Sustained-release oral fampridine in multiple sclerosis: a randomised, double-blind, controlled trial

New approaches in the management of multiple sclerosis

Multiple sclerosis (MS) is a central nervous system chronic inflammatory disease that is characterized by an extensive and complex immune response. Scientific advances have occurred in immunology, pathophysiology, and diagnostic and clinical assessment tools, and recent discovery of unique therapeutic targets has spurred numerous Phase II and Phase III clinical trials. Reductions in MS relapse rates and improvements in T₂ or gadolinium-enhancing lesion burdens have been reported from Phase III trials that include fingolimod, alemtuzumab, cladribine, and rituximab. Promising Phase II trial data exist for teriflunomide, daclizumab, laquinimod, and fumarate. The optimism created by these favorable findings must be tempered with evaluation of the adverse effect profile produced by these new agents. Given the discovery of progressive multifocal leukoencephalopathy with the use of natalizumab, ongoing vigilance for rare and life-threatening reactions due to new agents should be paramount. Patients with MS often experience difficulty with ambulation, spasticity, and cognition. Recent clinical trial data from two Phase III dalfampridine-SR trials indicate certain patients receive benefits in ambulation. This article provides an overview of data from clinical trials of newer agents of potential benefit in MS.

Walking impairment in patients with multiple sclerosis: exercise training as a treatment option

Multiple sclerosis (MS) is a chronic disease of the central nervous system that culminates in the progression of physical and cognitive disability over time. Walking impairment is a ubiquitous feature of MS and a sentinel characteristic of the later or advanced stages of the disease. This paper presents a conceptual rationale along with empirical evidence for exercise training as a rehabilitation approach for managing walking impairment and improving walking function in persons with MS. Conceptually, MS is associated with a decrease in physical activity, which, in turn, can result in deconditioning across multiple domains of physiological functioning. The resulting deconditioning feeds back and further drives physical inactivity until a threshold is reached that likely initiates the progression of walking impairment in MS. Empirically, physical activity and exercise training have been associated with beneficial effects on walking function in persons with MS. This is based on cross-sectional, longitudinal, and experimental research that included diversity in the breadth of measures of walking, persons with MS, and exercise/physical activity characteristics. Of particular importance, future researchers might consider examining the combinatory effects of exercise training plus pharmacological agents on walking mobility in MS. Collectively, exercise training and physical activity might hold significant potential for the management of progressive mobility disability in MS.

Dalfampridine extended release: in multiple sclerosis

Dalfampridine extended release (ER) is an orally administered formulation of dalfampridine (fampridine, 4-aminopyridine), a potassium channel antagonist indicated for the improvement in walking ability in patients with multiple sclerosis (MS). Oral dalfampridine ER improved walking ability in patients with MS in three randomized, double-blind trials of up to 15 weeks' duration. In a phase II trial, percentage improvements in walking speed on the Timed 25-Foot Walk (T25FW) test (primary endpoint) were not significant versus baseline or placebo during treatment with dalfampridine ER 10, 15 or 20 mg twice daily. However, according to a post hoc analysis, response rates were significantly higher with dalfampridine ER than placebo, with a consistent mean improvement in walking speed of 25-29% seen in the pooled results from dalfampridine ER responders during the double-blind treatment period. In two phase III trials, the proportion of timed walk responders (primary endpoint) was significantly greater with dalfampridine ER 10 mg twice daily than with placebo, with improvements in walking speed of approximately 25% seen during dalfampridine ER treatment amongst timed walk responders. Interim results of noncomparative extensions of the two phase III trials showed that consistent improvements in walking speed were sustained above baseline for up to 2.5 years of dalfampridine ER treatment. Oral dalfampridine ER 10 mg twice daily was generally well tolerated in patients with MS, according to the results of the three randomized, double-blind, placebo-controlled trials.

