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Khan P, Saini S, Hussain S, Majid H, Gupta S, Agarwal N. A systematic review and meta-analysis on efficacy and safety of Ganaxolone in epilepsy. Expert Opin Pharmacother 2024; 25:621-632. [PMID: 38606458 DOI: 10.1080/14656566.2024.2342413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/09/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION Ganaxolone has exhibited potential in managing seizures for epilepsy. This systematic review and meta-analysis aim to assess both the safety and efficacy of Ganaxolone for refractory epilepsy. METHODS A thorough search of electronic databases was conducted to identify relevant randomized controlled trials involving patients with drug-resistant focal epilepsy and CDKL5 deficiency disorder. Efficacy and safety outcomes were extracted from the selected studies. Cochrane Review Manager was utilized for data synthesis and analysis, with risk ratios and mean differences calculated to evaluate the efficacy and safety profile of Ganaxolone. RESULTS The meta-analysis included a total of five randomized controlled trials. Ganaxolone exhibited significant efficacy in reducing seizure frequency by at least 50% from baseline [RR 0.90 (95% CI: 0.83, 0.98), p = 0.02]. However, the results did not reach significance for reducing 28-day seizure frequency [Mean Difference -1.45 (95% CI: -3.39, 0.49), p = 0.14]. Ganaxolone exhibited a positive safety profile, with no statistically significant occurrence of adverse events [RR 1.30 (95% CI: 0.93, 1.83), p = 0.12] and adverse events leading to discontinuation of the study drug [RR 1.01 (95% CI: 0.42, 2.39), p = 0.99] compared to placebo. CONCLUSION Ganaxolone presents itself as a viable therapeutic option for refractory epilepsy, showing efficacy in reducing seizure frequency and exhibited a favorable safety profile. PROSPERO REGISTRATION NUMBER CRD42023434883.
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Affiliation(s)
- Parvej Khan
- Department for Translational and Clinical Research, School of Chemical & Life Sciences, Jamia Hamdard, New Delhi, India
| | - Sparsh Saini
- Department for Translational and Clinical Research, School of Chemical & Life Sciences, Jamia Hamdard, New Delhi, India
| | - Shadan Hussain
- Department for Translational and Clinical Research, School of Chemical & Life Sciences, Jamia Hamdard, New Delhi, India
| | - Haya Majid
- Department for Translational and Clinical Research, School of Chemical & Life Sciences, Jamia Hamdard, New Delhi, India
| | - Sparsh Gupta
- Department of Pharmacology, Vardhman Mahavir Medical College & Safdarjung hospital, New Delhi, India
| | - Nidhi Agarwal
- Department for Translational and Clinical Research, School of Chemical & Life Sciences, Jamia Hamdard, New Delhi, India
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Gasior M, Husain A, Barra ME, Raja SM, MacLeod D, Guptill JT, Vaitkevicius H, Rybak E. Intravenous Ganaxolone: Pharmacokinetics, Pharmacodynamics, Safety, and Tolerability in Healthy Adults. Clin Pharmacol Drug Dev 2024; 13:248-258. [PMID: 38231434 DOI: 10.1002/cpdd.1365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 12/04/2023] [Indexed: 01/18/2024]
Abstract
Ganaxolone, a neuroactive steroid anticonvulsant that modulates both synaptic and extrasynaptic γ-aminobutyric acid type A (GABAA ) receptors, is in development for treatment of status epilepticus (SE) and rare epileptic disorders, and has been approved in the United States for treatment of seizures associated with cyclin-dependent kinase-like 5 deficiency disorder in patients ≥2 years old. This phase 1 study in 36 healthy volunteers evaluated the pharmacokinetics, pharmacodynamics, and safety of intravenous ganaxolone administered as a (i) single bolus, (ii) infusion, and (iii) bolus followed by continuous infusion. After a single bolus over 2 minutes (20 mg) or 5 minutes (10 or 30 mg), ganaxolone was detected in plasma with a median Tmax of 5 minutes, whereas a 60-minute infusion (10 or 30 mg) or a bolus (6 mg over 5 minutes) followed by infusion (20 mg/h) for 4 hours achieved a median Tmax of approximately 1 and 3 hours, respectively. Cmax was dose and administration-time dependent, ranging from 73.8 ng/mL (10 mg over 5 minutes) to 1240 ng/mL (30 mg over 5 minutes). Bolus doses above 10 mg of ganaxolone markedly influenced the bispectral index score with a rapid decline; smaller changes occurred on the Modified Observer's Assessment of Alertness/Sedation scale and in quantitative electroencephalogram. Most adverse events were of mild severity, with 2 events of moderate severity; none were reported as serious. No effects on systemic hemodynamics or respiratory functions were reported. Overall, ganaxolone was generally well tolerated at the doses studied and demonstrated pharmacokinetic and pharmacodynamic properties suitable to treat SE.
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Affiliation(s)
| | - Aatif Husain
- Duke University School of Medicine, Durham, NC, USA
| | | | | | | | | | | | - Eva Rybak
- Marinus Pharmaceuticals, Inc., Radnor, PA, USA
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Reddy DS. Neurosteroids as Novel Anticonvulsants for Refractory Status Epilepticus and Medical Countermeasures for Nerve Agents: A 15-Year Journey to Bring Ganaxolone from Bench to Clinic. J Pharmacol Exp Ther 2024; 388:273-300. [PMID: 37977814 PMCID: PMC10801762 DOI: 10.1124/jpet.123.001816] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 10/05/2023] [Accepted: 10/23/2023] [Indexed: 11/19/2023] Open
Abstract
This article describes recent advances in the use of neurosteroids as novel anticonvulsants for refractory status epilepticus (RSE) and as medical countermeasures (MCs) for organophosphates and chemical nerve agents (OPNAs). We highlight a comprehensive 15-year journey to bring the synthetic neurosteroid ganaxolone (GX) from bench to clinic. RSE, including when caused by nerve agents, is associated with devastating morbidity and permanent long-term neurologic dysfunction. Although recent approval of benzodiazepines such as intranasal midazolam and intranasal midazolam offers improved control of acute seizures, novel anticonvulsants are needed to suppress RSE and improve neurologic function outcomes. Currently, few anticonvulsant MCs exist for victims of OPNA exposure and RSE. Standard-of-care MCs for postexposure treatment include benzodiazepines, which do not effectively prevent or mitigate seizures resulting from nerve agent intoxication, leaving an urgent unmet medical need for new anticonvulsants for RSE. Recently, we pioneered neurosteroids as next-generation anticonvulsants that are superior to benzodiazepines for treatment of OPNA intoxication and RSE. Because GX and related neurosteroids that activate extrasynaptic GABA-A receptors rapidly control seizures and offer robust neuroprotection by reducing neuronal damage and neuroinflammation, they effectively improve neurologic outcomes after acute OPNA exposure and RSE. GX has been selected for advanced, Biomedical Advanced Research and Development Authority-supported phase 3 trials of RSE and nerve agent seizures. In addition, in mechanistic studies of neurosteroids at extrasynaptic receptors, we identified novel synthetic analogs with features that are superior to GX for current medical needs. Development of new MCs for RSE is complex, tedious, and uncertain due to scientific and regulatory challenges. Thus, further research will be critical to fill key gaps in evaluating RSE and anticonvulsants in vulnerable (pediatric and geriatric) populations and military persons. SIGNIFICANCE STATEMENT: Following organophosphate and nerve agent intoxication, refractory status epilepticus (RSE) occurs despite benzodiazepine treatment. RSE occurs in 40% of status epilepticus patients, with a 35% mortality rate and significant neurological morbidity in survivors. To treat RSE, neurosteroids are better anticonvulsants than benzodiazepines. Our pioneering use of neurosteroids for RSE and nerve agents led us to develop ganaxolone as a novel anticonvulsant and neuroprotectant with significantly improved neurological outcomes. This article describes the bench-to-bedside journey of bringing neurosteroid therapy to patients, with ganaxolone leading the way.
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Affiliation(s)
- Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, Texas and Institute of Pharmacology and Neurotherapeutics, Texas A&M University Health Science Center, Bryan, Texas
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De SK. Ganaxolone: First FDA-approved Medicine for the Treatment of Seizures Associated with Cyclin-dependent Kinase-like 5 Deficiency Disorder. Curr Med Chem 2024; 31:388-392. [PMID: 36959132 DOI: 10.2174/0929867330666230320123952] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 02/09/2023] [Accepted: 02/22/2023] [Indexed: 03/25/2023]
Abstract
The neurosteroids progesterone and allopregnanolone control numerous neuroprotective functions in neural tissues, including inhibition of epileptic seizures and cell death. Ganaxolone (3α-hydroxy-3β-methyl-5α-pregnan-20-one) (GNX) is the 3β- methylated synthetic analog of allopregnanolone and an allosteric GABAA positive modulator. Ganaxolone reduces the frequency of CDD-associated seizures.
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Affiliation(s)
- Surya K De
- Department of Chemistry, Conju-Probe, San Diego, CA, USA
- Bharath University, Chennai, Tamil Nadu, 600126, India
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Zhang JY, Wang YT, Sun L, Wang SQ, Chen ZS. Synthesis and clinical application of new drugs approved by FDA in 2022. MOLECULAR BIOMEDICINE 2023; 4:26. [PMID: 37661221 PMCID: PMC10475455 DOI: 10.1186/s43556-023-00138-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 07/24/2023] [Indexed: 09/05/2023] Open
Abstract
The pharmaceutical industry had a glorious year in 2022, with a total of 37 new drugs including 20 new chemical entities (NCEs) and 17 new biological entities (NBEs) approved by the Food and Drug Administration (FDA). These drugs are mainly concentrated in oncology, central nervous system, antiinfection, hematology, cardiomyopathy, dermatology, digestive system, ophthalmology, MRI enhancer and other therapeutic fields. Of the 37 drugs, 25 (68%) were approved through an expedited review pathway, and 19 (51%) were approved to treat rare diseases. These newly listed drugs have unique structures and new mechanisms of action, which can serve as lead compounds for designing new drugs with similar biological targets and enhancing therapeutic efficacy. This review aims to outline the clinical applications and synthetic methods of 19 NCEs newly approved by the FDA in 2022, but excludes contrast agent (Xenon Xe-129). We believe that an in-depth understanding of the synthetic methods of drug molecules will provide innovative and practical inspiration for the development of new, more effective, and practical synthetic techniques. According to the therapeutic areas of these 2022 FDA-approved drugs, we have classified these 19 NCEs into seven categories and will introduce them in the order of their approval for marketing.
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Affiliation(s)
- Jing-Yi Zhang
- College of Chemistry and Chemical Engineering, Zhengzhou Normal University, Zhengzhou, 450044, China
| | - Ya-Tao Wang
- First People's Hospital of Shangqiu, Henan Province, Shangqiu, 476100, China
- Henan Engineering Research Center of Precision Therapy of Gastrointestinal Cancer, Zhengzhou Key Laboratory for Precision Therapy of Gastrointestinal Cancer, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, 450008, China
| | - Lu Sun
- Henan Engineering Research Center of Precision Therapy of Gastrointestinal Cancer, Zhengzhou Key Laboratory for Precision Therapy of Gastrointestinal Cancer, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, 450008, China.
- Zhongshan Hospital Affiliated to Dalian University, Dalian, 116001, China.
| | - Sai-Qi Wang
- Henan Engineering Research Center of Precision Therapy of Gastrointestinal Cancer, Zhengzhou Key Laboratory for Precision Therapy of Gastrointestinal Cancer, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, 450008, China.
| | - Zhe-Sheng Chen
- College of Pharmacy and Health Sciences, St. John's University, Queens, NY, 11439, USA.
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Perucca E, Bialer M, White HS. New GABA-Targeting Therapies for the Treatment of Seizures and Epilepsy: I. Role of GABA as a Modulator of Seizure Activity and Recently Approved Medications Acting on the GABA System. CNS Drugs 2023; 37:755-779. [PMID: 37603262 PMCID: PMC10501955 DOI: 10.1007/s40263-023-01027-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/22/2023]
Abstract
γ-Aminobutyric acid (GABA) is the most prevalent inhibitory neurotransmitter in the mammalian brain and has been found to play an important role in the pathogenesis or the expression of many neurological diseases, including epilepsy. Although GABA can act on different receptor subtypes, the component of the GABA system that is most critical to modulation of seizure activity is the GABAA-receptor-chloride (Cl-) channel complex, which controls the movement of Cl- ions across the neuronal membrane. In the mature brain, binding of GABA to GABAA receptors evokes a hyperpolarising (anticonvulsant) response, which is mediated by influx of Cl- into the cell driven by its concentration gradient between extracellular and intracellular fluid. However, in the immature brain and under certain pathological conditions, GABA can exert a paradoxical depolarising (proconvulsant) effect as a result of an efflux of chloride from high intracellular to lower extracellular Cl- levels. Extensive preclinical and clinical evidence indicates that alterations in GABAergic inhibition caused by drugs, toxins, gene defects or other disease states (including seizures themselves) play a causative or contributing role in facilitating or maintaning seizure activity. Conversely, enhancement of GABAergic transmission through pharmacological modulation of the GABA system is a major mechanism by which different antiseizure medications exert their therapeutic effect. In this article, we review the pharmacology and function of the GABA system and its perturbation in seizure disorders, and highlight how improved understanding of this system offers opportunities to develop more efficacious and better tolerated antiseizure medications. We also review the available data for the two most recently approved antiseizure medications that act, at least in part, through GABAergic mechanisms, namely cenobamate and ganaxolone. Differences in the mode of drug discovery, pharmacological profile, pharmacokinetic properties, drug-drug interaction potential, and clinical efficacy and tolerability of these agents are discussed.
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Affiliation(s)
- Emilio Perucca
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, VIC, Australia.
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.
