Finding a better drug for epilepsy: preclinical screening strategies and experimental trial design

Issues for new antiepilepsy drug development

PURPOSE OF REVIEW

Preclinical research in epileptology has been very successful in producing effective drugs. Unfortunately, however, seizures are still not adequately controlled in a third of the affected individuals, and comorbidities still impose a major burden on the quality of life. New preclinical and clinical drug development strategies are needed to identify drugs that target these unmet medical needs.

RECENT FINDINGS

Even in recent years, the antiseizure approach based on screenings has contributed to the identification of new drugs. Thus, it should not be abandoned. However, we propose that a radically new approach, specifically designed to tackle the existing gaps in care, should be developed to complement the traditional screening. This new approach will require integrated strategies for preclinical screening and experimental trial design. In this review, we will attempt to address some of the issues that must be resolved to engage this effort. Are there suitable models to tackle the unmet therapeutic needs in epilepsy? Are there ways to de-risk the transition from preclinical to clinical studies? Are there ways to improve the efficiency of clinical trials and to design ad hoc trials for the unmet therapeutic needs?

SUMMARY

Development and validation of a new, integrated strategy for antiepilepsy drug development is needed to identify truly innovative drugs.

Role of hormones and neurosteroids in epileptogenesis

This article describes the emerging evidence of hormonal influence on epileptogenesis, which is a process whereby a brain becomes progressively epileptic due to an initial precipitating event of diverse origin such as brain injury, stroke, infection, or prolonged seizures. The molecular mechanisms underlying the development of epilepsy are poorly understood. Neuroinflammation and neurodegeneration appear to trigger epileptogenesis. There is an intense search for drugs that truly prevent the development of epilepsy in people at risk. Hormones play an important role in children and adults with epilepsy. Corticosteroids, progesterone, estrogens, and neurosteroids have been shown to affect seizure activity in animal models and in clinical studies. However, the impact of hormones on epileptogenesis has not been investigated widely. There is emerging new evidence that progesterone, neurosteroids, and endogenous hormones may play a role in regulating the epileptogenesis. Corticosterone has excitatory effects and triggers epileptogenesis in animal models. Progesterone has disease-modifying activity in epileptogenic models. The antiepileptogenic effect of progesterone has been attributed to its conversion to neurosteroids, which binds to GABA-A receptors and enhances phasic and tonic inhibition in the brain. Neurosteroids are robust anticonvulsants. There is pilot evidence that neurosteroids may have antiepileptogenic properties. Future studies may generate new insight on the disease-modifying potential of hormonal agents and neurosteroids in epileptogenesis.

New drug classes for the treatment of partial onset epilepsy: focus on perampanel

Perampanel (2-[2-oxo-1-phenyl-5-pyridin-2-yl-1,2-dihydropyridin-3-yl] benzonitrile hydrate) is the latest in the line of new antiepileptic drugs with a novel mechanism of action. Perampanel inhibits α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA)-induced increases in intracellular Ca²⁺ and selectively blocks AMPA receptor-mediated synaptic transmission, thus reducing neuronal excitation. Three Phase III multicenter, randomized, double-blind, placebo-controlled trials demonstrated the efficacy and good tolerability of perampanel as adjunctive treatment in patients with refractory partial-onset seizures. The drug is approved for use in the European Union and United States, with expected release onto the American market in June–September 2013, pending US Drug Enforcement Agency classification. The pharmacology of perampanel offers potential as more than just another new antiepileptic drug. This first-in-class drug will provide another option for practitioners of rational polytherapy. As an AMPA-receptor antagonist, perampanel may possess antiepileptogenic properties in addition to its demonstrated antiseizure properties.

Electroacupuncture-induced attenuation of experimental epilepsy: a comparative evaluation of acupoints and stimulation parameters

The efficacy of electroacupuncture (EA) on epilepsy remains to be verified because of previous controversies that might be due to the complexity of the effects induced by different acupoints and stimulation approaches adopted. Therefore, we investigated the effects of EA on epilepsy to determine the specific acupoints and optimal stimulation parameters in this work. Experimental epilepsy was induced by injecting kainic acid to the lateral cerebral ventricle of adult male SD rats. EA with a low-frequency (10 Hz/1 mA) or high-frequency (100 Hz/1 mA) current was applied to the epileptic model for 30 minutes starting at 0.5 hour after the injection. Four pairs of acupoints were tested, that is, Shuigou (DU26) + Dazhui (DU14), Jinsuo (DU8) + Yaoqi (EXB9), Neiguan (PC6) + Quchi (LI11), and Fenglong (ST40) + Yongquan (KI1). We found that (1) low- or high-frequency EA at different acupoints reduced epileptic seizures (P < 0.05 versus the control) with an exception of low-frequency EA at Neiguan (PC6) and Quchi (LI11); (2) low-frequency EA induced a better effect at Fenglong (ST40) plus Yongquan (KI1) than that of the other acupoints (P < 0.05); (3) there is no significant difference in the effects of high-frequency EA at these acupoints; and (4) the high-frequency EA elicited a greater effect than that of low-frequency EA in all groups (P < 0.05), with an exception at Jinsuo (DU8) + Yaoqi (EXB9). The EA-induced attenuation appeared 1–1.5 hours after EA with no appreciable effect in the first hour after EA in either the EEG or the behavioral tests. We conclude that EA attenuation of epileptic seizures is dependent on the stimulation parameters and acupoints and that the delay in appearance of the EA effect could be a reflection of the time required by the EA signal to regulate neural function in the central nervous system.

The epilepsies: complex challenges needing complex solutions

It is widely accepted that epilepsies are complex syndromes due to their multi-factorial origins and manifestations. Different mathematical and computational descriptions use appropriate methods to address nonlinear relationships, chaotic behaviors and emergent properties. These theoretical approaches can be divided into two major categories: descriptive, such as flowcharts, graphs and other statistical analyses, and explicative, which include both realistic and abstract models. Although these modeling tools have brought great advances, a common framework to guide their design, implementation and evaluation, with the goal of future integration, is still needed. In the current review, we discuss two examples of complexity analysis that can be performed with epilepsy data: behavioral sequences of temporal lobe seizures and alterations in an experimental cellular model. We also highlight the importance of the creation of model repositories for the epileptology field and encourage the development of mathematical descriptions of complex systems, together with more accurate simulation techniques.

New vistas on astroglia in convulsive and non-convulsive epilepsy highlight novel astrocytic targets for treatment

Our current knowledge of the role of astrocytes in health and disease states supports the view that many physiological brain functions and neurological diseases are finely tuned, and in certain cases fully determined, by the continuous cross-talk between astrocytes and neurons. This novel way of interpreting brain activity as a dynamic and reciprocal interplay between astrocytic and neuronal networks has also influenced our understanding of epilepsy, not only forcing a reinterpretation of old findings, but also being a catalyst for novel experimentation. In this review, we summarize some of the recent studies that highlight these novel distinct contributions of astrocytes to the expression of convulsive and non-convulsive epileptiform discharges and seizures. The emerging picture suggests a general framework based on bilateral signalling between astrocytes and neurons for a fuller understanding of epileptogenic and epileptic mechanisms in the brain network. Astrocytes potentially represent targets for the development of those novel chemical entities with improved efficacy for the treatment of convulsive and non-convulsive epilepsy that expert groups have recognized as one of the key priorities for the management of epilepsy.