Dalfampridine for the treatment of ambulatory impairment in multiple sclerosis

Dalfampridine is a potassium-channel blocker that is approved by the US FDA as 10 mg extended-release tablets to improve walking in patients with multiple sclerosis. Approval is currently pending in Europe. This is the first pharmacological symptomatic treatment approved for multiple sclerosis patients of any type with walking difficulties. Relative to an immediate-release formulation, the extended-release formulation of dalfampridine lowers peak serum concentrations that contribute to toxicity while maintaining a comparable amount of total drug exposure. Several studies show the efficacy and tolerability of dalfampridine. The pivotal published clinical trial demonstrated a treatment–responder rate of 35% compared with an 8% placebo–responder rate (p < 0.0001). The subjects who responded to treatment had an average improvement in their 25-foot walking test time of 25.2% (95% CI: 21.5–28.8) compared with an average improvement of 4.7% (95% CI: 1.0–8.4) in subjects who responded to placebo. Seizures are the most serious adverse effect of dalfampridine with a probable dose-dependent likelihood of occurrence.

Pharmacological modulation of voltage-gated potassium channels as a therapeutic strategy

IMPORTANCE OF THE FIELD

The human genome encodes at least 40 distinct voltage-gated potassium channel subtypes, which vary in regional expression, pharmacological and biophysical properties. Voltage-dependent potassium (Kv) channels help orchestrate many of the physiological and pathophysiological processes that promote and sometimes hinder the healthy functioning of our bodies.

AREAS COVERED IN THIS REVIEW

This review summarizes patent and scientific literature reports from the past decade highlighting the opportunities that Kv channels offer for the development of new therapeutic interventions for a wide variety of disorders.

WHAT THE READER WILL GAIN

The reader will gain an insight from an analysis of the associations of different Kv family members with disease processes, summary and evaluation of the development of therapeutically relevant pharmacological modulators of these channels, particularly focusing on proprietary agents being developed.

TAKE HOME MESSAGE

Development of new drugs that target Kv channels continue to be of great interest but is proving to be challenging. Nevertheless, opportunities for Kv channel modulators to have an impact on a wide range of disorders in the future remain an exciting prospect.

New drug therapies for multiple sclerosis

PURPOSE OF REVIEW

Multiple sclerosis (MS) is an autoimmune and inflammatory disease of the central nervous system (CNS) that causes neurological disability in young adults and that to date has no cure. Until now, expensive and only partially efficacious therapies have become available. For this reason, researchers, clinicians and pharmaceutical companies are currently investigating new drugs for the treatment of MS. Here, we review the most recent data on drug candidates for MS.

RECENT FINDINGS

In the preclinical phase, such drug candidates have shown a beneficial effect on the onset of experimental autoimmune encephalomyelitis (microtubule-stabilizing drugs, MS14, Lithium, GEMSP...), a decrease in CNS cell infiltrates (recombinant T cell receptor ligand, lovastatin-rolipram, ribavirin, GEMSP...), prevention of demyelination (lovastatin-rolipram, calpain inhibitor, lithium...); and a reduction of axonal loss (phenytoin, lovastatin-rolipram, calpain inhibitor). In clinical trials, drug candidates against MS have shown safety (rituximab, ustekinumab, intravenous immunoglobulin, laquinimod, BHT-3009, fumarate, chaperonin 10, GEMSP...), an improvement of gadolinium-enhanced lesions (protiramer, fingolimod, laquinimod, BHT-3009, fumarate, daclizumab...), and an improvement of the relapse rate (fingolimod, fumarate...).

SUMMARY

Future research into MS should focus on a combination of therapies and on the development of drugs directed against the remitting and progressive phases of the disease. In this sense, MS is a very complex multifactorial disease that requires treatment able to cover all the aspects of MS and not only the anti-inflammatory aspect.