- Melbourne Brain Centre, 245 Burgundy Street, Heidelberg, VIC, 3084, Australia.
| | - Meir Bialer
- Institute of Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- David R. Bloom Center for Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
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Sills GJ. Pharmacological diversity amongst approved and emerging antiseizure medications for the treatment of developmental and epileptic encephalopathies. Ther Adv Neurol Disord 2023; 16:17562864231191000. [PMID: 37655228 PMCID: PMC10467199 DOI: 10.1177/17562864231191000] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 07/13/2023] [Indexed: 09/02/2023] Open
Abstract
Developmental and epileptic encephalopathies (DEEs) are rare neurodevelopmental disorders characterised by early-onset and often intractable seizures and developmental delay/regression, and include Dravet syndrome and Lennox-Gastaut syndrome (LGS). Rufinamide, fenfluramine, stiripentol, cannabidiol and ganaxolone are antiseizure medications (ASMs) with diverse mechanisms of action that have been approved for treating specific DEEs. Rufinamide is thought to suppress neuronal hyperexcitability by preventing the functional recycling of voltage-gated sodium channels from the inactivated to resting state. It is licensed for adjunctive treatment of seizures associated with LGS. Fenfluramine increases extracellular serotonin levels and may reduce seizures via activation of specific serotonin receptors and positive modulation of the sigma-1 receptor. Fenfluramine is licensed for adjunctive treatment of seizures associated with Dravet syndrome and LGS. Stiripentol is a positive allosteric modulator of type-A gamma-aminobutyric acid (GABAA) receptors. As a broad-spectrum inhibitor of cytochrome P450 enzymes, its antiseizure effects may additionally arise through pharmacokinetic interactions with co-administered ASMs. Stiripentol is licensed for treating seizures associated with Dravet syndrome in patients taking clobazam and/or valproate. The mechanism(s) of action of cannabidiol remains largely unclear although multiple targets have been proposed, including transient receptor potential vanilloid 1, G protein-coupled receptor 55 and equilibrative nucleoside transporter 1. Cannabidiol is licensed as adjunctive treatment in conjunction with clobazam for seizures associated with Dravet syndrome and LGS, and as adjunctive treatment of seizures associated with tuberous sclerosis complex. Like stiripentol, ganaxolone is a positive allosteric modulator at GABAA receptors. It has recently been licensed in the USA for the treatment of seizures associated with cyclin-dependent kinase-like 5 deficiency disorder. Greater understanding of the causes of DEEs has driven research into the potential use of other novel and repurposed agents. Putative ASMs currently in clinical development for use in DEEs include soticlestat, carisbamate, verapamil, radiprodil, clemizole and lorcaserin.
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Affiliation(s)
- Graeme J. Sills
- School of Life Sciences, University of Glasgow, Room 341, Sir James Black Building, Glasgow G12 8QQ, UK
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Valerio E, Stocchero M, Pirillo P, D'Errico I, Bonadies L, Galderisi A, Giordano G, Baraldi E. Neurosteroid pathway derangement in asphyctic infants treated with hypothermia: an untargeted metabolomic approach. EBioMedicine 2023; 92:104636. [PMID: 37257315 PMCID: PMC10244906 DOI: 10.1016/j.ebiom.2023.104636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/29/2023] [Accepted: 05/15/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND The pathobiological mechanisms associated with perinatal asphyxia and hypoxic-ischemic encephalopathy are complex and poorly understood. The metabolic effects of therapeutic hypothermia have been partially explored. METHODS We conducted a single-center longitudinal study to investigate the metabolic effects of perinatal asphyxia and hypoxic-ischemic encephalopathy on the urinary metabolome of a group of 12 asphyctic infants over time compared to 22 matched healthy newborns, using untargeted metabolomics based on mass spectrometry. FINDINGS Over-representation pathway analysis identified the steroidogenesis pathway as being significantly disrupted, with reduced steroid levels in the first three days of life despite treatment with hypothermia. Comparison with matched healthy newborns showed that the urinary steroid content was lower in asphyctic infants before hypothermia. The lysine degradation and carnitine synthesis pathways were also significantly affected. INTERPRETATION Steroidogenesis is significantly disrupted in asphyctic infants compared to healthy newborns. Given how neurosteroids are involved in neuromodulation and neuroprotection, translational research is warranted on the potential role of neurosteroid-based intervention in asphyctic infants. FUNDING None.
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Affiliation(s)
- Enrico Valerio
- Neonatal Intensive Care Unit, Department of Woman's and Child's Health, Azienda Ospedale-Università di Padova, Italy; Institute of Pediatric Research "Città Della Speranza", Padova, Italy
| | - Matteo Stocchero
- Neonatal Intensive Care Unit, Department of Woman's and Child's Health, Azienda Ospedale-Università di Padova, Italy; Institute of Pediatric Research "Città Della Speranza", Padova, Italy
| | - Paola Pirillo
- Neonatal Intensive Care Unit, Department of Woman's and Child's Health, Azienda Ospedale-Università di Padova, Italy; Institute of Pediatric Research "Città Della Speranza", Padova, Italy
| | - Ignazio D'Errico
- Department of Neuroradiology, Azienda Ospedale-Università di Padova, Italy
| | - Luca Bonadies
- Neonatal Intensive Care Unit, Department of Woman's and Child's Health, Azienda Ospedale-Università di Padova, Italy; Institute of Pediatric Research "Città Della Speranza", Padova, Italy
| | - Alfonso Galderisi
- Neonatal Intensive Care Unit, Department of Woman's and Child's Health, Azienda Ospedale-Università di Padova, Italy; Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, CT 06511, USA
| | - Giuseppe Giordano
- Neonatal Intensive Care Unit, Department of Woman's and Child's Health, Azienda Ospedale-Università di Padova, Italy; Institute of Pediatric Research "Città Della Speranza", Padova, Italy
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Woman's and Child's Health, Azienda Ospedale-Università di Padova, Italy; Institute of Pediatric Research "Città Della Speranza", Padova, Italy.
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Meng J, Yan Z, Tao X, Wang W, Wang F, Xue T, Liu Y, Wang Z. The efficacy and safety of ganaxolone for the treatment of refractory epilepsy: A meta-analysis from randomized controlled trials. Epilepsia Open 2023; 8:90-99. [PMID: 36333279 PMCID: PMC9978077 DOI: 10.1002/epi4.12669] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/02/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Epilepsy is one of the most common and refractory neurological disorders globally. Ganaxolone, a neuroactive steroid that enhances GABAergic inhibition, has been tested in many trials for the resolution of refractory epilepsy. Based on these, our study implemented a meta-analysis to evaluate the general benefit of ganaxolone for refractory epilepsy. METHODS EMBASE, Medline, Scopus, Cochrane Library, and Clinicaltrials.gov were searched for relevant randomized controlled trials (RCTs) up to June 20, 2022. The risk ratio (RR) and standard mean difference (SMD) were analyzed using dichotomous and continuous outcomes, respectively with a random effect model. Trial sequential analysis (TSA) was also performed to judge the reliability of results. RESULTS We totally collected 659 patients from four RCTs to evaluate the efficacy and safety of ganaxolone. As results showed, ≥50% reduction in mean seizure frequency has improved significantly compared with placebo (RR = 1.60, 95%CI: 1.02-2.49, p = 0.04, I2 = 30%), which is supported by TSA. However, the percentage of seizure-free days shows no statistical significance (p = 0.36). For safety outcomes, adverse events (AEs), serious adverse events, and AE leading to study drug discontinuation all revealed no obvious difference between ganaxolone and placebo (p > 0.05). SIGNIFICANCE Based on our research, we have observed that ganaxolone is safe and has potential efficacy in the treatment of refractory epilepsy, waiting for further studies.
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Affiliation(s)
- Jiahao Meng
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Zeya Yan
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xinyu Tao
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Wei Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Fei Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Tao Xue
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yanfei Liu
- Department of Neurosurgery, Suzhou Integrated Traditional Chinese and Western Medicine Hospital, Suzhou, Jiangsu Province, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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Miller SL, Bennet L, Sutherland AE, Pham Y, McDonald C, Castillo‐Melendez M, Allison BJ, Mihelakis J, Nitsos I, Boyd BJ, Hirst JJ, Walker DW, Hunt RW, Jenkin G, Wong F, Malhotra A, Fahey MC, Yawno T. Ganaxolone versus Phenobarbital for Neonatal Seizure Management. Ann Neurol 2022; 92:1066-1079. [PMID: 36054160 PMCID: PMC9828769 DOI: 10.1002/ana.26493] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Seizures are more common in the neonatal period than at any other stage of life. Phenobarbital is the first-line treatment for neonatal seizures and is at best effective in approximately 50% of babies, but may contribute to neuronal injury. Here, we assessed the efficacy of phenobarbital versus the synthetic neurosteroid, ganaxolone, to moderate seizure activity and neuropathology in neonatal lambs exposed to perinatal asphyxia. METHODS Asphyxia was induced via umbilical cord occlusion in term lambs at birth. Lambs were treated with ganaxolone (5mg/kg/bolus then 5mg/kg/day for 2 days) or phenobarbital (20mg/kg/bolus then 5mg/kg/day for 2 days) at 6 hours. Abnormal brain activity was classified as stereotypic evolving (SE) seizures, epileptiform discharges (EDs), and epileptiform transients (ETs) using continuous amplitude-integrated electroencephalographic recordings. At 48 hours, lambs were euthanized for brain pathology. RESULTS Asphyxia caused abnormal brain activity, including SE seizures that peaked at 18 to 20 hours, EDs, and ETs, and induced neuronal degeneration and neuroinflammation. Ganaxolone treatment was associated with an 86.4% reduction in the number of seizures compared to the asphyxia group. The total seizure duration in the asphyxia+ganaxolone group was less than the untreated asphyxia group. There was no difference in the number of SE seizures between the asphyxia and asphyxia+phenobarbital groups or duration of SE seizures. Ganaxolone treatment, but not phenobarbital, reduced neuronal degeneration within hippocampal CA1 and CA3 regions, and cortical neurons, and ganaxolone reduced neuroinflammation within the thalamus. INTERPRETATION Ganaxolone provided better seizure control than phenobarbital in this perinatal asphyxia model and was neuroprotective for the newborn brain, affording a new therapeutic opportunity for treatment of neonatal seizures. ANN NEUROL 2022;92:1066-1079.
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Affiliation(s)
- Suzanne L. Miller
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Laura Bennet
- Department of PhysiologyUniversity of AucklandAucklandNew Zealand
| | - Amy E. Sutherland
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Yen Pham
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Courtney McDonald
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Margie Castillo‐Melendez
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Beth J. Allison
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Jamie Mihelakis
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Ilias Nitsos
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Ben J. Boyd
- Monash Institute of Pharmaceutical SciencesMonash UniversityParkvilleVictoriaAustralia
| | - Jonathan J. Hirst
- School of Biomedical Sciences and Pharmacy, University of NewcastleNewcastleNew South WalesAustralia
| | - David W. Walker
- School of Health and Biomedical Sciences, RMIT UniversityBundooraVictoriaAustralia
| | - Rodney W. Hunt
- Department of PaediatricsMonash UniversityClaytonVictoriaAustralia
| | - Graham Jenkin
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Flora Wong
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,School of Health and Biomedical Sciences, RMIT UniversityBundooraVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia
| | - Atul Malhotra
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia,Monash Children's HospitalClaytonVictoriaAustralia
| | - Michael C. Fahey
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia,Monash Children's HospitalClaytonVictoriaAustralia
| | - Tamara Yawno
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia
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11
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Intravenous ganaxolone in pediatric super-refractory status epilepticus: A single hospital experience. Epilepsy Behav Rep 2022; 20:100567. [PMID: 36325100 PMCID: PMC9619166 DOI: 10.1016/j.ebr.2022.100567] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/29/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022] Open
Abstract
Synaptic GABAA receptor (GABAAR) internalization contributes to the drug resistant nature of super-refractory status epilepticus (SRSE). Ganaxolone is a 3β-methylated synthetic analog of the endogenous neuroactive steroid, allopregnanolone, that has positive allosteric modulatory activity on synaptic and extrasynaptic GABAA receptors. Ganaxolone is currently in clinical trials to treat rare pediatric seizure disorders and established and refractory SE. Two pediatric patients with SRSE (age 17 and age 7) were treated under emergency investigational new drug (E-IND) applications with intravenous (IV) ganaxolone administered as an initial bolus and a maintenance infusion for up to 4.5 days with intermittent IV boluses as-needed followed by taper on day 5 and transitioned to chronic treatment using ganaxolone suspension. Adjunctive ganaxolone was effective in terminating SRSE in both patients, safely permitting IV anesthetics to be weaned. Seizure control has been maintained after transitioning to enteric ganaxolone. Further investigation of ganaxolone as a safe and effective treatment for SRSE is warranted.
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Key Words
- AMPA, alpha-amino-3-hydroxy-5-methyl-4-isoxazoleproprionic acid
- ASMs, anti-seizure medications
- E-IND, emergency investigational new drug
- FIRES, fever-induced refractory epilepsy syndrome
- GABAAR, GABAA receptors
- GNX, ganaxolone
- KA, kainate
- NMDA, N-methyl-d-aspartate
- NORSE, new onset refractory status epilepticus
- Neurosteroids
- Pediatric
- SE, status epilepticus
- SRSE, super-refractory status epilepticus
- Status epilepticus
- Super-refractory status epilepticus
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12
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Bialer M, Johannessen SI, Koepp MJ, Levy RH, Perucca E, Perucca P, Tomson T, White HS. Progress report on new antiepileptic drugs: A summary of the Sixteenth Eilat Conference on New Antiepileptic Drugs and Devices (EILAT XVI): II. Drugs in more advanced clinical development. Epilepsia 2022; 63:2883-2910. [PMID: 35950617 DOI: 10.1111/epi.17376] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/19/2022] [Accepted: 07/25/2022] [Indexed: 11/27/2022]
Abstract
The Sixteenth Eilat Conference on New Antiepileptic Drugs and Devices (EILAT XVI) was held in Madrid, Spain on May 22-25, 2022 and was attended by 157 delegates from 26 countries representing basic and clinical science, regulatory agencies, and pharmaceutical industries. One day of the conference was dedicated to sessions presenting and discussing investigational compounds under development for the treatment of seizures and epilepsy. The current progress report summarizes recent findings and current knowledge for seven of these compounds in more advanced clinical development for which either novel preclinical or patient data are available. These compounds include bumetanide and its derivatives, darigabat, ganaxolone, lorcaserin, soticlestat, STK-001, and XEN1101. Of these, ganaxolone was approved by the US Food and Drug Administration in March 2022 for the treatment of seizures associated with cyclin-dependent kinase-like 5 deficiency disorder in patients 2 years of age and older.
