs Vavers
- Latvian Institute of Organic Synthesis, Aizkraukles Str. 21, Riga, LV-1006, Latvia; Riga Stradins University, Dzirciema Str. 16, Riga, LV-1007, Latvia.
| | - Baiba Svalbe
- Latvian Institute of Organic Synthesis, Aizkraukles Str. 21, Riga, LV-1006, Latvia
| | - Lasma Lauberte
- Latvian Institute of Organic Synthesis, Aizkraukles Str. 21, Riga, LV-1006, Latvia
| | | | - Ilga Misane
- JSC Grindeks, Krustpils Str. 53, Riga, LV-1057, Latvia
| | - Maija Dambrova
- Latvian Institute of Organic Synthesis, Aizkraukles Str. 21, Riga, LV-1006, Latvia; Riga Stradins University, Dzirciema Str. 16, Riga, LV-1007, Latvia
| | - Liga Zvejniece
- Latvian Institute of Organic Synthesis, Aizkraukles Str. 21, Riga, LV-1006, Latvia
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Matias M, Campos G, Silvestre S, Falcão A, Alves G. Early preclinical evaluation of dihydropyrimidin(thi)ones as potential anticonvulsant drug candidates. Eur J Pharm Sci 2017; 102:264-274. [DOI: 10.1016/j.ejps.2017.03.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 02/19/2017] [Accepted: 03/10/2017] [Indexed: 11/28/2022]
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Zaccara G, Giovannelli F, Giorgi FS, Franco V, Gasparini S, Benedetto U. Tolerability of new antiepileptic drugs: a network meta-analysis. Eur J Clin Pharmacol 2017; 73:811-817. [PMID: 28378057 DOI: 10.1007/s00228-017-2245-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/28/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The objective of this study was to perform a comparative assessment of tolerability of all licensed new antiepileptic drugs (AEDs) through a network meta-analysis (NMA) including all placebo-controlled double-blind clinical trials (RCTs) in all conditions in which these drugs have been tested. METHODS NMA with a frequentist approach was used to compare proportions of patients withdrawing because of adverse events (AEs). Analyses were conducted for all therapeutic doses pooled and specifically for high therapeutic doses. Patients treated with non-therapeutic doses of each drug were excluded. RESULTS A total of 195 RCTs were included in the current analysis, comprising a total of 28,013 patients treated with AEDs and 17,908 patients treated with placebo. RCTs included in the analysis were 8 for brivaracetam; 5 for eslicarbazepine; 22 for gabapentin; 7 for lacosamide; 14 for levetiracetam; 14 for lamotrigine; 6 for oxcarbazepine; 9 for perampanel; 50 for pregabalin; 5 for tiagabine; 36 for topiramate; 7 for zonisamide; 4 for gabapentin-extended formulation (ER); 2 each for levetiracetam-ER, lamotrigine-ER, and topiramate-ER; and 1 each for oxcarbazepine-ER and pregabalin-ER. Brivaracetam, gabapentin, gabapentin-ER, and levetiracetam had a significantly lower withdrawal rate compared to several other AEDs, while eslicarbazepine, lacosamide, oxcarbazepine, and topiramate had a higher withdrawal rate. Perampanel, lamotrigine, pregabalin, tiagabine, and zonisamide showed an intermediate pattern of tolerability. Additional analysis has been conducted through selection of highly recommended doses for each drug. This analysis has roughly confirmed results of head to head comparisons of the all-dose analysis, with some exceptions. A further analysis has been conducted after exclusion of RCTs in which patients were allocated to the therapeutic dose of the experimental drug without titration, and it failed to show clinically important differences. SIGNIFICANCE Relevant differences in short-term tolerability of AEDs have been observed between AEDs. Brivaracetam, gabapentin, and levetiracetam show the best tolerability profile while other AEDs are at higher risk for intolerable adverse effects.