Thermoregulation in multiple sclerosis

Multiple sclerosis (MS) is a progressive neurological disorder that disrupts axonal myelin in the central nervous system. Demyelination produces alterations in saltatory conduction, slowed conduction velocity, and a predisposition to conduction block. An estimated 60-80% of MS patients experience temporary worsening of clinical signs and neurological symptoms with heat exposure. Additionally, MS may produce impaired neural control of autonomic and endocrine functions. This review focuses on five main themes regarding the current understanding of thermoregulatory dysfunction in MS: 1) heat sensitivity; 2) central regulation of body temperature; 3) thermoregulatory effector responses; 4) heat-induced fatigue; and 5) countermeasures to improve or maintain function during thermal stress. Heat sensitivity in MS is related to the detrimental effects of increased temperature on action potential propagation in demyelinated axons, resulting in conduction slowing and/or block, which can be quantitatively characterized using precise measurements of ocular movements. MS lesions can also occur in areas of the brain responsible for the control and regulation of body temperature and thermoregulatory effector responses, resulting in impaired neural control of sudomotor pathways or neural-induced changes in eccrine sweat glands, as evidenced by observations of reduced sweating responses in MS patients. Fatigue during thermal stress is common in MS and results in decreased motor function and increased symptomatology likely due to impairments in central conduction. Although not comprehensive, some evidence exists concerning treatments (cooling, precooling, and pharmacological) for the MS patient to preserve function and decrease symptom worsening during heat stress.

A home-based walking program using rhythmic auditory stimulation improves gait performance in patients with multiple sclerosis: a pilot study

BACKGROUND

Few interventions have been successful in improving gait dysfunction in patients with multiple sclerosis (MS). Rhythmic auditory stimulation (RAS) has demonstrated positive results on gait performance in other neurologically impaired populations.

OBJECTIVE

To measure the effects of RAS on quantitative walking parameters in ambulatory patients with MS.

METHODS

Ten MS patients with gait disturbance were randomly assigned to receive RAS versus no intervention for 2 weeks. All participants received RAS for another 2 weeks. Between weekly clinic visits, they were provided with MP3 players containing songs whose tempo was 10% above the participant's spontaneous cadence and were instructed to walk to the music 20 minutes daily. Quantitative gait parameters were measured using the GAITRite system.

RESULTS

A statistically significant decrease between groups was found for change in double-support time (left, P = .0176; right, P = .0247), whereas trends with medium to high effect sizes were found for other gait parameters, including walking speed. A pooled within-group analysis showed significant improvement of cadence, stride length, step length, velocity, and normalized velocity after 1 week of treatment. Satisfaction level with RAS was high.

CONCLUSIONS

These results in a convenience sample of MS patients demonstrate the feasibility and safety of RAS when used at home and suggest a potential benefit on gait parameters.

Axon-oligodendrocyte interactions during developmental myelination, demyelination and repair

In multiple sclerosis, CNS demyelination is often followed by spontaneous repair, mostly achieved by adult oligodendrocyte precursor cells. Extent of this myelin repair differs, ranging from very low, limited to the plaque border, to extensive, with remyelination throughout the 'shadow plaques.' In addition to restoring neuronal connectivity, new myelin is neuroprotective. It reduces axonal loss and thus disability progression. Reciprocal communication between neurons and oligodendrocytes is essential for both myelin biogenesis and myelin repair. Hence, deciphering neuron-oligodendrocyte communication is not only important for understanding myelination per se, but also the pathophysiology that underlies demyelinating diseases and the development of innovative therapeutic strategies.

Translational research in spinal cord injury: a survey of opinion from the SCI community

Much like our colleagues studying neuroprotection for acute stroke, we in the spinal cord injury (SCI) community have witnessed the preclinical emergence of numerous promising neuroprotective and neuro-regenerative treatments that have then disappointingly failed to demonstrate convincing efficacy in clinical trials. In contrast to the stroke field, the SCI community lacks guidelines to steer the preclinical development of therapies and maximize their chance of success prior to translation into expensive and laborious clinical trials. We conducted a survey of the SCI research community to garner perspectives on the question of what preclinical evidence was required before translating an experimental treatment into clinical trials. The opinions of the 324 respondents about what constitutes necessary preclinical evidence before moving to human SCI trials revealed strong support for the demonstration of efficacy in large-animal models, cervical injury models, and for independent replication of promising results. Marked differences exist between the sentiments of the respondents and the translational experience of our field. A framework for guiding the preclinical development of novel therapies prior to human translation would be helpful for ensuring clinical success. Greater dialogue on this issue is necessary to improve our chances of successfully bringing effective treatments to patients with this devastating injury.