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Affiliation(s)
- Meir Bialer
- Institute for Drug Research, Faculty of Medicine, School of Pharmacy, and David R. Bloom Center for Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Svein I Johannessen
- National Center for Epilepsy, Sandvika, Norway.,Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Matthias J Koepp
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK
| | - René H Levy
- Department of Pharmaceutics and Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Emilio Perucca
- Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Piero Perucca
- Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia.,Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
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13
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CDKL5 Deficiency Disorder-Related Epilepsy: A Review of Current and Emerging Treatment. CNS Drugs 2022; 36:591-604. [PMID: 35633486 PMCID: PMC9876658 DOI: 10.1007/s40263-022-00921-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2022] [Indexed: 01/27/2023]
Abstract
Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) is a developmental and epileptic encephalopathy with infantile-onset epilepsy. Most individuals with CDD develop refractory epilepsy with multiple seizure types. Management of seizures in CDD remains challenging for clinicians given the highly refractory nature of seizures and the limited number of disease-specific studies that offer a high level of evidence. Epileptic spasms are the most common seizure type in CDD and are more often refractory to standard first-line treatment than are spasms of other etiologies. In other seizure types, the effectiveness of antiseizure medications is limited and wanes over time. Ketogenic diet and palliative surgical treatments have both had mixed results in observational studies. When treating refractory seizures in CDD, we recommend carefully balancing seizure control and treatment-related side effects to optimize each individual's overall quality of life. Clinical trials of medications targeting epilepsy in CDD have been conducted, and additional investigational small molecules, gene therapy, and other disease-modifying therapies are in development for CDD.
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14
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Shaw JC, Dyson RM, Palliser HK, Sixtus RP, Barnes H, Pavy CL, Crombie GK, Berry MJ, Hirst JJ. Examining Neurosteroid-Analogue Therapy in the Preterm Neonate For Promoting Hippocampal Neurodevelopment. Front Physiol 2022; 13:871265. [PMID: 35514343 PMCID: PMC9062084 DOI: 10.3389/fphys.2022.871265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Preterm birth can lead to brain injury and currently there are no targeted therapies to promote postnatal brain development and protect these vulnerable neonates. We have previously shown that the neurosteroid-analogue ganaxolone promotes white matter development and improves behavioural outcomes in male juvenile guinea pigs born preterm. Adverse side effects in this previous study necessitated this current follow-up dosing study, where a focus was placed upon physical wellbeing during the treatment administration and markers of neurodevelopment at the completion of the treatment period. Methods: Time-mated guinea pigs delivered preterm (d62) by induction of labour or spontaneously at term (d69). Preterm pups were randomized to receive no treatment (Prem-CON) or ganaxolone at one of three doses [0.5 mg/kg ganaxolone (low dose; LOW-GNX), 1.0 mg/kg ganaxolone (mid dose; MID-GNX), or 2.5 mg/kg ganaxolone (high dose; HIGH-GNX) in vehicle (45% β-cyclodextrin)] daily until term equivalence age. Physical parameters including weight gain, ponderal index, supplemental feeding, and wellbeing (a score based on respiration, activity, and posture) were recorded throughout the preterm period. At term equivalence, brain tissue was collected, and analysis of hippocampal neurodevelopment was undertaken by immunohistochemistry and RT-PCR. Results: Low and mid dose ganaxolone had some impacts on early weight gain, supplemental feeding, and wellbeing, whereas high dose ganaxolone significantly affected all physical parameters for multiple days during the postnatal period when compared to the preterm control neonates. Deficits in the preterm hippocampus were identified using neurodevelopmental markers including mRNA expression of oligodendrocyte lineage cells (CSPG4, MBP), neuronal growth (INA, VEGFA), and the GABAergic/glutamatergic system (SLC32A1, SLC1A2, GRIN1, GRIN2C, DLG4). These deficits were not affected by ganaxolone at the doses used at the equivalent of normal term. Conclusion: This is the first study to investigate the effects of a range of doses of ganaxolone to improve preterm brain development. We found that of the three doses, only the highest dose of ganaxolone (2.5 mg/kg) impaired key indicators of physical health and wellbeing over extended periods of time. Whilst it may be too early to see improvements in markers of neurodevelopment, further long-term study utilising the lower doses are warranted to assess functional outcomes at ages when preterm birth associated behavioural disorders are observed.
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Affiliation(s)
- Julia C Shaw
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia.,Mothers and Babies Research Centre, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Rebecca M Dyson
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand.,Centre for Translational Physiology, University of Otago, Wellington, New Zealand
| | - Hannah K Palliser
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia.,Mothers and Babies Research Centre, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Ryan P Sixtus
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand.,Centre for Translational Physiology, University of Otago, Wellington, New Zealand
| | - Heather Barnes
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand.,Centre for Translational Physiology, University of Otago, Wellington, New Zealand
| | - Carlton L Pavy
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia.,Mothers and Babies Research Centre, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Gabrielle K Crombie
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia.,Mothers and Babies Research Centre, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Mary J Berry
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand.,Centre for Translational Physiology, University of Otago, Wellington, New Zealand
| | - Jonathan J Hirst
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia.,Mothers and Babies Research Centre, Hunter Medical Research Institute, Newcastle, NSW, Australia
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15
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Gunduz‐Bruce H, Takahashi K, Huang M. Development of neuroactive steroids for the treatment of postpartum depression. J Neuroendocrinol 2022; 34:e13019. [PMID: 34462985 PMCID: PMC9285576 DOI: 10.1111/jne.13019] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/22/2021] [Accepted: 07/25/2021] [Indexed: 01/25/2023]
Abstract
Postpartum depression (PPD) is a common major depressive episode surrounding childbirth, with estimated rates ranging from 5.5% to 23.5% of all live births across Europe and the USA based on the presence of key symptoms. PPD has been associated with significant impairments in both maternal functioning and mother-infant attachment, and these impairments can have lasting effects on the emotional and cognitive development of children. Although the precise pathophysiology of PPD is unknown, preclinical findings suggest that large fluctuations in neurosteroid hormone levels can induce physiological plasticity in the expression of functional GABAA receptors during pregnancy and the postpartum period, and that deficits in this plasticity may underpin a biological mechanism that contributes to the manifestation of depressive symptoms. Here, we review the controlled clinical trials to date that have assessed the efficacy of pharmacological treatments for PPD, including oestradiol, selective serotonin reuptake inhibitors, brexanolone (an iv formulation of allopregnanolone) and an investigational neuroactive steroid and GABAA positive allosteric modulator, zuranolone. Coupled with the GABAergic deficits implicated in major depressive disorder, these findings highlight not only the potential role of GABAA receptor plasticity in the pathophysiology of PPD, but also the novel therapeutic approach of using positive allosteric modulators targeting GABAergic transmission to treat women affected by PPD.
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16
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Reddy DS. Neurosteroid replacement therapy for catamenial epilepsy, postpartum depression and neuroendocrine disorders in women. J Neuroendocrinol 2022; 34:e13028. [PMID: 34506047 PMCID: PMC9247111 DOI: 10.1111/jne.13028] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/27/2021] [Accepted: 08/05/2021] [Indexed: 12/11/2022]
Abstract
Neurosteroids are involved in the pathophysiology of many neuroendocrine disorders in women. This review describes recent advancements in pharmacology of neurosteroids and emphasizes the benefits of neurosteroid replacement therapy for the management of neuroendocrine disorders such as catamenial epilepsy (CE), postpartum depression (PPD) and premenstrual brain conditions. Neurosteroids are endogenous modulators of neuronal excitability. A variety of neurosteroids are present in the brain including allopregnanolone (AP), allotetrahydro-deoxycorticosterone and androstanediol. Neurosteroids interact with synaptic and extrasynaptic GABAA receptors in the brain. AP and related neurosteroids, which are positive allosteric modulators of GABAA receptors, are powerful anticonvulsants, anxiolytic, antistress and neuroprotectant agents. In CE, seizures are most often clustered around a specific menstrual period in women. Neurosteroid withdrawal-linked plasticity in extrasynaptic receptors has been shown to play a key role in catamenial seizures, anxiety and other mood disorders. Based on our extensive research spanning two decades, we have proposed and championed neurosteroid replacement therapy as a rational strategy for treating disorders marked by neurosteroid-deficiency, such as CE and other related ovarian or menstrual disorders. In 2019, AP (renamed as brexanolone) was approved for treating PPD. A variety of synthetic neurosteroids are in clinical trials for epilepsy, depression and other brain disorders. Recent advancements in our understanding of neurosteroids have entered a new era of drug discovery and one that offers a high therapeutic potential for treating complex brain disorders.
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Affiliation(s)
- Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University College of Medicine, Bryan, TX, USA
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17
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van der Lei MB, Kooy RF. Therapeutic potential of GABAA receptor subunit expression abnormalities in fragile X syndrome. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2022. [DOI: 10.1080/23808993.2021.2008168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - R. Frank Kooy
- Department of Medical Genetics, University of Antwerp, Antwerp, Belgium
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18
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Olson HE, Daniels CI, Haviland I, Swanson LC, Greene CA, Denny AMM, Demarest ST, Pestana-Knight E, Zhang X, Moosa AN, Fidell A, Weisenberg JL, Suter B, Fu C, Neul JL, Percy AK, Marsh ED, Benke TA, Poduri A. Current neurologic treatment and emerging therapies in CDKL5 deficiency disorder. J Neurodev Disord 2021; 13:40. [PMID: 34530725 PMCID: PMC8447578 DOI: 10.1186/s11689-021-09384-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/16/2021] [Indexed: 12/05/2022] Open
Abstract
Background CDKL5 deficiency disorder (CDD) is associated with refractory infantile onset epilepsy, global developmental delay, and variable features that include sleep, behavioral disturbances, and movement disorders. Current treatment is primarily symptom-based and informed by experience in caring for this population. Methods We describe medication and non-medication approaches to treatment of epilepsy and additional key neurologic symptoms (sleep disturbances, behavioral issues, movement disorders, and swallowing dysfunction) in a cohort of 177 individuals meeting criteria for CDD, 154 evaluated at 4 CDKL5 Centers of Excellence in the USA and 40 identified through the NIH Natural History Study of Rett and Related Disorders. Results The four most frequently prescribed anti-seizure medications were broad spectrum, prescribed in over 50% of individuals. While the goal was not to ascertain efficacy, we obtained data from 86 individuals regarding response to treatment, with 2-week response achieved in 14–48% and sustained 3-month response in 5–36%, of those with known response. Additional treatments for seizures included cannabis derivatives, tried in over one-third of individuals, and clinical trial medications. In combination with pharmacological treatment, 50% of individuals were treated with ketogenic diet for attempted seizure control. Surgical approaches included vagus nerve stimulators, functional hemispherectomy, and corpus callosotomy, but numbers were too limited to assess response. Nearly one-third of individuals received pharmacologic treatment for sleep disturbances, 13% for behavioral dysregulation and movement disorders, and 43% had gastrostomy tubes. Conclusions Treatment for neurologic features of CDD is currently symptom-based and empiric rather than CDD-specific, though clinical trials for CDD are emerging. Epilepsy in this population is highly refractory, and no specific anti-seizure medication was associated with improved seizure control. Ketogenic diet is commonly used in patients with CDD. While behavioral interventions are commonly instituted, information on the use of medications for sleep, behavioral management, and movement disorders is sparse and would benefit from further characterization and optimization of treatment approaches. The heterogeneity in treatment approaches highlights the need for systematic review and guidelines for CDD. Additional disease-specific and disease-modifying treatments are in development. Supplementary Information The online version contains supplementary material available at 10.1186/s11689-021-09384-z.
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Affiliation(s)
- Heather E Olson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA.
| | - Carolyn I Daniels
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
| | - Isabel Haviland
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
| | - Lindsay C Swanson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
| | - Caitlin A Greene
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
| | - Anne Marie M Denny
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA.,Division of Pediatric Neurology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Scott T Demarest
- Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Elia Pestana-Knight
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaoming Zhang
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahsan N Moosa
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andrea Fidell
- Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Judith L Weisenberg
- Department of Pediatric Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Bernhard Suter
- Division of Child Neurology, Texas Children's Hospital, Departments of Neurology and Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Cary Fu
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey L Neul
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan K Percy
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Eric D Marsh
- Division of Child Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy A Benke
- Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, CO, USA.,Departments of Pharmacology, Neurology, and Otolaryngology, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Annapurna Poduri
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
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19
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Sun S, Wesolowski SS. Biologically active metabolites in drug discovery. Bioorg Med Chem Lett 2021; 48:128255. [PMID: 34245850 DOI: 10.1016/j.bmcl.2021.128255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/02/2021] [Accepted: 07/05/2021] [Indexed: 12/30/2022]
Abstract
Biologically active metabolites are a valuable resource for development of drug candidates and lead structures for drug design. This digest highlights a selection of biologically active metabolites that have been used as new chemical entities for development or as lead structures for drug design.
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Affiliation(s)
- Shaoyi Sun
- Xenon Pharmaceuticals Inc, 200-3650 Gilmore Way, Burnaby, BC V5G 4W8, Canada.
| | - Steven S Wesolowski
- Xenon Pharmaceuticals Inc, 200-3650 Gilmore Way, Burnaby, BC V5G 4W8, Canada
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20
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Lou S, Cui S. Drug treatment of epilepsy: From serendipitous discovery to evolutionary mechanisms. Curr Med Chem 2021; 29:3366-3391. [PMID: 34514980 DOI: 10.2174/0929867328666210910124727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/17/2021] [Accepted: 07/21/2021] [Indexed: 11/22/2022]
Abstract
Epilepsy is a chronic brain disorder caused by abnormal firing of neurons. Up to now, using antiepileptic drugs is the main method of epilepsy treatment. The development of antiepileptic drugs lasted for centuries. In general, most agents entering clinical practice act on the balance mechanisms of brain "excitability-inhibition". More specifically, they target voltage-gated ion channels, GABAergic transmission and glutamatergic transmission. In recent years, some novel drugs representing new mechanisms of action have been discovered. Although there are about 30 available drugs in the market, it is still in urgent need of discovering more effective and safer drugs. The development of new antiepileptic drugs is into a new era: from serendipitous discovery to evolutionary mechanism-based design. This article presents an overview of drug treatment of epilepsy, including a series of traditional and novel drugs.