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Affiliation(s)
- Gaetano Zaccara
- Department of Medicine, Unit of Neurology, Florence Health Authority, Florence, Italy
| | - Fabio Giovannelli
- Department of Medicine, Unit of Neurology, Florence Health Authority, Florence, Italy. .,Department of Neuroscience, Psychology, Pharmacology and Child Health (NEUROFARBA), University of Florence, Florence, Italy.
| | | | - Valentina Franco
- Department of Internal Medicine and Therapeutics, Division of Clinical and Experimental Pharmacology, University of Pavia, Pavia, Italy
| | - Sara Gasparini
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Umberto Benedetto
- School of Clinical Science, Bristol Heart Institute, University of Bristol, Bristol, UK
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Shih JJ, Whitlock JB, Chimato N, Vargas E, Karceski SC, Frank RD. Epilepsy treatment in adults and adolescents: Expert opinion, 2016. Epilepsy Behav 2017; 69:186-222. [PMID: 28237319 DOI: 10.1016/j.yebeh.2016.11.018] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 11/11/2016] [Accepted: 11/14/2016] [Indexed: 01/12/2023]
Abstract
INTRODUCTION There are over twenty anti-seizure medications and anti-seizure devices available commercially in the United States. The multitude of treatment options for seizures can present a challenge to clinicians, especially those who are not subspecialists in the epilepsy field. Many clinical questions are not adequately answered in double-blind randomized controlled studies. In the presence of a knowledge gap, many clinicians consult a respected colleague with acknowledged expertise in the field. Our survey was designed to provide expert opinions on the treatment of epilepsy in adults and adolescents. METHOD We surveyed a group of 42 physicians across the United States who are considered experts based on publication record in the field of epilepsy, or a leadership role in a National Association of Epilepsy Centers comprehensive epilepsy program. The survey consisted of 43 multiple-part patient scenario questions and was administered online using Redcap software. The experts provided their opinion on 1126 treatment options based on a modified Rand 9-point scale. The patient scenarios focused on genetically-mediated generalized epilepsy and focal epilepsy. The scenarios first focused on overall treatment strategy and then on specific pharmacotherapies. Other questions focused on treatment of specific patient populations (pregnancy, the elderly, patients with brain tumors, and post organ transplant patients), epilepsy patients with comorbidities (renal and hepatic disease, depression), and how to combine medications after failure of monotherapy. Statistical analysis of data used the expert consensus method. RESULTS Valproate was considered a drug of choice in all genetically-mediated generalized epilepsies, except in the population of women of child-bearing age. Ethosuximide was a drug of choice in patient with absence seizures, and levetiracetam was a drug of choice in patients with genetic generalized tonic-clonic seizures and myoclonic seizures. Lamotrigine, levetiracetam and oxcarbazepine were considered drugs of choice for initial treatment of focal seizures. Lamotrigine and levetiracetam were the drugs of choice for women of child-bearing age with either genetic generalized epilepsy or focal epilepsy. Lamotrigine and levetiracetam were the drugs of choice in the elderly population. Lamotrigine was preferred in patients with co-morbid depression. Levetiracetam was the drug of choice in treating patients with hepatic failure, or who have undergone organ transplantation. Compared to the 2005 and 2001 surveys, there was increased preference for the use of levetiracetam and lamotrigine, and decreased preference for the use of phenytoin, gabapentin, phenobarbital and carbamazepine. DISCUSSION The study presented here provides a "snapshot" of the clinical practices of experts in the treatment of epilepsy. The experts were very often in agreement, and reached consensus in 81% of the possible responses. However, expert opinion does not replace the medical literature; instead, it acts to supplement existing information. Using the study results is similar to requesting an expert consultation. Our findings suggest options that the clinician should consider to achieve best practice.