Update on the treatment options for multiple sclerosis

Recent progress in the treatment of multiple sclerosis (MS) is remarkable, and the introduction of new therapies is yielding improvements in the management of MS. Furthermore, clinical trials with many different types of agents, especially selected monoclonal antibodies, have been undertaken or are ongoing, and some of the agents involved will probably be available as treatments for MS in the near future. Although these new and promising agents include targeted immunotherapies, some of them have limitations such as associated severe adverse events and the development of neutralizing antibodies. With regard to risk-benefit ratios, pharmacogenetics could shed light on inherited differences in drug metabolism and response, which would make individualized therapy possible in MS. Here, we review the recent progress in current therapeutic strategies for MS, and the potential options for future MS treatment.

Assessment of the cardiac safety of fampridine-SR sustained-release tablets in a thorough QT/QTc evaluation at therapeutic and supratherapeutic doses in healthy individuals

OBJECTIVE

To characterize the effects of a sustained-release formulation of fampridine (fampridine-SR) on QT interval in healthy subjects.

METHODS

In a double-blind, double-dummy trial, healthy subjects were randomized to 5 days treatment with fampridine-SR at therapeutic (10 mg twice daily) or supratherapeutic (30 mg twice daily) doses, placebo or moxifloxacin (400 mg on treatment day 5). Digital 12-lead electrocardiograms were recorded before treatment and on day 5; blood samples determined fampridine concentrations. Central tendency analysis determined whether the upper limit of the CI for the QT (individual-corrected QT; QTcI) interval change exceeded 10 ms. Outlier analysis determined new-onset QT (corrected QT; QTc) intervals; maximum change in QTc from baseline of 30 - 60 ms and maximum change from baseline >or= 60 ms. The relationship between pharmacokinetic parameters and QTcI values is explored.

RESULTS

Moxifloxacin was associated with a QTcI interval increase > 5 ms at 7 time points; no increase was observed with either dose of fampridine-SR; there were no fampridine outliers. Pharmacokinetic evaluation failed to find dose-dependent cardiac effects. Fampridine was well tolerated, with a higher frequency of adverse events at the supratherapeutic dose.

CONCLUSION

This study showed that fampridine-SR at therapeutic and supratherapeutic doses was not associated with QT prolongation in healthy subjects.

[4-Aminopyridine (Fampridine). A new attempt for the symptomatic treatment of multiple sclerosis]

Mobility limitation is a frequent clinical symptom of multiple sclerosis (MS) that poses a therapeutic challenge. For years results of animal experiments and clinical experience have indicated that the potassium channel blocker 4-aminopyridine improves axonal excitatory circuits and thus muscular strength in demyelinating diseases. A recently conducted randomized, placebo-controlled, multicenter phase 3 clinical trial in MS patients was able to show that an oral sustained-release formulation of 4-aminopyridine (Fampridine-SR) represents a suitable agent for treatment of walking disability in MS patients.This overview presents the study data and discusses the value of 4-aminopyridine for the symptomatic treatment of MS as a neurofunctional modifier of this disabling disease.

Steady-state pharmacokinetics and tolerability of orally administered fampridine sustained-release 10-mg tablets in patients with multiple sclerosis: a 2-week, open-label, follow-up study

BACKGROUND

Fampridine sustained release (SR) has generally been well tolerated in clinical studies in patients with multiple sclerosis (MS) at doses < or = 20 mg/d. The pharmacokinetics of single escalating doses of fampridine SR (5, 10, 15, and 20 mg) were evaluated in a companion study.

OBJECTIVES

The primary objective of this study, which followed on from the single-dose pharmacokinetic study, was to assess the steady-state pharmacokinetics of fampridine in patients with MS over 2 weeks of oral administration of open-label fampridine SR 20 mg BID. Tolerability was also evaluated.

METHODS

The dose of fampridine SR was titrated upward to twice-daily administration over days 1 and 2, with 20 mg given in the morning and 10 mg in the evening. From days 3 to 14, patients received fampridine SR 20 mg BID (total daily dose, 40 mg). Fampridine pharmacokinetic parameters were determined on days 1, 8, and 15. The parameters of interest included C(max), T(max), C(min), AUC, and apparent t((1/2)) These parameters were compared with those from the single-dose study. Tolerability was assessed based on adverse events, physical examinations, vital signs, laboratory tests, and ECGs.