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Affiliation(s)
- Shengying Lou
- Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou. China
| | - Sunliang Cui
- Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou. China
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21
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de Nys R, Kumar R, Gecz J. Protocadherin 19 Clustering Epilepsy and Neurosteroids: Opportunities for Intervention. Int J Mol Sci 2021; 22:9769. [PMID: 34575929 PMCID: PMC8469663 DOI: 10.3390/ijms22189769] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 01/23/2023] Open
Abstract
Steroids yield great influence on neurological development through nuclear hormone receptor (NHR)-mediated gene regulation. We recently reported that cell adhesion molecule protocadherin 19 (encoded by the PCDH19 gene) is involved in the coregulation of steroid receptor activity on gene expression. PCDH19 variants cause early-onset developmental epileptic encephalopathy clustering epilepsy (CE), with altered steroidogenesis and NHR-related gene expression being identified in these individuals. The implication of hormonal pathways in CE pathogenesis has led to the investigation of various steroid-based antiepileptic drugs in the treatment of this disorder, with mixed results so far. Therefore, there are many unmet challenges in assessing the antiseizure targets and efficiency of steroid-based therapeutics for CE. We review and assess the evidence for and against the implication of neurosteroids in the pathogenesis of CE and in view of their possible clinical benefit.
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Affiliation(s)
- Rebekah de Nys
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia; (R.d.N.); (R.K.)
- Robinson Research Institute, The University of Adelaide, Adelaide, SA 5006, Australia
| | - Raman Kumar
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia; (R.d.N.); (R.K.)
- Robinson Research Institute, The University of Adelaide, Adelaide, SA 5006, Australia
| | - Jozef Gecz
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia; (R.d.N.); (R.K.)
- Robinson Research Institute, The University of Adelaide, Adelaide, SA 5006, Australia
- School of Biological Sciences, The University of Adelaide, Adelaide, SA 5005, Australia
- South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia
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22
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Lattanzi S, Riva A, Striano P. Ganaxolone treatment for epilepsy patients: from pharmacology to place in therapy. Expert Rev Neurother 2021; 21:1317-1332. [PMID: 33724128 DOI: 10.1080/14737175.2021.1904895] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Nonsulfated neurosteroids can provide phasic and tonic inhibition through activation of synaptic and extra-synaptic γ-aminobutyric acid (GABA)A receptors, exhibiting a greater potency for the latter. These actions occur by interacting with modulatory sites that are distinct from those bound by benzodiazepines and barbiturates. Ganaxolone (GNX) is a synthetic analog of the endogenous neurosteroid allopregnanolone and a member of a novel class of neuroactive steroids called epalons.Areas covered: The authors review the pharmacology of GNX, summarize the main clinical evidence about its antiseizure efficacy and tolerability, and suggest implications for clinical practice and future research.Expert opinion: The clinical development of GNX is mainly oriented to target unmet needs and focused on status epilepticus and rare genetic epilepsies that have few or no treatment options.The availability of oral and intravenous formulations allows reaching adult and pediatric patients in acute and chronic care settings. Further evidence will complement the understanding of the potentialities of GNX and possibly lead to indications for use in clinical practice.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Antonella Riva
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, "G. Gaslini" Institute, University of Genoa, Genova, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, "G. Gaslini" Institute, University of Genoa, Genova, Italy
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23
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Biosynthesis and signalling functions of central and peripheral nervous system neurosteroids in health and disease. Essays Biochem 2021; 64:591-606. [PMID: 32756865 PMCID: PMC7517341 DOI: 10.1042/ebc20200043] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/09/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023]
Abstract
Neurosteroids are steroid hormones synthesised de novo in the brain and peripheral nervous tissues. In contrast to adrenal steroid hormones that act on intracellular nuclear receptors, neurosteroids directly modulate plasma membrane ion channels and regulate intracellular signalling. This review provides an overview of the work that led to the discovery of neurosteroids, our current understanding of their intracellular biosynthetic machinery, and their roles in regulating the development and function of nervous tissue. Neurosteroids mediate signalling in the brain via multiple mechanisms. Here, we describe in detail their effects on GABA (inhibitory) and NMDA (excitatory) receptors, two signalling pathways of opposing function. Furthermore, emerging evidence points to altered neurosteroid function and signalling in neurological disease. This review focuses on neurodegenerative diseases associated with altered neurosteroid metabolism, mainly Niemann-Pick type C, multiple sclerosis and Alzheimer disease. Finally, we summarise the use of natural and synthetic neurosteroids as current and emerging therapeutics alongside their potential use as disease biomarkers.
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Bialer M, Johannessen SI, Koepp MJ, Levy RH, Perucca E, Perucca P, Tomson T, White HS. Progress report on new antiepileptic drugs: A summary of the Fifteenth Eilat Conference on New Antiepileptic Drugs and Devices (EILAT XV). II. Drugs in more advanced clinical development. Epilepsia 2020; 61:2365-2385. [PMID: 33165915 DOI: 10.1111/epi.16726] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/20/2020] [Accepted: 09/21/2020] [Indexed: 12/16/2022]
Abstract
The Fifteenth Eilat Conference on New Antiepileptic Drugs and Devices (EILAT XV) was held as a fully virtual conference from July 27 to July 30, 2020 for the sessions on drugs, and on August 3, 2020 for the sessions on devices. A total of 534 delegates from 63 countries attended lectures and interactive discussions, representing a broad range of disciplines from basic science, clinical research, and clinical care. This progress report provides summaries of recent findings on investigational compounds for which preclinical data as well as data from patient studies were presented. The report includes the following five compounds: anakinra, cenobamate, CVL-865, fenfluramine, and ganaxolone, all with novel modes of action compared to more established antiepileptic drugs. Some of these compounds demonstrated promising results in placebo-controlled phase 3 trials, and two have recently received approval from the US Food and Drug Administration (FDA). These include cenobamate, which was approved by the FDA on November 21, 2019 for the treatment of partial onset (focal) seizures in adults, and fenfluramine oral solution, which was approved by the FDA on June 25, 2020 for the treatment of seizures associated with Dravet syndrome in patients 2 years and older.
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Affiliation(s)
- Meir Bialer
- Faculty of Medicine, School of Pharmacy and David R. Bloom Center for Pharmacy, Institute for Drug Research, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Svein I Johannessen
- National Center for Epilepsy, Sandvika, Norway.,Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Matthias J Koepp
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, UK
| | - René H Levy
- Department of Pharmaceutics and Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Emilio Perucca
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy.,IRCCS Mondino Foundation, Pavia, Italy
| | - Piero Perucca
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
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Brillatz T, Jacmin M, Vougogiannopoulou K, Petrakis EA, Kalpoutzakis E, Houriet J, Pellissier L, Rutz A, Marcourt L, Queiroz EF, Crawford AD, Skaltsounis AL, Wolfender JL. Antiseizure potential of the ancient Greek medicinal plant Helleborus odorus subsp. cyclophyllus and identification of its main active principles. JOURNAL OF ETHNOPHARMACOLOGY 2020; 259:112954. [PMID: 32445663 DOI: 10.1016/j.jep.2020.112954] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/22/2020] [Accepted: 05/06/2020] [Indexed: 06/11/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Ethnopharmacological data and ancient texts support the use of black hellebore (Helleborus odorus subsp. cyclophyllus, Ranunculaceae) for the management and treatment of epilepsy in ancient Greece. AIM OF THE STUDY A pharmacological investigation of the root methanolic extract (RME) was conducted using the zebrafish epilepsy model to isolate and identify the compounds responsible for a potential antiseizure activity and to provide evidence of its historical use. In addition, a comprehensive metabolite profiling of this studied species was proposed. MATERIALS AND METHODS The roots were extracted by solvents of increasing polarity and root decoction (RDE) was also prepared. The extracts were evaluated for antiseizure activity using a larval zebrafish epilepsy model with pentylenetetrazole (PTZ)-induced seizures. The RME exhibited the highest antiseizure activity and was therefore selected for bioactivity-guided fractionation. Isolated compounds were fully characterized by NMR and high-resolution tandem mass spectrometry (HRMS/MS). The UHPLC-HRMS/MS analyses of the RME and RDE were used for dereplication and metabolite profiling. RESULTS The RME showed 80% inhibition of PTZ-induced locomotor activity (300 μg/ml). This extract was fractionated and resulted in the isolation of a new glucopyranosyl-deoxyribonolactone (1) and a new furostanol saponin derivative (2), as well as of 20-hydroxyecdysone (3), hellebrin (4), a spirostanol glycoside derivative (5) and deglucohellebrin (6). The antiseizure activity of RME was found to be mainly due to the new furostanol saponin (2) and hellebrin (4), which reduced 45% and 60% of PTZ-induced seizures (135 μM, respectively). Besides, the aglycone of hellebrin, hellebrigenin (S34), was also active (45% at 7 μM). To further characterize the chemical composition of both RME and RDE, 30 compounds (A7-33, A35-37) were annotated based on UHPLC-HRMS/MS metabolite profiling. This revealed the presence of additional bufadienolides, furostanols, and evidenced alkaloids. CONCLUSIONS This study is the first to identify the molecular basis of the ethnopharmacological use of black hellebore for the treatment of epilepsy. This was achieved using a microscale zebrafish epilepsy model to rapidly quantify in vivo antiseizure activity. The UHPLC-HRMS/MS profiling revealed the chemical diversity of the extracts and the presence of numerous bufadienolides, furostanols and ecdysteroids, also present in the decoction.
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Affiliation(s)
- Théo Brillatz
- School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CMU - Rue Michel Servet 1, CH-1211, Geneva 4, Switzerland
| | - Maxime Jacmin
- Luxembourg Centre for Systems Biomedicine, Université du Luxembourg 6, Avenue du Swing, 4367, Belvaux, Luxembourg; Theracule S.á r.l., 9, Avenue des Hauts-Fourneaux, 4362, Belval, Luxembourg
| | - Konstantina Vougogiannopoulou
- Department of Pharmacognosy and Natural Products Chemistry, Faculty of Pharmacy, National and Kapodistrian University of Athens, Panepistimiopolis Zografou, 15771, Athens, Greece
| | - Eleftherios A Petrakis
- Department of Pharmacognosy and Natural Products Chemistry, Faculty of Pharmacy, National and Kapodistrian University of Athens, Panepistimiopolis Zografou, 15771, Athens, Greece
| | - Eleftherios Kalpoutzakis
- Department of Pharmacognosy and Natural Products Chemistry, Faculty of Pharmacy, National and Kapodistrian University of Athens, Panepistimiopolis Zografou, 15771, Athens, Greece
| | - Joëlle Houriet
- School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CMU - Rue Michel Servet 1, CH-1211, Geneva 4, Switzerland
| | - Léonie Pellissier
- School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CMU - Rue Michel Servet 1, CH-1211, Geneva 4, Switzerland
| | - Adriano Rutz
- School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CMU - Rue Michel Servet 1, CH-1211, Geneva 4, Switzerland
| | - Laurence Marcourt
- School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CMU - Rue Michel Servet 1, CH-1211, Geneva 4, Switzerland
| | - Emerson Ferreira Queiroz
- School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CMU - Rue Michel Servet 1, CH-1211, Geneva 4, Switzerland
| | - Alexander D Crawford
- Luxembourg Centre for Systems Biomedicine, Université du Luxembourg 6, Avenue du Swing, 4367, Belvaux, Luxembourg; Theracule S.á r.l., 9, Avenue des Hauts-Fourneaux, 4362, Belval, Luxembourg; Department of Preclinical Sciences & Pathology, Norwegian University of Life Sciences, Ullevålsveien 72, 0454, Oslo, Norway
| | - Alexios-Leandros Skaltsounis
- Department of Pharmacognosy and Natural Products Chemistry, Faculty of Pharmacy, National and Kapodistrian University of Athens, Panepistimiopolis Zografou, 15771, Athens, Greece.
| | - Jean-Luc Wolfender
- School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CMU - Rue Michel Servet 1, CH-1211, Geneva 4, Switzerland.
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Jeon M, Park D, Lee J, Jeon H, Ko M, Kim S, Choi Y, Tan AC, Kang J. ReSimNet: drug response similarity prediction using Siamese neural networks. Bioinformatics 2020; 35:5249-5256. [PMID: 31116384 DOI: 10.1093/bioinformatics/btz411] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 04/02/2019] [Accepted: 05/16/2019] [Indexed: 11/14/2022] Open
Abstract
MOTIVATION Traditional drug discovery approaches identify a target for a disease and find a compound that binds to the target. In this approach, structures of compounds are considered as the most important features because it is assumed that similar structures will bind to the same target. Therefore, structural analogs of the drugs that bind to the target are selected as drug candidates. However, even though compounds are not structural analogs, they may achieve the desired response. A new drug discovery method based on drug response, which can complement the structure-based methods, is needed. RESULTS We implemented Siamese neural networks called ReSimNet that take as input two chemical compounds and predicts the CMap score of the two compounds, which we use to measure the transcriptional response similarity of the two compounds. ReSimNet learns the embedding vector of a chemical compound in a transcriptional response space. ReSimNet is trained to minimize the difference between the cosine similarity of the embedding vectors of the two compounds and the CMap score of the two compounds. ReSimNet can find pairs of compounds that are similar in response even though they may have dissimilar structures. In our quantitative evaluation, ReSimNet outperformed the baseline machine learning models. The ReSimNet ensemble model achieves a Pearson correlation of 0.518 and a precision@1% of 0.989. In addition, in the qualitative analysis, we tested ReSimNet on the ZINC15 database and showed that ReSimNet successfully identifies chemical compounds that are relevant to a prototype drug whose mechanism of action is known. AVAILABILITY AND IMPLEMENTATION The source code and the pre-trained weights of ReSimNet are available at https://github.com/dmis-lab/ReSimNet. SUPPLEMENTARY INFORMATION Supplementary data are available at Bioinformatics online.