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Affiliation(s)
- Jerry J Shih
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States.
| | - Julia B Whitlock
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
| | - Nicole Chimato
- Department of Health Sciences and Research, Mayo Clinic, Jacksonville, FL, United States
| | - Emily Vargas
- Department of Health Sciences and Research, Mayo Clinic, Jacksonville, FL, United States
| | - Steven C Karceski
- Department of Neurology, Weill Cornell Medical Center, New York, NY, United States
| | - Ryan D Frank
- Department of Health Sciences and Research, Mayo Clinic, Jacksonville, FL, United States
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Matias M, Silvestre S, Falcão A, Alves G. Gastrodia elata and epilepsy: Rationale and therapeutic potential. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2016; 23:1511-1526. [PMID: 27765372 DOI: 10.1016/j.phymed.2016.09.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 08/29/2016] [Accepted: 09/03/2016] [Indexed: 05/25/2023]
Abstract
BACKGROUND Gastrodia elata Blume (G. elata) is a traditional Chinese herb used for centuries in folk medicine. Due to the claimed anticonvulsant properties of G. elata, it is expected that this herb continues to be a target of research, aiming to deepen the available knowledge on its biological activity and safety. PURPOSE The current review aims to discuss the most recent advances on the elucidation of the phytochemical composition and anticonvulsant potential of G. elata. METHODS Available literature was reviewed from PubMed, ISI Web of Knowledge and Science Direct, using combinations of the following keywords: Gastrodia elata, tianma, epilepsy, anticonvulsant and pharmacokinetics. Abstracts and full texts were evaluated for their clarity and scientific merit. RESULTS G. elata rhizome, as well as specific phenolic compounds isolated from this herb, have demonstrated anticonvulsant potential in a variety of in vitro and in vivo models. The pharmacological mechanisms potentially involved in the anticonvulsant activity have been extensively studied, being similar to the known mechanisms claimed for the available antiepileptic drugs. In addition, the pharmacokinetics of the main bioactive component of G. elata (gastrodin) has also been studied. CONCLUSION Due to its recognised therapeutic properties, G. elata has gained an increasing interest within the scientific community and, therefore, new medicinal preparations containing G. elata rhizome itself or its bioactive components are expected to be developed in the coming years. Moreover, specific phytochemical constituents isolated from G. elata may also be considered to integrate programs of discovery and development of new anticonvulsant drug candidates.
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Affiliation(s)
- Mariana Matias
- CICS-UBI - Health Sciences Research Centre, University of Beira Interior, Rua Marquês d'Ávila e Bolama, 6201-001 Covilhã, Portugal; CNC - Center for Neuroscience and Cell Biology, University of Coimbra, 3004-517 Coimbra, Portugal
| | - Samuel Silvestre
- CICS-UBI - Health Sciences Research Centre, University of Beira Interior, Rua Marquês d'Ávila e Bolama, 6201-001 Covilhã, Portugal; CNC - Center for Neuroscience and Cell Biology, University of Coimbra, 3004-517 Coimbra, Portugal
| | - Amílcar Falcão
- CNC - Center for Neuroscience and Cell Biology, University of Coimbra, 3004-517 Coimbra, Portugal; Department of Pharmacology, Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal
| | - Gilberto Alves
- CICS-UBI - Health Sciences Research Centre, University of Beira Interior, Rua Marquês d'Ávila e Bolama, 6201-001 Covilhã, Portugal; CNC - Center for Neuroscience and Cell Biology, University of Coimbra, 3004-517 Coimbra, Portugal.
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De Sarro G. Managing epilepsy in the third millenium: Recent achievements and future perspectives. Pharmacol Res 2016; 113:332-334. [PMID: 27594420 DOI: 10.1016/j.phrs.2016.08.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 08/27/2016] [Indexed: 12/30/2022]
Affiliation(s)
- Giovambattista De Sarro
- Department of Science of Health, Clinical Pharmacology and Pharmacovigilance Unit, School of Medicine and Surgery, University of Catanzaro, Italy.
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Analgesic opioid use in a health-insured epilepsy population during 2012: Response to Derakhshan. Epilepsy Behav 2016; 60:239. [PMID: 27220566 DOI: 10.1016/j.yebeh.2016.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 04/04/2016] [Indexed: 11/20/2022]
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Citraro R, Leo A, Constanti A, Russo E, De Sarro G. mTOR pathway inhibition as a new therapeutic strategy in epilepsy and epileptogenesis. Pharmacol Res 2016; 107:333-343. [DOI: 10.1016/j.phrs.2016.03.039] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/23/2016] [Accepted: 03/31/2016] [Indexed: 12/24/2022]
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