RESULTS

Twenty-one white patients who participated in the single-dose study were enrolled in the steady-state study (52.4% female; mean [SD] age, 45.1 [7.4] years; weight range, 54-87 kg). Fampridine pharmacokinetic parameters on day 1 were consistent with those obtained in the single-dose study. The T(max) did not differ significantly between day 1, day 8, day 15, and the single-dose study (range, 3.25-3.78 hours). C(max) values on days 8 and 15 (66.7 and 62.6 ng/mL, respectively) were significantly higher than those on day 1 (48.6 ng/mL) and in the single-dose study (50.5 ng/mL) (all, P < 0.001), reflecting accumulation of fampridine with multiple dosing. Values for C(max)/C(min) did not differ significantly between day 1 and the single-dose study (2.44 and 2.43, respectively) or between days 8 and 15 (2.90 and 2.88, respectively); however, the single-dose and day-1 values differed significantly from the day-8 and day-15 values (P < or = 0.001). There were no significant differences with respect to any other pharmacokinetic parameters. One hundred adverse events were reported by 21 patients. With the exception of 1 case of severe nausea, all adverse events were of mild to moderate severity. Thirty-five events reported by 14 subjects were considered treatment related. Dizziness was the most common treatment-related adverse event, with 11 episodes reported by 8 patients. No clinically significant changes were found in clinical laboratory values, vital signs, or physical examination findings from baseline to the last visit, and there were no clinically significant changes in QTc intervals (Bazett's correction).

CONCLUSIONS

In these patients with MS, the steady-state pharmacokinetic profile of fampridine SR 20 mg BID administered for 2 weeks appeared to support the use of twice-daily dosing in this population. This dosage was generally well tolerated.

Pharmacokinetics and tolerability of single escalating doses of fampridine sustained-release tablets in patients with multiple sclerosis: a Phase I-II, open-label trial

BACKGROUND

Fampridine (4-aminopyridine) is a potassium channel-blocking agent that has been reported to have therapeutic potential for improving walking and mobility in patients with multiple sclerosis (MS). A sustained-release (SR) formulation of fampridine was developed to improve the agent's pharmacokinetic profile by extending its t((1/2)) relative to that of immediate-release fampridine.

OBJECTIVES

The primary study objective was to examine the pharmacokinetics of fampridine SR tablets after single escalating doses in patients with MS. Tolerability was evaluated as a secondary end point.

METHODS

This multicenter, Phase I-II, open-label trial evaluated the dose proportionality and tolerability of 4 single doses of fampridine SR (5, 10, 15, and 20 mg) in patients with MS. There was a 4-day washout between doses. Blood samples were collected immediately before drug administration, hourly for the first 8 hours after administration, and at 10, 12, 14, 18, and 24 hours after administration. The pharmacokinetic parameters evaluated included C(max), T(max), AUC, elimination rate constant, apparent elimination t((1/2)), and apparent CL/F. Twelve-lead ECGs were obtained at baseline (0.5 hour before dosing) and at 1, 4, 12, and 24 hours after drug administration to evaluate potential effects on the QTc interval. All adverse events, abnormal laboratory values, and ECG abnormalities were recorded and evaluated for clinical relevance. Adverse-event data were monitored for 24 hours after the last dose, and patients were instructed to report any adverse events for 14 days after the conclusion of the study.

RESULTS

Twenty-four white patients were enrolled (58% female; mean [SD] age, 45.4 [7.3] years; weight range, 47.8-87.1 kg), and 23 completed the study. Mean plasma concentrations and AUC values were dose proportional. T(max) occurred at 3.36 to 3.92 hours after dosing; the apparent elimination t((1/2)) was 5.47 hours. Both sex and weight affected the pharmacokinetic parameters of fampridine SR. Eleven treament-related adverse events were reported in 10 patients, with dizziness being the most common (7 incidents reported by 6 patients [1 at 10 mg, 3 at 15 mg, and 3 at 20 mg]). Other adverse events included amblyopia, asthenia, headache, and ataxia. All treatment-related adverse events were mild to moderate in severity, with the exception of 1 case of dizziness (20 mg) that was considered severe. No serious adverse events were reported, and no clinically significant changes in corrected QT intervals were observed. No patients with-drew due to treatment-related adverse events.