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Affiliation(s)
- Minji Jeon
- Department of Computer Science and Engineering, Korea University, Seoul 02841, South Korea
| | - Donghyeon Park
- Department of Computer Science and Engineering, Korea University, Seoul 02841, South Korea
| | - Jinhyuk Lee
- Department of Computer Science and Engineering, Korea University, Seoul 02841, South Korea
| | - Hwisang Jeon
- Interdisciplinary Graduate Program in Bioinformatics, Korea University, Seoul 02841, South Korea
| | - Miyoung Ko
- Department of Computer Science and Engineering, Korea University, Seoul 02841, South Korea
| | - Sunkyu Kim
- Department of Computer Science and Engineering, Korea University, Seoul 02841, South Korea
| | - Yonghwa Choi
- Department of Computer Science and Engineering, Korea University, Seoul 02841, South Korea
| | - Aik-Choon Tan
- Division of Medical Oncology, Department of Medicine, Translational Bioinformatics and Cancer Systems Biology Laboratory, University of Colorado Anschutz Medical Campus, Aurora, CO 12801, USA
| | - Jaewoo Kang
- Department of Computer Science and Engineering, Korea University, Seoul 02841, South Korea.,Interdisciplinary Graduate Program in Bioinformatics, Korea University, Seoul 02841, South Korea
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Berglund J. Treating Postpartum Depression: Beyond the Baby Blues. IEEE Pulse 2020; 11:17-20. [PMID: 32175847 DOI: 10.1109/mpuls.2020.2972723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Amanda Bumgarner knows about babies. As a pediatric nurse in Richmond, VA, she's spent her working life consoling sleep-deprived parents, administering shots to screaming infants, and tenderly attending to the needs of fragile premature babies, often in the most heartbreaking and dire circumstances. When she gave birth to a little girl of her own, she wasn't expecting any surprises but two weeks into motherhood, she knew something wasn't right. At first, it was the tears-she couldn't get through a single day without crying. Then it was the debilitating anxiety-the overwhelming panic that once overcame her when her best friend, herself a mother and infant nurse, held her baby. She recognized that her feelings were far from rational. "How do you turn those things off?" she wondered, far too often. Breastfeeding was also a problem. "My daughter wouldn't latch without just destroying me," she said. "I was feeling like a failure, because this is supposed to be the most natural thing ever."
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Miziak B, Chrościńska-Krawczyk M, Czuczwar SJ. Neurosteroids and Seizure Activity. Front Endocrinol (Lausanne) 2020; 11:541802. [PMID: 33117274 PMCID: PMC7561372 DOI: 10.3389/fendo.2020.541802] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 09/09/2020] [Indexed: 12/13/2022] Open
Abstract
Still circa 25% to 30% of patients with epilepsy cannot be efficiently controlled with available antiepileptic drugs so newer pharmacological treatment options have been continuously searched for. In this context, a group of endogenous or exogenous neurosteroids allosterically positively modulating GABA-A receptors may offer a promising approach. Among endogenous neurosteroids synthesized in the brain, allopregnanolone or allotetrahydrodeoxycorticosterone have been documented to exert anticonvulsant activity in a number of experimental models of seizures-pentylenetetrazol-, bicuculline- pilocarpine-, or 6 Hz-induced convulsions in rodents. Neurosteroids can also inhibit fully kindled seizures and some of them have been reported to counteract maximal electroshock-induced convulsions. An exogenous neurosteroid, alphaxalone, significantly elevated the threshold for maximal electroconvulsions in mice but it did not potentiate the anticonvulsive action of a number of conventional antiepileptic drugs against maximal electroshock-induced seizures. Androsterone not only elevated the threshold but significantly enhanced the protective action of carbamazepine, gabapentin and phenobarbital against maximal electroshock in mice, as well. Ganaxolone (a 3beta-methylated analog of allopregnanolone) needs special consideration for two reasons. First, it performed better than conventional antiepileptic drugs, diazepam or valproate, in suppressing convulsive and lethal effects of pentylenetetrazol in pentylenetetrazol-kindled mice. Second, ganaxolone has been evaluated in the randomized, double-blind, placebo-controlled phase 2 trial in patients with intractable partial seizures, taking maximally 3 antiepileptic drugs. The initial results indicate that add-on therapy with ganaxolone resulted in reduced seizure frequency with adverse effect being mainly mild to moderate. Possibly, ganaxolone may be also considered against catamenial seizures. Some positive effects of ganaxolone as an adjuvant were also observed in children with refractory seizures and its use may also prove efficient for the management of neonatal seizures associated with hypoxic injury. Neurosteroids positively modulating GABA-A receptor complex exert anticonvulsive activity in many experimental models of seizures. Their interactions with antiepileptic drugs seem ambiguous in mice. Initial clinical data indicate that ganaxolone may provide a better seizure control in patients with drug-resistant epilepsy.
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Affiliation(s)
- Barbara Miziak
- Department of Pathophysiology, Medical University of Lublin, Lublin, Poland
| | | | - Stanisław J. Czuczwar
- Department of Pathophysiology, Medical University of Lublin, Lublin, Poland
- *Correspondence: Stanisław J. Czuczwar,
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Thomas P, Pang Y. Anti-apoptotic Actions of Allopregnanolone and Ganaxolone Mediated Through Membrane Progesterone Receptors (PAQRs) in Neuronal Cells. Front Endocrinol (Lausanne) 2020; 11:417. [PMID: 32670200 PMCID: PMC7331777 DOI: 10.3389/fendo.2020.00417] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/26/2020] [Indexed: 12/19/2022] Open
Abstract
The neurosteroids progesterone and allopregnanolone regulate numerous neuroprotective functions in neural tissues including inhibition of epileptic seizures and cell death. Many of progesterone's actions are mediated through the nuclear progesterone receptor (PR), while allopregnanolone is widely considered to be devoid of hormonal activity and instead acts through modulation of GABA-A receptor activity. However, allopregnanolone can also exert hormonal actions in neuronal cells through binding and activating membrane progesterone receptors (mPRs) belonging to the progestin and adipoQ receptor (PAQR) family. The distribution and functions of the five mPR subtypes (α, β, γ, δ, ε) in neural tissues are briefly reviewed. mPRδ has the highest binding affinity for allopregnanolone and is highly expressed throughout the human brain. Low concentrations (20 nM) of allopregnanolone act through mPRδ to stimulate G protein (Gs)-dependent signaling pathways resulting in reduced cell death and apoptosis in mPRδ-transfected cells. The 3-methylated synthetic analog of allopregnanolone, ganaxolone, is currently undergoing clinical trials as a promising GABA-A receptor-selective antiepileptic drug (AED). New data show that low concentrations (20 nM) of ganaxolone also activate mPRδ signaling and exert anti-apoptotic actions through this receptor. Preliminary evidence suggests that ganaxolone can also exert neuroprotective effects by activating inhibitory G protein (Gi)-dependent signaling through mPRα and/or mPRβ in neuronal cells. The results indicate that mPRs are likely intermediaries in multiple actions of natural and synthetic neurosteroids in the brain. Potential off-target effects of ganaxolone through activation of mPRs in patients receiving long-term treatment for epilepsy and other disorders should be considered and warrant further investigation.
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Chuang SH, Reddy DS. Isobolographic Analysis of Antiseizure Activity of the GABA Type A Receptor-Modulating Synthetic Neurosteroids Brexanolone and Ganaxolone with Tiagabine and Midazolam. J Pharmacol Exp Ther 2019; 372:285-298. [PMID: 31843812 DOI: 10.1124/jpet.119.261735] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 12/13/2019] [Indexed: 12/11/2022] Open
Abstract
Epilepsy is often treated with a combination of antiepileptic drugs. Although neurosteroids are potent anticonvulsants, little is known about their combination potential for the treatment of refractory epilepsy. Here, we investigated the combination efficacy of neurosteroids allopregnanolone (AP, brexanolone) and ganaxolone (GX) with the GABA-reuptake inhibitor tiagabine (TG) or the benzodiazepine midazolam (MDZ) on tonic inhibition in dentate gyrus granule cells and seizure protection in the hippocampus kindling and 6-Hz seizure models. Isobolographic analysis indicated that combinations of GX and TG or AP and TG at three standard ratios (1:1, 3:1, and 1:3) displayed significant synergism in augmenting tonic inhibition. In pharmacological studies, GX, AP, and TG produced dose-dependent antiseizure effects in mice (ED50 = 1.46, 4.20, and 0.20 mg/kg, respectively). The combination of GX and TG at the fixed ratio of 1:1 exerted the greatest combination index (CI = 0.53), indicating strong synergistic interaction in seizure protection. In addition, combination regimens of AP and TG showed robust synergism for seizure protection (CI = 0.4). Finally, combination regimens of GX and MDZ elicited synergistic (CI = 0.6) responses for seizure protection. These results demonstrate striking synergism of neurosteroids and TG combination for seizure protection, likely because of their effects at extrasynaptic GABA type A (GABA-A) receptors from TG-induced elevation in GABA levels. Superadditive antiseizure activity of neurosteroid-MDZ combinations may stem from their actions at both synaptic and extrasynaptic GABA-A receptors. Together, these findings provide a potential mechanistic basis for combination potential of neurosteroids with TG or benzodiazepines for the management of refractory epilepsy, status epilepticus, and seizure disorders. SIGNIFICANCE STATEMENT: This paper investigates for the first time the potential synergistic interactions between two neurosteroids with anticonvulsant properties, allopregnanolone (brexanolone) and the very similar synthetic analog, ganaxolone, and two conventional antiepileptic drugs active at GABA type A receptors: the GABA-reuptake inhibitor tiagabine and a benzodiazepine, midazolam. The results demonstrate a synergistic protective effect of neurosteroid-tiagabine combinations, as well as neurosteroid-midazolam regimens in seizure models.
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Affiliation(s)
- Shu-Hui Chuang
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas
| | - Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas
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Lee M, Kim MJ, Kim EJ, Woo DC, Yum MS, Ko TS. How can methylprednisolone work on epileptic spasms with malformation of cortical development? Eur J Neurosci 2019; 50:4018-4027. [PMID: 31397941 DOI: 10.1111/ejn.14539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/04/2019] [Accepted: 07/25/2019] [Indexed: 12/15/2022]
Abstract
Although steroids are suggested as the treatment of choice for infantile spasms, the mechanism of action is still unclear. Using a rat model of malformation of cortical development with refractory infantile spasms, we evaluated the efficacy of methylprednisolone on spasms susceptibility and behaviors. Additionally, we investigated the in vivo electrophysiological and neurochemical changes of the brain after methylprednisolone treatment. Infant rats with prenatal exposure of methylazoxymethanol at gestational day 15 were used. After a single dose of methylprednisolone or three different doses of methylprednisolone for 3 days, spasms were triggered by intraperitoneal injection of N-methyl-d-aspartic acid. In rats with 3 days of methylprednisolone pretreatment and their controls, behavioral testing was performed at postnatal day 15. In vivo magnetic resonance imaging was conducted at postnatal day 15 after 3 days of methylprednisolone treatment. The rats with single methylprednisolone pretreatment showed significantly delayed onset of spasms and multiple doses of methylprednisolone significantly suppressed the development of spasms in a dose-dependent manner. After multiple methylprednisolone pretreatment and a cluster of N-methyl-d-aspartic acid-induced spasms, the rats showed significantly increased freezing behaviors to conditioned stimuli. Glutamate-weighted chemical exchange saturation transfer revealed significant elevation of glutamate concentration in the cortices of the rats with multiple methylprednisolone pretreatments. Methylprednisolone pretreatment could attenuate N-methyl-d-aspartic acid-induced spasms with in vivo neurochemical and electrophysiological changes, which indicates this steroid's action on the brain and in epilepsy.
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Affiliation(s)
- Minyoung Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, Seoul, Korea
| | - Min-Jee Kim
- Department of Pediatrics, Eulji University Hospital, Eulji University College of Medicine, Daejeon, Korea
| | - Eun-Jin Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, Seoul, Korea
| | - Dong-Cheol Woo
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, Seoul, Korea
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, Seoul, Korea
| | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, Seoul, Korea
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Mouihate A, Kalakh S. Ganaxolone enhances microglial clearance activity and promotes remyelination in focal demyelination in the corpus callosum of ovariectomized rats. CNS Neurosci Ther 2019; 26:240-250. [PMID: 31332963 PMCID: PMC6978248 DOI: 10.1111/cns.13195] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 06/24/2019] [Accepted: 06/27/2019] [Indexed: 12/01/2022] Open
Abstract
Aim Experimental studies have shown that the progesterone metabolite, allopregnanolone, is endowed with promyelinating effects. The mechanisms underlying these promyelinating effects are not well understood. Therefore, we explored the impact of allopregnanolone's synthetic analogue, ganaxolone, on remyelination and microglial activation following focal demyelination in the corpus callosum of ovariectomized rats. Methods Ovariectomized adult Sprague Dawley rats received a stereotaxic injection of 2 µL of 1% lysolecithin solution in the corpus callosum followed by daily injections of either ganaxolone (intraperitoneal injection [i.p.], 2.5 mg/kg) or vehicle. The demyelination lesion was assessed 3 and 7 days postdemyelination insult using Luxol fast blue staining and transmission electron microscopy. The expression levels of myelin proteins (MBP, MAG, MOG, CNPase) were explored using Western blot. The inflammatory response and clearance of damaged myelin were evaluated using immunofluorescent staining (Iba1, dMBP, GFAP) and multiplex enzyme‐linked immunosorbent assay (IL‐1β, TNF‐α, IL‐4, IL‐10, IL‐6). Results Systemic administration of ganaxolone promoted remyelination of lysolecithin‐induced demyelination, upregulated the expression of major myelin proteins, and enhanced microglial clearance of damaged myelin. Astrocytosis, as well as locally produced pro‐ and antiinflammatory cytokines, was not affected by ganaxolone treatment. Conclusion Ganaxolone promotes remyelination in response to focal demyelination of the corpus callosum of ovariectomized rats. This effect is, at least in part, mediated by enhancing microglial clearance of myelin debris, which creates a conducive environment for a successful remyelination process.
