Progabide: a controlled trial in partial epilepsy

New GABA-Targeting Therapies for the Treatment of Seizures and Epilepsy: II. Treatments in Clinical Development

The inhibitory neurotransmitter γ-aminobutyric acid (GABA) plays an important role in the modulation of neuronal excitability, and a disruption of GABAergic transmission contributes to the pathogenesis of some seizure disorders. Although many currently available antiseizure medications do act at least in part by potentiating GABAergic transmission, there is an opportunity for further research aimed at developing more innovative GABA-targeting therapies. The present article summarises available evidence on a number of such treatments in clinical development. These can be broadly divided into three groups. The first group consists of positive allosteric modulators of GABAA receptors and includes Staccato® alprazolam (an already marketed benzodiazepine being repurposed in epilepsy as a potential rescue inhalation treatment for prolonged and repetitive seizures), the α2/3/5 subtype-selective agents darigabat and ENX-101, and the orally active neurosteroids ETX155 and LPCN 2101. A second group comprises two drugs already marketed for non-neurological indications, which could be repurposed as treatments for seizure disorders. These include bumetanide, a diuretic agent that has undergone clinical trials in phenobarbital-resistant neonatal seizures and for which the rationale for further development in this indication is under debate, and ivermectin, an antiparasitic drug currently investigated in a randomised double-blind trial in focal epilepsy. The last group comprises a series of highly innovative therapies, namely GABAergic interneurons (NRTX-001) delivered via stereotactic cerebral implantation as a treatment for mesial temporal lobe epilepsy, an antisense oligonucleotide (STK-001) aimed at upregulating NaV1.1 currents and restoring the function of GABAergic interneurons, currently tested in a trial in patients with Dravet syndrome, and an adenoviral vector-based gene therapy (ETX-101) scheduled for investigation in Dravet syndrome. Another agent, a subcutaneously administered neuroactive peptide (NRP2945) that reportedly upregulates the expression of GABAA receptor α and β subunits is being investigated, with Lennox-Gastaut syndrome and other epilepsies as proposed indications. The diversity of the current pipeline underscores a strong interest in the GABA system as a target for new treatment development in epilepsy. To date, limited clinical data are available for these investigational treatments and further studies are required to assess their potential value in addressing unmet needs in epilepsy management.

Epilepsy care: image of the future

A number of factors have contributed to improvements in the care of epilepsy during the past decade, including the International League Against Epilepsy classifications, therapeutic antiepileptic drug (AED) monitoring and the concept of monotherapy, new AEDs with novel mechanisms of action, and new insights into etiology that suggest novel therapies. Pharmacologically "clean" AEDs acting on a single known mechanism will be an important element in the future care of patients with epilepsy. Augmentation of GABAergic inhibition is being successfully exploited by AEDs, and there remains much room for further pharmacologic innovation. The potential role of AEDs acting specifically on the GAT-1 or GAT-4 subgroup of gamma-aminobutyric acid transporters is a topic of current research. Specifically acting AEDs designed to have a single and known mode of action will permit true monotherapy, one AED with one target as opposed to one AED with several targets, and may open the way to rational polytherapy, i.e., designed use of one AED per mechanism in epilepsies with multifactorial causation. New research demonstrating a possible autoimmune basis for some forms of epilepsy illustrates the potential for novel nonpharmacologic approaches, and the role of prevention must also be emphasized. The image of the future is an optimistic one.

Clobazam, oxcarbazepine, tiagabine, topiramate, and other new antiepileptic drugs

Clinical investigators recently have studied at least 21 new antiepileptic drugs (AEDs) in people with epilepsy. This review briefly examines 15 of these new AEDs: clobazam (CLB), dezinamide, flunarizine (FNR), loreclezole, milacemide (MLM), MK-801, nafimidone, ORG-6370, oxcarbazepine (OCBZ), progabide (PGB), ralitoline, stiripentol, tiagabine (TGB), topiramate (TPM), and zonisamide (ZNS). CLB, PGB, and TGB represent agents that act on the GABA system, and MLM acts on the glycine system. MK-801 and ZNS (in part) are excitatory amino acid antagonists, and FNR is a calcium-channel antagonist. OCBZ is a keto analogue of carbamazepine, which is not metabolized to the epoxide and may have fewer side effects. The remaining agents are novel compounds with a variety of suspected mechanisms. TPM appears especially effective for intractable partial seizures but has a high incidence of cognitive side effects. None of these new AEDs is useful for all patients with inadequate seizure control or ongoing toxicity. The role of each will require further clinical study and experience.

Tiagabine: a novel drug with a GABAergic mechanism of action

The various possibilities for manipulating the gamma-aminobutyric acid (GABA) system to augment GABAergic inhibition have been surveyed with reference to the relevant antiepileptic compounds that have been successfully or unsuccessfully investigated in relation to these different mechanisms of action. The first clinical studies of tiagabine (TGB), a novel GABA-uptake inhibitor are now available. These studies utilized a novel design, the enrichment (Amery) design, which is put into perspective compared to classical clinical trial designs. Possible advantages and disadvantages of TGB, as seen at this stage in development, have been identified.