CONCLUSION

In these patients with MS, fampridine SR (5-20 mg) had a potentially advantageous pharmacokinetic profile relative to that associated with immediate-release fampridine and was generally well tolerated.

Fatigue in multiple sclerosis: mechanisms and management

Multiple sclerosis [MS] is a chronic immune-mediated disorder of the central nervous system [CNS]. Fatigue may be a debilitating symptom in MS patients, adversely impacting on their quality of life. Clinically, fatigue may manifest as exhaustion, lack of energy, increased somnolence, or worsening of MS symptoms. Activity and heat typically serve to exacerbate symptoms of fatigue. There is now strong evidence to suggest that fatigue results from reduced voluntary activation of muscles by means of central mechanisms. Given that axonal demyelination is a pathological hallmark of MS, activity-dependent conduction block [ADCB] has been proposed as a mechanism underlying fatigue in MS. This ADCB results from axonal membrane hyperpolarization, mediated by the Na(+)/K(+) electrogenic pump, with conduction failure precipitated in demyelinated axons with a reduced safety factor of impulse transmission. In addition, Na(+)/K(+) pump dysfunction, as reported in MS, may induce a depolarizing conduction block associated with inactivation of Na(+) channels. These processes may induce secondary effects including axonal degeneration triggered by raised levels of intracellular Ca(2+) through reverse operation of the Na(+)-Ca(2+) exchanger. Restoration of normal conduction in demyelinated axons with selective channel blockers improves fatigue and may yet prove useful as a neuroprotective strategy, in preventing secondary axonal degeneration and consequent functional impairment.

Voltage-gated potassium channels as therapeutic targets

The human genome encodes 40 voltage-gated K(+) channels (K(V)), which are involved in diverse physiological processes ranging from repolarization of neuronal and cardiac action potentials, to regulating Ca(2+) signalling and cell volume, to driving cellular proliferation and migration. K(V) channels offer tremendous opportunities for the development of new drugs to treat cancer, autoimmune diseases and metabolic, neurological and cardiovascular disorders. This Review discusses pharmacological strategies for targeting K(V) channels with venom peptides, antibodies and small molecules, and highlights recent progress in the preclinical and clinical development of drugs targeting the K(V)1 subfamily, the K(V)7 subfamily (also known as KCNQ), K(V)10.1 (also known as EAG1 and KCNH1) and K(V)11.1 (also known as HERG and KCNH2) channels.

Single-Dose pharmacokinetics of sustained-release fampridine (Fampridine-SR) in healthy volunteers and adults with renal impairment

Fampridine-SR is a sustained-release formulation of fampridine (4-aminopyridine), a potassium channel blocker demonstrated to improve walking ability in patients with multiple sclerosis. This study evaluated the pharmacokinetics of fampridine and its metabolites after administration of fampridine-SR 10 mg in healthy volunteers and in subjects with mild, moderate, or severe renal impairment (5 per group). Analysis of variance was used to calculate 90% confidence intervals (CIs) for the ratios (impaired/healthy) of least squares mean in maximum plasma concentration (C(max)) and area under the plasma concentration-time curve (AUC). Clearance was primarily through urinary excretion. In renally impaired subjects, fampridine plasma concentrations were consistently higher than in healthy individuals: ratios for C(max) ranged from 166.5% to 199.9% for mild and severe renal impairment, respectively. AUC(0-infinity) ratios ranged from 175.3% to 398.7%, respectively, for mild and severe renal impairment. Mean terminal disposition half-life was 6.4 hours in healthy individuals, compared with 7.4, 8.1, and 14.3 hours in patients with mild, moderate, and severe renal impairment, respectively. Regression analysis confirmed the significant relationship between creatinine clearance and extent of exposure as quantified by AUC for fampridine and its metabolites, suggesting cautious use in patients with mild renal impairment and avoidance in cases of moderate or severe renal impairment.

Motor rehabilitation after stroke, traumatic brain, and spinal cord injury: common denominators within recent clinical trials

PURPOSE OF REVIEW

Experimental studies and clinical trials that aim to improve motor function for use of the upper extremity and walking are traditionally separated by the category of neurological disease. This boundary may deter investigators from finding common denominators in the conceptual basis and deployment of rehabilitation interventions, especially across nonprogressive diseases in adults, such as stroke, brain trauma, and spinal cord injury.