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Affiliation(s)
- Abdeslam Mouihate
- Department of Physiology, Faculty of Medicine, Kuwait University, Safat, Kuwait
| | - Samah Kalakh
- Department of Physiology, Faculty of Medicine, Kuwait University, Safat, Kuwait
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Shaw JC, Berry MJ, Dyson RM, Crombie GK, Hirst JJ, Palliser HK. Reduced Neurosteroid Exposure Following Preterm Birth and Its' Contribution to Neurological Impairment: A Novel Avenue for Preventative Therapies. Front Physiol 2019; 10:599. [PMID: 31156466 PMCID: PMC6529563 DOI: 10.3389/fphys.2019.00599] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 04/26/2019] [Indexed: 12/21/2022] Open
Abstract
Children born preterm are at an increased risk of developing cognitive problems and neuro-behavioral disorders such as attention deficit hyperactivity disorder (ADHD) and anxiety. Whilst neonates born at all gestational ages, even at term, can experience poor cognitive outcomes due to birth-complications such as birth asphyxia, it is becoming widely known that children born preterm in particular are at significant risk for learning difficulties with an increased utilization of special education resources, when compared to their healthy term-born peers. Additionally, those born preterm have evidence of altered cerebral myelination with reductions in white matter volumes of the frontal cortex, hippocampus and cerebellum evident on magnetic resonance imaging (MRI). This disruption to myelination may underlie some of the pathophysiology of preterm-associated brain injury. Compared to a fetus of the same post-conceptional age, the preterm newborn loses access to in utero factors that support and promote healthy brain development. Furthermore, the preterm ex utero environment is hostile to the developing brain with a myriad of environmental, biochemical and excitotoxic stressors. Allopregnanolone is a key neuroprotective fetal neurosteroid which has promyelinating effects in the developing brain. Preterm birth leads to an abrupt loss of the protective effects of allopregnanolone, with a dramatic drop in allopregnanolone concentrations in the preterm neonatal brain compared to the fetal brain. This occurs in conjunction with reduced myelination of the hippocampus, subcortical white matter and cerebellum; thus, damage to neurons, astrocytes and especially oligodendrocytes of the developing nervous system can occur in the vulnerable developmental window prior to term as a consequence reduced allopregnanolone. In an effort to prevent preterm-associated brain injury a number of therapies have been considered, but to date, other than antenatal magnesium sulfate and corticosteroid therapy, none have become part of standard clinical care for vulnerable infants. Therefore, there remains an urgent need for improved therapeutic options to prevent brain injury in preterm neonates. The actions of the placentally derived neurosteroid allopregnanolone on GABAA receptor signaling has a major role in late gestation neurodevelopment. The early loss of this intrauterine neurotrophic support following preterm birth may be pivotal to development of neurodevelopmental morbidity. Thus, restoring the in utero neurosteroid environment for preterm neonates may represent a new and clinically feasible treatment option for promoting better trajectories of myelination and brain development, and therefore reducing neurodevelopmental disorders in children born preterm.
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Affiliation(s)
- Julia C. Shaw
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Mary J. Berry
- Department of Paediatrics and Child Health, University of Otago, Wellington, Wellington, New Zealand
- Centre for Translational Physiology, University of Otago, Wellington, Wellington, New Zealand
| | - Rebecca M. Dyson
- Department of Paediatrics and Child Health, University of Otago, Wellington, Wellington, New Zealand
- Centre for Translational Physiology, University of Otago, Wellington, Wellington, New Zealand
| | - Gabrielle K. Crombie
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Jonathan J. Hirst
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Hannah K. Palliser
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
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Antkowiak B, Rammes G. GABA(A) receptor-targeted drug development -New perspectives in perioperative anesthesia. Expert Opin Drug Discov 2019; 14:683-699. [DOI: 10.1080/17460441.2019.1599356] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Bernd Antkowiak
- Department of Anesthesiology and Intensive Care, Experimental Anesthesiology Section, Eberhard-Karls-University,
Tübingen, Germany
- Department of Anaesthesiology and Intensive Care, Experimental Anaesthesiology Section, Werner Reichardt Center for Integrative Neuroscience, Tübingen,
Germany
| | - Gerhard Rammes
- University Hospital rechts der Isar, Department of Anesthesiology, München,
Germany
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35
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Neurosteroid replacement therapy using the allopregnanolone-analogue ganaxolone following preterm birth in male guinea pigs. Pediatr Res 2019; 85:86-96. [PMID: 30237570 DOI: 10.1038/s41390-018-0185-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/27/2018] [Accepted: 08/30/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Children born preterm, especially boys, are at increased risk of developing attention deficit hyperactivity disorder (ADHD) and learning difficulties. We propose that neurosteroid-replacement therapy with ganaxolone (GNX) following preterm birth may mitigate preterm-associated neurodevelopmental impairment. METHODS Time-mated sows were delivered preterm (d62) or at term (d69). Male preterm pups were randomized to ganaxolone (Prem-GNX; 2.5 mg/kg subcutaneously twice daily until term equivalence), or preterm control (Prem-CON). Surviving male juvenile pups underwent behavioural testing at d25-corrected postnatal age (CPNA). Brain tissue was collected at CPNA28 and mature myelinating oligodendrocytes of the hippocampus and subcortical white matter were quantified by immunostaining of myelin basic protein (MBP). RESULTS Ganaxolone treatment returned the hyperactive behavioural phenotype of preterm-born juvenile males to a term-born phenotype. Deficits in MBP immunostaining of the preterm hippocampus and subcortical white matter were also ameliorated in animals receiving ganaxolone. However, during the treatment period weight gain was poor, and pups were sedated, ultimately increasing the neonatal mortality rate. CONCLUSION Ganaxolone improved neurobehavioural outcomes in males suggesting that neonatal treatment may be an option for reducing preterm-associated neurodevelopmental impairment. However, dosing studies are required to reduce the burden of unwanted side effects.
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36
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Saporito MS, Gruner JA, DiCamillo A, Hinchliffe R, Barker-Haliski M, White HS. Intravenously Administered Ganaxolone Blocks Diazepam-Resistant Lithium-Pilocarpine–Induced Status Epilepticus in Rats: Comparison with Allopregnanolone. J Pharmacol Exp Ther 2018; 368:326-337. [DOI: 10.1124/jpet.118.252155] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 12/12/2018] [Indexed: 11/22/2022] Open
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37
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Hsu YT, Chang YG, Chern Y. Insights into GABA Aergic system alteration in Huntington's disease. Open Biol 2018; 8:rsob.180165. [PMID: 30518638 PMCID: PMC6303784 DOI: 10.1098/rsob.180165] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 10/30/2018] [Indexed: 12/15/2022] Open
Abstract
Huntington's disease (HD) is an autosomal dominant progressive neurodegenerative disease that is characterized by a triad of motor, psychiatric and cognitive impairments. There is still no effective therapy to delay or halt the disease progress. The striatum and cortex are two particularly affected brain regions that exhibit dense reciprocal excitatory glutamate and inhibitory gamma-amino butyric acid (GABA) connections. Imbalance between excitatory and inhibitory signalling is known to greatly affect motor and cognitive processes. Emerging evidence supports the hypothesis that disrupted GABAergic circuits underlie HD pathogenesis. In the present review, we focused on the multiple defects recently found in the GABAergic inhibitory system, including altered GABA level and synthesis, abnormal subunit composition and distribution of GABAA receptors and aberrant GABAA receptor-mediated signalling. In particular, the important role of cation–chloride cotransporters (i.e. NKCC1 and KCC2) is discussed. Recent studies also suggest that neuroinflammation contributes significantly to the abnormal GABAergic inhibition in HD. Thus, GABAA receptors and cation–chloride cotransporters are potential therapeutic targets for HD. Given the limited availability of therapeutic treatments for HD, a better understanding of GABAergic dysfunction in HD could provide novel therapeutic opportunities.
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Affiliation(s)
- Yi-Ting Hsu
- PhD Program for Translational Medicine, China Medical University and Academia Sinica, Taiwan, Republic of China.,Department of Neurology, China Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Ya-Gin Chang
- Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan, Republic of China.,Taiwan International Graduate Program in Interdisciplinary Neuroscience, National Yang-Ming University and Academia Sinica, Taipei, Taiwan, Republic of China
| | - Yijuang Chern
- PhD Program for Translational Medicine, China Medical University and Academia Sinica, Taiwan, Republic of China .,Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan, Republic of China
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38
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Chuang SH, Reddy DS. Zinc reduces antiseizure activity of neurosteroids by selective blockade of extrasynaptic GABA-A receptor-mediated tonic inhibition in the hippocampus. Neuropharmacology 2018; 148:244-256. [PMID: 30471294 DOI: 10.1016/j.neuropharm.2018.11.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 11/11/2018] [Accepted: 11/20/2018] [Indexed: 01/31/2023]
Abstract
Zinc is an abundant trace metal in the hippocampus nerve terminals. Previous studies demonstrate the ability of zinc to selectively block neurosteroid-sensitive, extrasynaptic GABA-A receptors in the hippocampus (Carver et al, 2016). Here we report that zinc prevents the seizure protective effects of the synthetic neurosteroid ganaxolone (GX) in an experimental model of epilepsy. GABA-gated and tonic currents were recorded from dissociated dentate gyrus granule cells (DGGCs), CA1 pyramidal cells (CA1PCs), and hippocampal slices from adult mice. Antiseizure effects of GX and the reversal of these effects by zinc were evaluated in fully-kindled mice expressing generalized (stage 5) seizures. In electrophysiological studies, zinc blocked the GABA-evoked and GX-potentiated GABA-gated chloride currents in DGGCs and CA1PCs in a concentration-dependent fashion similar to the competitive GABA-A receptor antagonists bicuculline and gabazine. Zinc completely blocked GX potentiation of extrasynaptic tonic currents, but not synaptic phasic currents. In hippocampus kindling studies, systemic administration of GX produced a dose-dependent suppression of behavioral and electrographic seizures in fully-kindled mice with complete seizure protection at the 10 mg/kg dose. However, the antiseizure effects of GX were significantly prevented by intrahippocampal administration of zinc (ED50, 150 μM). The zinc antagonistic response was reversible as animals responded normally to GX administration 24 h post-zinc blockade. These results demonstrate that zinc reduces the antiseizure effects of GX by selectively blocking extrasynaptic δGABA-A receptors in the hippocampus. These pharmacodynamic interactions have clinical implications in neurosteroid therapy for brain conditions associated with zinc fluctuations.
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Affiliation(s)
- Shu-Hui Chuang
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, TX, 77807, USA
| | - Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, TX, 77807, USA.
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Wu B, Jayakar SS, Zhou X, Titterton K, Chiara DC, Szabo AL, Savechenkov PY, Kent DE, Cohen JB, Forman SA, Miller KW, Bruzik KS. Inhibitable photolabeling by neurosteroid diazirine analog in the β3-Subunit of human hetereopentameric type A GABA receptors. Eur J Med Chem 2018; 162:810-824. [PMID: 30544077 DOI: 10.1016/j.ejmech.2018.11.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 11/06/2018] [Accepted: 11/08/2018] [Indexed: 12/22/2022]
Abstract
Pregnanolone and allopregnanolone-type ligands exert general anesthetic, anticonvulsant and anxiolytic effects due to their positive modulatory interactions with the GABAA receptors in the brain. Binding sites for these neurosteroids have been recently identified at subunit interfaces in the transmembrane domain (TMD) of homomeric β3 GABAA receptors using photoaffinity labeling techniques, and in homomeric chimeric receptors containing GABAA receptor α subunit TMDs by crystallography. Steroid binding sites have yet to be determined in human, heteromeric, functionally reconstituted, full-length, glycosylated GABAA receptors. Here, we report on the synthesis and pharmacological characterization of several photoaffinity analogs of pregnanolone and allopregnanolone, of which 21-[4-(3-(trifluoromethyl)-3H-diazirin-3-yl)benzoxy]allopregnanolone (21-pTFDBzox-AP) was the most potent ligand. It is a partial positive modulator of the human α1β3 and α1β3γ2L GABAA receptors at sub-micromolar concentrations. [3H]21-pTFDBzox-AP photoincorporated in a pharmacologically specific manner into the α and β subunits of those receptors, with the β3 subunit photolabeled most efficiently. Importantly, photolabeling by [3H]21-pTFDBzox-AP was inhibited by the positive steroid modulators alphaxalone, pregnanolone and allopregnanolone, but not by inhibitory neurosteroid pregnenolone sulfate or by two potent general anesthetics and GABAAR positive allosteric modulators, etomidate and an anesthetic barbiturate. The latter two ligands bind to sites at subunit interfaces in the GABAAR that are different from those interacting with neurosteroids. 21-pTFDBzox-AP's potency and pharmacological specificity of photolabeling indicate its suitability for characterizing neurosteroid binding sites in native GABAA receptors.
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Affiliation(s)
- Bo Wu
- Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, 833 South Wood Street, Chicago, IL, 60612, USA
| | - Selwyn S Jayakar
- Department of Neurobiology, 220 Longwood Avenue, Harvard Medical School, Boston, MA, 02115, USA
| | - Xiaojuan Zhou
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 32 Fruit Street, Boston, MA, 02114, USA
| | - Katherine Titterton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 32 Fruit Street, Boston, MA, 02114, USA
| | - David C Chiara
- Department of Neurobiology, 220 Longwood Avenue, Harvard Medical School, Boston, MA, 02115, USA
| | - Andrea L Szabo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 32 Fruit Street, Boston, MA, 02114, USA
| | - Pavel Y Savechenkov
- Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, 833 South Wood Street, Chicago, IL, 60612, USA
| | - Daniel E Kent
- Department of Health Science, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA
| | - Jonathan B Cohen
- Department of Neurobiology, 220 Longwood Avenue, Harvard Medical School, Boston, MA, 02115, USA
| | - Stuart A Forman
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 32 Fruit Street, Boston, MA, 02114, USA
| | - Keith W Miller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 32 Fruit Street, Boston, MA, 02114, USA; Department of Biological Chemistry and Molecular Pharmacology, 220 Longwood Avenue, Harvard Medical School, Boston, MA, 02115, USA
| | - Karol S Bruzik
- Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, 833 South Wood Street, Chicago, IL, 60612, USA.