Innovative designs of controlled clinical trials in epilepsy

Uncontrolled noncomparative clinical observations of investigational antiepileptic drugs (AEDs) often lead to overoptimistic efficacy results and are therefore of very limited value for clinical AED development. The classic add-on trial with placebo as control treatment, in contrast, has provided unequivocal evidence of the efficacy of classic and new AEDs and has also identified less useful AEDs. Drug interactions, carryover effects, difficulty in analyzing individual drug action, and the recognition that monotherapy is by far the more common way of prescribing AEDs have led to the development of classic active control monotherapy trials. A major problem of these trials is a no-difference outcome, which allows no useful interpretation. Recently, two alternative monotherapy designs have been developed to avoid the deadlock of a no-difference outcome. In these designs the active control drug is administered in an attenuated form (low dosage or low concentration) or a placebo control is used when standard treatment is discontinued during presurgical evaluation. Both designs have produced unequivocal evidence of the efficacy of the investigational AED during monotherapy. Ethical concerns are minimized by the introduction of preset escape criteria for patient protection. These designs are valuable new supplements for the clinical development of investigational AEDs for monotherapy in epilepsy. In our opinion, alternative monotherapy designs should be preceded by more than one pivotal add-on, placebo-controlled trial.

Comparative study of the anticonvulsant effect of gamma-aminobutyric acid agonists in the feline kindling model of epilepsy

We made a comparative study of the anticonvulsant effect of GABA agonists on feline amygdala or hippocampal kindled seizures. Progabide (PGB) [gamma-aminobutyric acid (GABA) receptor agonist 25-100 mg/kg intraperitoneally, i.p.] significantly reduced both the kindled seizure stage and after discharge (AD) duration in a dose-dependent manner. SKF89976A (GABA uptake inhibitor 0.5-2.0 mg/kg i.p.) also significantly reduced the kindled seizure stage. Toxic doses of SKF89976A caused generalized paroxysmal EEG discharges and myoclonus, but AD generation in the kindled focus was suppressed completely. Furthermore, gamma-vinyl GABA (GABA catabolic enzyme inhibitor, GVG 50-200 mg/kg i.p.) significantly reduced the seizure stage, while causing prolongation of the AD duration. In contrast, baclofen (selective GABAB receptor agonist, 1 or 5 mg/kg) did not show anticonvulsant effects on any parameters of kindled seizures. Therefore, these GABA agonists, which potentiate the inhibitory function of the GABAA systems, have potent anticonvulsant effects on partial onset and secondarily generalized limbic seizures.

Double-blind, placebo-controlled, cross-over trial of progabide as add-on therapy in epileptic patients

In a double-blind, cross-over trial, progabide (PGB) and placebo were compared as add-on therapy in 59 patients with moderate to severe epilepsy. Eight patients did not complete the study, 4 because of adverse drug reactions (elevation of liver transaminases, 2; gastritis, 1; and acute psychosis, 1) and 4 because of administrative reasons. Among the remaining 51 patients, seizure frequency was reduced greater than 50% in 18 patients with PGB treatment and in 8 patients with placebo (p less than 0.05). The number of days with seizures was significantly (p = 0.034) reduced during PGB treatment. Both patients' and physicians' preferences at the end of the trial were in favor (p less than 0.01) of PGB. Mild clinical side effects were present in 54.7% of the patients treated with PGB and in 37.7% with placebo. Increase in liver transaminases was observed in 2 patients during the double-blind study and in 1 during the follow-up period. Our data show that PGB, as previously reported, is useful in 30-40% of patients who are not responding completely to other antiepileptic drugs (AEDs). The compound is well tolerated, but liver function must be monitored.

An analysis of anticonvulsant actions of GABA agonists (progabide and baclofen) in the kindling model of epilepsy

The anticonvulsant action of progabide, an agonist of gamma-aminobutyric acid (GABA)A and GABAB receptors, was investigated in the kindling model of epilepsy in rats. Progabide shortened afterdischarge durations and attenuated the severity of the accompanying convulsive responses in previously kindled rats from the amygdala (AM), frontal cortex (FC), ventral and dorsal hippocampus (HIPP), in a dose-dependent manner. Although progabide was less effective in the dorsal HIPP kindled seizures, the efficacy was potent in AM, FC and ventral HIPP kindled seizures. On the other hand, the anticonvulsant action of baclofen, a selective agonist of GABAB receptors, was relatively weak in terms of the measurement of the afterdischarge duration of AM and HIPP kindled seizures even at toxic doses, compared with progabide. In addition, the anticonvulsant effects of progabide were partially reversed by treatment with the antagonist of benzodiazepine receptors, Ro 15-1788, whereas Ro 15-1788 administration alone did not alter AM kindled seizures. We concluded that the action of progabide may be mediated via the GABA/benzodiazepine receptor complex. These results support the hypothesis that a failure of GABAA-mediated inhibition is one of the bases of induction and generalization of seizures.