RECENT FINDINGS

The results of recent randomized clinical trials for walking by treadmill training and robotic devices and for the upper extremity by constraint-induced therapy, robotics, and brain stimulation suggest that more efficient strategies are needed to devise and prove the value of new therapies.

SUMMARY

Investigators should consider working across disease platforms to develop and test the most optimal methods for training patients, the most practical trial designs, the best dose-response characteristics of interventions, the most meaningful outcome measures, and the likelihood of transfer of trained performance to real-world settings. Clinicians in the community may be more likely to adopt evidence-based practices drawn from positive trial results if these treatment strategies focus on key motor impairments and related disabilities, rather than on diseases.

A review of published reports on neuroprotection in spinal cord injury

STUDY DESIGN

Literature review.

OBJECTIVES

To review the main published current neuroprotection research trends and results in spinal cord injury (SCI).

SETTING

This paper is the result of a collaboration between a group of European scientists.

METHODS

Recent studies, especially in genetic, immune, histochemical and bio (nano)-technological fields, have provided new insight into the cellular and molecular mechanisms occurring within the central nervous system (NS), including SCIs. As a consequence, a new spectrum of therapies aiming to antagonize the 'secondary injury' pathways (that is, to provide neuroprotection) and also to repair such classically irreparable structures is emerging. We reviewed the most significant published works related to such novel, but not yet entirely validated, clinical practice therapies.

RESULTS

There have been identified many molecules, primarily expressed by heterogenous glial and neural subpopulations of cells, which are directly or indirectly critical for tissue damaging/sparing/re-growth inhibiting, angiogenesis and neural plasticity, and also various substances/energy vectors with regenerative properties, such as MAG (myelin-associated glycoprotein), Omgp (oligodendrocyte myelin glycoprotein), KDI (synthetic: Lysine-Asparagine-Isoleucine 'gamma-1 of Laminin Kainat Domain'), Nogo (Neurite outgrowth inhibitor), NgR (Nogo protein Receptor), the Rho signaling pathway (superfamily of 'Rho-dopsin gene-including neurotransmitter-receptors'), EphA4 (Ephrine), GFAP (Glial Fibrillary Acidic Protein), different subtypes of serotonergic and glutamatergic receptors, antigens, antibodies, immune modulators, adhesion molecules, scavengers, neurotrophic factors, enzymes, hormones, collagen scar inhibitors, remyelinating agents and neurogenetic/plasticity inducers, all aiming to preserve/re-establish the morphology and functional connections across the lesion site. Accordingly, modern research and experimental SCI therapies focus on several intricate, rather overlapping, therapeutic objectives and means, such as neuroprotective, neurotrophic, neurorestorative, neuroreparative, neuroregenerative, neuro(re)constructive and neurogenetic interventions.

CONCLUSION

The first three of these therapeutical directions are generically assimilated as neuroprotective, and are synthetically presented and commented in this paper in an attempt to conceptually systematize them; thus, the aim of this article is, by emphasizing the state-of-the art in the domain, to optimize theoretical support in selecting the most effective pharmacological and physical interventions for preventing, as much as possible, paralysis, and for maximizing recovery chances after SCI.

Seizures in patients with multiple sclerosis: epidemiology, pathophysiology and management

Seizures have been recognized to occur in multiple sclerosis (MS) since early descriptions of the disease. Various studies have attempted to determine the incidence and prevalence of seizures in MS; although they differ in the reported prevalence, seizures do appear to be more common in MS cohorts than in the general population. The pathological underpinning of seizures in MS remains indeterminate. Cortical and subcortical demyelination and inflammation may explain the increased frequency of seizures in MS, although this hypothetical correlation remains to be proven. Management of seizures in MS is similar to the management of seizures in other patients. Consideration of the underlying neurological deficits related to MS may be necessary, and dosages of antiepileptic drugs should be adjusted if increased sensitivity to the adverse effects of these agents or interaction with other centrally acting medications is suspected. The prognosis of epilepsy in patients with MS remains uncertain, with some studies suggesting a more favourable prognosis than others.