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40
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Amengual-Gual M, Sánchez Fernández I, Wainwright MS. Novel drugs and early polypharmacotherapy in status epilepticus. Seizure 2018; 68:79-88. [PMID: 30473267 DOI: 10.1016/j.seizure.2018.08.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 08/05/2018] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Rescue medications for status epilepticus (SE) have a relatively high rate of failure. The purpose of this review is to summarize the evidence for the efficacy of novel drugs and early polypharmacotherapy for SE. METHOD Literature review. RESULTS New drugs and treatment strategies aim to target the pathophysiology of SE in order to improve seizure control and outcomes. Changes at the synapse level during SE include a progressive decrease in synaptic GABAA receptors and increase in synaptic NMDA receptors. These changes tend to promote self-sustaining seizures. Current SE guidelines recommend a rapid stepwise treatment using benzodiazepines in monotherapy as the first-line treatment, targeting GABAA synaptic receptors. Novel treatment approaches target GABAA synaptic and extrasynaptic receptors with allopregnanolone, and NMDA receptors with ketamine. Novel rescue treatments used for SE include topiramate, brivaracetam, and perampanel, which are already marketed in epilepsy. Some available drugs not marketed for use in epilepsy have been used in the treatment of SE, and other agents are being studied for this purpose. Early polytherapy, most frequently combining a benzodiazepine with a second-line drug or an NMDA receptor antagonist, might potentially increase seizure control with relatively minor increase in side effects. Although many preclinical studies support novel drugs and early polytherapy in SE, human studies are scarce and inconclusive. Currently, evidence is lacking to recommend specific combinations of these new agents. CONCLUSIONS Novel drugs and strategies target the underlying pathophysiology of SE with the intent to improve seizure control and outcomes.
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Affiliation(s)
- Marta Amengual-Gual
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Pediatric Neurology Unit, Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain.
| | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Child Neurology, Hospital Sant Joan de Déu, Universidad de Barcelona, Spain
| | - Mark S Wainwright
- Department of Neurology, Division of Pediatric Neurology. University of Washington School of Medicine, Seattle, WA, USA
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41
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Chuang SH, Reddy DS. 3 β-Methyl-Neurosteroid Analogs Are Preferential Positive Allosteric Modulators and Direct Activators of Extrasynaptic δ-Subunit γ-Aminobutyric Acid Type A Receptors in the Hippocampus Dentate Gyrus Subfield. J Pharmacol Exp Ther 2018; 365:583-601. [PMID: 29602830 DOI: 10.1124/jpet.117.246660] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 03/28/2018] [Indexed: 02/06/2023] Open
Abstract
Neurosteroids are powerful modulators of γ-aminobutyric acid (GABA)-A receptors. Ganaxolone (3α-hydroxy-3β-methyl-5α-pregnan-20-one, GX) and synthetic analogs of the neurosteroid allopregnanolone (AP) are designed to treat epilepsy and related conditions. However, their precise mechanism of action in native neurons remains unclear. Here, we sought to determine the mode of action of GX and its analogs at GABA-A receptors in native hippocampal neurons by analyzing extrasynaptic receptor-mediated tonic currents and synaptic receptor-mediated phasic currents. Concentration-response profiles of GX were determined in two cell types: δ-containing dentate gyrus granule cells (DGGCs) and γ2-containing CA1 pyramidal cells (CA1PCs). GX produced significantly greater potentiation of the GABA-A receptor-activated chloride currents in DGGCs (500%) than CA1PCs (200%). In the absence of GABA, GX evoked 2-fold greater inward currents in DGGCs than CA1PCs, which were 2-fold greater than AP within DGGCs. In hippocampus slices, GX potentiated and directly activated tonic currents in DGGCs. These responses were significantly diminished in DGGCs from δ-subunit knockout (δKO) mice, confirming GX's selectivity for δGABA-A receptors. Like AP, GX potentiation of tonic currents was prevented by protein kinase C inhibition. Furthermore, GX's protection against hippocampus-kindled seizures was significantly diminished in δKO mice. GX analogs exhibited greater potency and efficacy than GX on δGABA-A receptor-mediated tonic inhibition. In summary, these results provide strong evidence that GX and its analogs are preferential allosteric modulators and direct activators of extrasynaptic δGABA-A receptors regulating network inhibition and seizures in the dentate gyrus. Therefore, these findings provide a mechanistic rationale for the clinical use of synthetic neurosteroids in epilepsy and seizure disorders.
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Affiliation(s)
- Shu-Hui Chuang
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas
| | - Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas
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42
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Zolkowska D, Wu CY, Rogawski MA. Intramuscular allopregnanolone and ganaxolone in a mouse model of treatment-resistant status epilepticus. Epilepsia 2018; 59 Suppl 2:220-227. [PMID: 29453777 DOI: 10.1111/epi.13999] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 11/28/2022]
Abstract
Allopregnanolone (5α-pregnan-3α-ol-20-one) and its synthetic 3β-methyl analog, ganaxolone, are positive allosteric modulators of synaptic and extrasynaptic γ-aminobutyric acid (GABA)A receptors that exhibit antiseizure activity in diverse animal seizure models, including models of status epilepticus (SE). The 2 neuroactive steroids are being investigated as treatments for SE, including as a treatment for SE induced by chemical threat agents. Intramuscular injection is the preferred route of administration in the prehospital treatment of SE. The objective of this study was to assess the efficacy of intramuscular allopregnanolone and ganaxolone in the treatment of SE induced by the chemical threat agent tetramethylenedisulfotetramine (TETS). The test agents were administered 40 minutes after the onset of SE when mice are refractory to treatment. Allopregnanolone and ganaxolone (each at 3 mg/kg) terminated SE in, respectively, 92% and 75% of animals, and prevented mortality in 85% and 50% of animals; the mean times to termination of behavioral seizures were, respectively, 172 ± 16 and 447 ± 52 seconds. In a separate series of experiments, mice were dosed with the neuroactive steroids by intramuscular injection, and plasma and brain levels were sampled at various time points following injection to estimate pharmacokinetic parameters. Plasma Cmax (maximum concentration) values for allopregnanolone and ganaxolone were 645 and 550 ng/mL, respectively. Brain exposure of both steroids was approximately 3-fold the plasma exposure. Two-compartment pharmacokinetic analysis revealed that the central compartment Vd (volume of distribution), CL (clearance), t½ (terminal half-life), and F (intramuscular bioavailability) values for allopregnanolone and ganaxolone were, respectively, 4.95 L/kg 12.88 L/kg/h,16 minutes, 97%, and 5.07 L/kg, 8.35 L/kg/h, 25 minutes, 95%. Allopregnanolone and ganaxolone are effective in the treatment of TETS-induced SE when administered by the intramuscular route. Allopregnanolone is more rapidly acting and modestly more effective, possibly because it has greater potency on GABAA receptors.
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Affiliation(s)
- Dorota Zolkowska
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Chun-Yi Wu
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, USA.,Bioanalysis and Pharmacokinetics Core Facility, UC Davis Medical Center, Sacramento, CA, USA
| | - Michael A Rogawski
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Pharmacology, School of Medicine, University of California, Davis, Sacramento, CA, USA
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43
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Eimon PM, Ghannad-Rezaie M, De Rienzo G, Allalou A, Wu Y, Gao M, Roy A, Skolnick J, Yanik MF. Brain activity patterns in high-throughput electrophysiology screen predict both drug efficacies and side effects. Nat Commun 2018; 9:219. [PMID: 29335539 PMCID: PMC5768723 DOI: 10.1038/s41467-017-02404-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 11/25/2017] [Indexed: 11/26/2022] Open
Abstract
Neurological drugs are often associated with serious side effects, yet drug screens typically focus only on efficacy. We demonstrate a novel paradigm utilizing high-throughput in vivo electrophysiology and brain activity patterns (BAPs). A platform with high sensitivity records local field potentials (LFPs) simultaneously from many zebrafish larvae over extended periods. We show that BAPs from larvae experiencing epileptic seizures or drug-induced side effects have substantially reduced complexity (entropy), similar to reduced LFP complexity observed in Parkinson’s disease. To determine whether drugs that enhance BAP complexity produces positive outcomes, we used light pulses to trigger seizures in a model of Dravet syndrome, an intractable genetic epilepsy. The highest-ranked compounds identified by BAP analysis exhibit far greater anti-seizure efficacy and fewer side effects during subsequent in-depth behavioral assessment. This high correlation with behavioral outcomes illustrates the power of brain activity pattern-based screens and identifies novel therapeutic candidates with minimal side effects. One challenge in drug screening for neurological disorders is how to accurately capture disease pathology and side effects. Here, the authors developed a multi-channel recording platform based on a zebrafish genetic model of epilepsy to screen for antiepileptic drugs.
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Affiliation(s)
- Peter M Eimon
- Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA, 02139, USA.
| | - Mostafa Ghannad-Rezaie
- Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA, 02139, USA.,UZH/ETH Irchel Campus, Y17-L76, Winterthurerstrasse 190, 8057, Zürich, Switzerland
| | - Gianluca De Rienzo
- Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA, 02139, USA.,Intellimedix, Cambridge, MA, 02139, USA.,Axcella Health, 840 Memorial Dr, Cambridge, MA, 02139, USA
| | - Amin Allalou
- Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA, 02139, USA
| | - Yuelong Wu
- Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA, 02139, USA
| | - Mu Gao
- Georgia Institute of Technology, 950 Atlantic Drive, Room 2151, Atlanta, GA, 30332, USA
| | - Ambrish Roy
- Georgia Institute of Technology, 950 Atlantic Drive, Room 2151, Atlanta, GA, 30332, USA
| | - Jeffrey Skolnick
- Georgia Institute of Technology, 950 Atlantic Drive, Room 2151, Atlanta, GA, 30332, USA
| | - Mehmet Fatih Yanik
- Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA, 02139, USA. .,UZH/ETH Irchel Campus, Y17-L76, Winterthurerstrasse 190, 8057, Zürich, Switzerland.
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Chuang SH, Reddy DS. Genetic and Molecular Regulation of Extrasynaptic GABA-A Receptors in the Brain: Therapeutic Insights for Epilepsy. J Pharmacol Exp Ther 2017; 364:180-197. [PMID: 29142081 DOI: 10.1124/jpet.117.244673] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 11/13/2017] [Indexed: 12/18/2022] Open
Abstract
GABA-A receptors play a pivotal role in many brain diseases. Epilepsy is caused by acquired conditions and genetic defects in GABA receptor channels regulating neuronal excitability in the brain. The latter is referred to as GABA channelopathies. In the last two decades, major advances have been made in the genetics of epilepsy. The presence of specific GABAergic genetic abnormalities leading to some of the classic epileptic syndromes has been identified. Advances in molecular cloning and recombinant systems have helped characterize mutations in GABA-A receptor subunit genes in clinical neurology. GABA-A receptors are the prime targets for neurosteroids (NSs). However, GABA-A receptors are not static but undergo rapid changes in their number or composition in response to the neuroendocrine milieu. This review describes the recent advances in the genetic and neuroendocrine control of extrasynaptic and synaptic GABA-A receptors in epilepsy and its impact on neurologic conditions. It highlights the current knowledge of GABA genetics in epilepsy, with an emphasis on the neuroendocrine regulation of extrasynaptic GABA-A receptors in network excitability and seizure susceptibility. Recent advances in molecular regulation of extrasynaptic GABA-A receptor-mediated tonic inhibition are providing unique new therapeutic approaches for epilepsy, status epilepticus, and certain brain disorders. The discovery of an extrasynaptic molecular mechanism represents a milestone for developing novel therapies such as NS replacement therapy for catamenial epilepsy.
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Affiliation(s)
- Shu-Hui Chuang
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas
| | - Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas
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Shaw JC, Palliser HK, Dyson RM, Berry MJ, Hirst JJ. Disruptions to the cerebellar GABAergic system in juvenile guinea pigs following preterm birth. Int J Dev Neurosci 2017; 65:1-10. [PMID: 29024720 DOI: 10.1016/j.ijdevneu.2017.10.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/05/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Children that are born preterm are at an increased risk of developing cognitive problems and behavioural disorders, such as attention deficit hyperactivity disorder (ADHD). There is increasing interest in the role of the cerebellum in these processes and the potential involvement of GABAergic pathways in neurodevelopmental disorders. We propose that preterm birth, and the associated loss of the trophic intrauterine environment, alters the development of the cerebellum, contributing to ongoing neurobehavioral disorders. METHODS Guinea pigs were delivered preterm (GA62) or spontaneously at term (GA69), and tissues collected at corrected postnatal day (PND) 28. Neurodevelopmental and GABAergic markers myelin basic protein (MBP), neuronal nuclei (NeuN), calbindin (Purkinje cells), and GAD67 (GABA synthesis enzyme) were analysed in cerebellar lobules IX and X by immunohistochemistry. Protein expression of GAD67 and GAT1 (GABA transporter enzyme) were quantified by western blot, whilst neurosteroid-sensitive GABAA receptor subunits were measured by RT-PCR. RESULTS MBP immunostaining was increased in lobule IX of preterm males, and reduced in lobule X of preterm females when compared to their term counterparts. GAD67 staining was decreased in lobule IX and X of the preterm males, but only in lobule X of the preterm females compared to term cohorts for each sex. Internal granule cell layer width of lobule X was decreased in preterm cohorts of both sexes compared to terms. There were no differences between gestational age groups for NeuN staining, GAD67 and GAT1 protein expression as measured by western blotting, or GABAA receptor subunits as measured by RT-PCR between preterm and term for either sex. CONCLUSIONS The present findings suggest that components of the cerebellar GABAergic system of the ex-preterm cerebellum are disrupted. The higher expression of myelin in the preterm males may be due to a deficit in axonal pruning, whereas females have a deficit in myelination at 28 corrected days of age. Together these ongoing alterations may contribute to the neurodevelopmental and behavioural disorders observed in those born preterm.
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Affiliation(s)
- Julia C Shaw
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, Australia; Mothers and Babies Research Centre, Hunter Medical Research Institute, Australia.
| | - Hannah K Palliser
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, Australia; Mothers and Babies Research Centre, Hunter Medical Research Institute, Australia
| | - Rebecca M Dyson
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand; Centre for Translational Physiology, University of Otago, Wellington, New Zealand
| | - Mary J Berry
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand; Centre for Translational Physiology, University of Otago, Wellington, New Zealand
| | - Jonathan J Hirst
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, Australia; Mothers and Babies Research Centre, Hunter Medical Research Institute, Australia
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Yawno T, Miller SL, Bennet L, Wong F, Hirst JJ, Fahey M, Walker DW. Ganaxolone: A New Treatment for Neonatal Seizures. Front Cell Neurosci 2017; 11:246. [PMID: 28878622 PMCID: PMC5572234 DOI: 10.3389/fncel.2017.00246] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 08/02/2017] [Indexed: 12/11/2022] Open
Abstract
Neonatal seizures are amongst the most common neurologic conditions managed by a neonatal care service. Seizures can exacerbate existing brain injury, induce “de novo” injury, and are associated with neurodevelopmental disabilities in post-neonatal life. In this mini-review, we present evidence in support of the use of ganaxolone, a GABAA agonist neurosteroid, as a novel neonatal therapy. We discuss evidence that ganaxolone can provide both seizure control and neuroprotection with a high safety profile when administered early following birth-related hypoxia, and show evidence that it is likely to prevent or reduce the incidence of the enduring disabilities associated with preterm birth, cerebral palsy, and epilepsy. We suggest that ganaxolone is an ideal anti-seizure treatment because it can be safely used prospectively, with minimal or no adverse effects on the neonatal brain.
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Affiliation(s)
- Tamara Yawno
- Ritchie Centre, Hudson Institute of Medical ResearchClayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash UniversityClayton, VIC, Australia
| | - Suzie L Miller
- Ritchie Centre, Hudson Institute of Medical ResearchClayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash UniversityClayton, VIC, Australia
| | - Laura Bennet
- Department of Physiology, The University of AucklandAuckland, New Zealand
| | - Flora Wong
- Ritchie Centre, Hudson Institute of Medical ResearchClayton, VIC, Australia.,Department of Paediatrics, Monash UniversityClayton, VIC, Australia
| | - Jonathan J Hirst
- School of Biomedical Sciences and Pharmacy, University of NewcastleCallaghan, NSW, Australia
| | - Michael Fahey
- Department of Paediatrics, Monash UniversityClayton, VIC, Australia
| | - David W Walker
- Ritchie Centre, Hudson Institute of Medical ResearchClayton, VIC, Australia.,School of Health and Biomedical Sciences, RMIT UniversityBundoora, VIC, Australia
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Ligsay A, Van Dijck A, Nguyen DV, Lozano R, Chen Y, Bickel ES, Hessl D, Schneider A, Angkustsiri K, Tassone F, Ceulemans B, Kooy RF, Hagerman RJ. A randomized double-blind, placebo-controlled trial of ganaxolone in children and adolescents with fragile X syndrome. J Neurodev Disord 2017; 9:26. [PMID: 28764646 PMCID: PMC5540519 DOI: 10.1186/s11689-017-9207-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 06/01/2017] [Indexed: 12/14/2022] Open
Abstract
Background Gamma-aminobutyric acid (GABA) system deficits are integral to the pathophysiologic development of fragile X syndrome (FXS). Ganaxolone, a GABAA receptor positive allosteric modulator, is hypothesized to improve symptoms such as anxiety, hyperactivity, and attention deficits in children with FXS. Methods This study was a randomized, double-blind, placebo-controlled, crossover trial of ganaxolone in children with FXS, aged 6–17 years. Results Sixty-one participants were assessed for eligibility, and 59 were randomized to the study. Fifty-five participants completed at least the first arm and were included in the intention-to-treat analysis; 51 participants completed both treatment arms. There were no statistically significant improvements observed on the primary outcome measure (Clinical Global Impression-Improvement), the key secondary outcome measure (Pediatric Anxiety Rating Scale-R), or any other secondary outcome measures in the overall study population. However, post-hoc analyses revealed positive trends in areas of anxiety, attention, and hyperactivity in participants with higher baseline anxiety and low full-scale IQ scores. No serious adverse events (AEs) occurred, although there was a significant increase in the frequency and severity of AEs related to ganaxolone compared to placebo. Conclusions While ganaxolone was found to be safe, there were no significant improvements in the outcome measures in the overall study population. However, ganaxolone in subgroups of children with FXS, including those with higher anxiety or lower cognitive abilities, might have beneficial effects. Trial registration ClinicalTrials.gov, NCT01725152
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Affiliation(s)
- Andrew Ligsay
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California, Davis Medical Center, 2825 50th Street, Sacramento, CA, 95817, USA.,University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Anke Van Dijck
- Department of Medical Genetics, University of Antwerp, Antwerp, Belgium.,Department of Neurology-Pediatric Neurology, University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
| | - Danh V Nguyen
- Department of Medicine, University of California, Irvine School of Medicine, Orange, California, USA.,Biostatistics Institute for Clinical and Translational Science, University of California, Irvine, California, USA
| | - Reymundo Lozano
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California, Davis Medical Center, 2825 50th Street, Sacramento, CA, 95817, USA.,Seaver Autism Center for Research and Treatment, Department of Genetics and Genomic Sciences, Psychiatry, and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Pediatrics, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Yanjun Chen
- Biostatistics Institute for Clinical and Translational Science, University of California, Irvine, California, USA
| | - Erika S Bickel
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California, Davis Medical Center, 2825 50th Street, Sacramento, CA, 95817, USA.,Department of Pediatrics, University of California, Davis Medical Center, Sacramento, CA, USA
| | - David Hessl
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California, Davis Medical Center, 2825 50th Street, Sacramento, CA, 95817, USA.,Department of Psychiatry and Behavioral Sciences, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Andrea Schneider
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California, Davis Medical Center, 2825 50th Street, Sacramento, CA, 95817, USA.,Department of Pediatrics, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Kathleen Angkustsiri
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California, Davis Medical Center, 2825 50th Street, Sacramento, CA, 95817, USA.,Department of Pediatrics, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Flora Tassone
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California, Davis Medical Center, 2825 50th Street, Sacramento, CA, 95817, USA.,Department of Biochemistry and Molecular Medicine, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Berten Ceulemans
- Department of Neurology-Pediatric Neurology, University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
| | - R Frank Kooy
- Department of Medical Genetics, University of Antwerp, Antwerp, Belgium
| | - Randi J Hagerman
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California, Davis Medical Center, 2825 50th Street, Sacramento, CA, 95817, USA. .,Department of Pediatrics, University of California, Davis Medical Center, Sacramento, CA, USA.
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Rasmusson AM, Marx CE, Jain S, Farfel GM, Tsai J, Sun X, Geracioti TD, Hamner MB, Lohr J, Rosse R, Summerall L, Naylor JC, Cusin C, Lang AJ, Raman R, Stein MB. A randomized controlled trial of ganaxolone in posttraumatic stress disorder. Psychopharmacology (Berl) 2017; 234:2245-2257. [PMID: 28667510 DOI: 10.1007/s00213-017-4649-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 05/13/2017] [Indexed: 12/20/2022]
Abstract
Preclinical and clinical research supports a role for neuroactive steroids in the pathophysiology of posttraumatic stress disorder (PTSD). We investigated ganaxolone (a synthetic 3β-methylated derivative of allopregnanolone, a GABAergic neuroactive steroid) for treatment of PTSD in a proof-of-concept, multisite, double-blind, placebo-controlled trial. Veteran and non-veteran participants (n = 112) were randomized to ganaxolone or placebo at biweekly escalating doses of 200, 400, and 600 mg twice daily for 6 weeks. During an open-label 6-week extension phase, the initial ganaxolone group continued ganaxolone, while the placebo group crossed over to ganaxolone. Eighty-six and 59 participants, respectively, completed the placebo-controlled and open-label phases. A modified intent-to-treat mixed model repeated measures analysis revealed no significant differences between the effects of ganaxolone and placebo on Clinician Administered PTSD Symptom (CAPS) scores, global well-being, negative mood, or sleep. Dropout rates did not differ between groups, and ganaxolone was generally well tolerated. Trough blood levels of ganaxolone at the end of the double-blind phase were, however, lower than the anticipated therapeutic level of ganaxolone in >35% of participants on active drug. Pharmacokinetic profiling of the ganaxolone dose regimen used in the trial and adverse event sensitivity analyses suggest that under-dosing may have contributed to the failure of ganaxolone to out-perform placebo. Future investigations of ganaxolone may benefit from higher dosing, rigorous monitoring of dosing adherence, a longer length of placebo-controlled testing, and targeting of treatment to PTSD subpopulations with demonstrably dysregulated pre-treatment neuroactive steroid levels. Clinicaltrials.gov identifier: NCT01339689.
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Affiliation(s)
- Ann M Rasmusson
- National Center for PTSD-Women's Health Science Division, Department of Veterans Affairs, Boston University School of Medicine, Boston, MA, USA. .,VA Boston Healthcare Center, (116B-3), 150 South Huntington Avenue, Boston, MA, 02130, USA.
| | - Christine E Marx
- Durham VA Medical Center, VA Mid-Atlantic MIRECC, Duke University School of Medicine, Durham, NC, USA
| | - Sonia Jain
- University of California, San Diego, La Jolla, CA, USA
| | - Gail M Farfel
- Marinus Pharmaceuticals, Inc., Radnor, PA, USA.,Zogenix, Inc., San Diego, CA, USA
| | - Julia Tsai
- Marinus Pharmaceuticals, Inc., Radnor, PA, USA
| | - Xiaoying Sun
- University of California, San Diego, La Jolla, CA, USA
| | - Thomas D Geracioti
- VA Medical Center Cincinnati and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mark B Hamner
- Ralph H. Johnson VA Medical Center and Medical University of South Carolina, Charleston, SC, USA
| | - James Lohr
- University of California, San Diego, La Jolla, CA, USA.,VA San Diego Healthcare System, San Diego, CA, USA
| | - Richard Rosse
- Washington DC VA Medical Center, Washington, DC, USA
| | - Lanier Summerall
- Manchester VA Medical Center and White River Junction VA Medical Center, White River Junction, VT, USA
| | - Jennifer C Naylor
- Durham VA Medical Center, VA Mid-Atlantic MIRECC, Duke University School of Medicine, Durham, NC, USA
| | - Cristine Cusin
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Ariel J Lang
- University of California, San Diego, La Jolla, CA, USA.,VA San Diego Healthcare System, San Diego, CA, USA
| | - Rema Raman
- University of Southern California, Los Angeles, CA, USA
| | - Murray B Stein
- University of California, San Diego, La Jolla, CA, USA.,VA San Diego Healthcare System, San Diego, CA, USA
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Pugin A, Faundes V, Santa María L, Curotto B, Aliaga S, Salas I, Soto P, Bravo P, Peña M, Alliende M. Clinical, molecular, and pharmacological aspects of FMR1 -related disorders. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2014.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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50
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Savechenkov PY, Chiara DC, Desai R, Stern AT, Zhou X, Ziemba AM, Szabo AL, Zhang Y, Cohen JB, Forman SA, Miller KW, Bruzik KS. Synthesis and pharmacological evaluation of neurosteroid photoaffinity ligands. Eur J Med Chem 2017; 136:334-347. [PMID: 28505538 DOI: 10.1016/j.ejmech.2017.04.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/17/2017] [Accepted: 04/18/2017] [Indexed: 10/19/2022]
Abstract
Neuroactive steroids are potent positive allosteric modulators of GABAA receptors (GABAAR), but the locations of their GABAAR binding sites remain poorly defined. To discover these sites, we synthesized two photoreactive analogs of alphaxalone, an anesthetic neurosteroid targeting GABAAR, 11β-(4-azido-2,3,5,6-tetrafluorobenzoyloxy)allopregnanolone, (F4N3Bzoxy-AP) and 11-aziallopregnanolone (11-AziAP). Both photoprobes acted with equal or higher potency than alphaxalone as general anesthetics and potentiators of GABAAR responses, left-shifting the GABA concentration - response curve for human α1β3γ2 GABAARs expressed in Xenopus oocytes, and enhancing [3H]muscimol binding to α1β3γ2 GABAARs expressed in HEK293 cells. With EC50 of 110 nM, 11-AziAP is one the most potent general anesthetics reported. [3H]F4N3Bzoxy-AP and [3H]11-AziAP, at anesthetic concentrations, photoincorporated into α- and β-subunits of purified α1β3γ2 GABAARs, but labeling at the subunit level was not inhibited by alphaxalone (30 μM). The enhancement of photolabeling by 3H-azietomidate and 3H-mTFD-MPAB in the presence of either of the two steroid photoprobes indicates the neurosteroid binding site is different from, but allosterically related to, the etomidate and barbiturate sites. Our observations are consistent with two hypotheses. First, F4N3Bzoxy-AP and 11-aziAP bind to a high affinity site in such a pose that the 11-photoactivatable moiety, that is rigidly attached to the steroid backbone, points away from the protein. Second, F4N3Bzoxy-AP, 11-aziAP and other steroid anesthetics, which are present at very high concentration at the lipid-protein interface due to their high lipophilicity, act via low affinity sites, as proposed by Akk et al. (Psychoneuroendocrinology2009, 34S1, S59-S66).
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Affiliation(s)
- Pavel Y Savechenkov
- Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, 833 South Wood Street (M/C 781), Chicago, IL 60612-7231, USA
| | - David C Chiara
- Department of Neurobiology, 220 Longwood Avenue, Harvard Medical School, Boston, MA 02115, USA
| | - Rooma Desai
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 32 Fruit Street, Boston, MA 02114, USA
| | - Alexander T Stern
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 32 Fruit Street, Boston, MA 02114, USA
| | - Xiaojuan Zhou
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 32 Fruit Street, Boston, MA 02114, USA
| | - Alexis M Ziemba
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 32 Fruit Street, Boston, MA 02114, USA
| | - Andrea L Szabo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 32 Fruit Street, Boston, MA 02114, USA
| | - Yinghui Zhang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 32 Fruit Street, Boston, MA 02114, USA
| | - Jonathan B Cohen
- Department of Neurobiology, 220 Longwood Avenue, Harvard Medical School, Boston, MA 02115, USA
| | - Stuart A Forman
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 32 Fruit Street, Boston, MA 02114, USA
| | - Keith W Miller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 32 Fruit Street, Boston, MA 02114, USA; Department of Biological Chemistry and Molecular Pharmacology, 220 Longwood Avenue, Harvard Medical School, Boston, MA 02115, USA
| | - Karol S Bruzik
- Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, 833 South Wood Street (M/C 781), Chicago, IL 60612-7231, USA.
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