Progabide-induced changes in carbamazepine metabolism

Carbamazepine (CBZ) and carbamazepine 10,11 epoxide (CBZ-E) concentrations were measured during a safety and efficacy trial of progabide. The average CBZ and CBZ-E serum concentrations were calculated from serial measurements during placebo and active treatment periods. Significant decreases in CBZ and significant increases in CBZ-E were observed after the first dose of progabide, and these changes persisted during 3 months of active treatment. Ninety-five percent of the patients had increases in the epoxide/CBZ ratio at the end of 3 months of treatment. These changes are consistent with displacement of CBZ from protein binding sites and inhibition of CBZ-E metabolism induced by progabide and are analagous to the interaction between valproate and CBZ.

Anticonvulsant action of a non-competitive antagonist of NMDA receptors (MK-801) in the kindling model of epilepsy

Anticonvulsant action of MK-801, a novel non-competitive antagonist of N-methyl-D-aspartate (NMDA) receptors, was investigated in the kindling model of epilepsy in rats. The results obtained were as follows. (1) Both the seizure stage and afterdischarge duration of previously kindled seizures from the amygdala were significantly suppressed following systemic injection of MK-801 (0.25-4 mg/kg) in a dose-dependent manner. The maximum effects were observed between 2 and 4 after the injection. (2) The MK-801 also showed significant anticonvulsant effects on kindled seizures from the frontal cortex and the ventral and dorsal hippocampus. The efficacy, however, significantly differed between these kindled sites. (3) Daily treatment of MK-801 (0.25 and 1 mg/kg) prior to each electrical stimulation of the amygdala significantly retarded kindling seizure development and increased the total amount of afterdischarge (accumulated AD) required to reach the first stage 5 seizure. During drug sessions of 1 mg/kg MK-801 for 19 days, all rats showed only partial seizures and the growth of afterdischarge was strongly prevented. (4) Pretreatment with reserpine did not antagonize the anticonvulsant effects of MK-801 on previously kindled seizures from the amygdala, suggesting that the effects may not be mediated by catecholaminergic systems. These results indicate that MK-801 has potent anticonvulsant actions on kindled seizures from both limbic and cortical foci, the NMDA system may play a critical role in the seizure-triggering mechanism of kindling. The possible application of NMDA antagonists in clinical epilepsy is suggested.

Experimental studies and controlled clinical testing of valproate and vigabatrin

Gamma-aminobutyric acid (GABA) is the most important inhibitory transmitter, quantitatively, in the CNS. Evidence exists that decreased GABAergic neurotransmission may play a role in some forms of epilepsy. Consequently, manipulating the GABA system may be a therapeutic possibility in the treatment of this disease. Inhibition of the major GABA degrading enzyme, GABA-transaminase (GABA-T), seems to be the most promising approach. Currently, 2 antiepileptic drugs, valproate (VPA) and vigabatrin, gamma-vinyl GABA (GVG), are available, which are supposed to inhibit the degradation of GABA. Both drugs cause an increase in the total concentration of GABA in the brain, but to a different extent. VPA produces a moderate elevation, which seems to be the result of a marked increase in the transmitter-related GABA pool, while the pronounced elevation in GABA concentration observed during treatment with GVG seems to be caused mainly by an increase in the non-transmitter-related (glial) GABA pool. In order to investigate this apparently differential influence of VPA and GVG on the GABA system, a number of studies were undertaken in selectively cultured astrocytes and neurons from mice. For both drugs neuronal GABA-T proved far more sensitive with regard to inhibition than glial GABA-T. In order to obtain a more direct measure of a potential GABAergic mechanism of action of VPA and GVG, synaptic release of endogenous GABA was determined after culturing neurons in the presence of clinically relevant concentrations of the drugs. GVG caused a significant increase in GABA release, even at concentrations as low as 25 microM. For VPA only the highest of the investigated concentrations (300 microM) augmented GABA release. It is concluded that the antiepileptic effect of GVG seems to be caused by a direct GABAergic mechanism of action. For VPA an influence on the GABA system may play a role in the antiepileptic effect of the drug. However, the lack of definite data on human brain levels of VPA after chronic treatment, combined with evidence that VPA exhibits a number of other effects that may be relevant for its antiepileptic properties, makes the interpretation of a GABAergic mechanism of action difficult. Controlled clinical trials have been increasingly applied within all areas of medicine. In 1982 a survey of the literature identified 29 studies of antiepileptic drugs, where the design involved randomization, the double-blind principle and a statistical analysis of the results.(ABSTRACT TRUNCATED AT 400 WORDS)

Submassive hepatic necrosis associated with the use of progabide: a GABA receptor agonist

Progabide, a recently introduced gamma-aminobutyric acid mimetic, is currently undergoing clinical evaluation for a variety of convulsive disorders. We describe a patient in whom severe hepatic failure developed after four weeks of Progabide therapy. The patient's course was marked by encephalopathy, jaundice, hypoglycemia, markedly elevated serum aminotransferase levels, and prolongation of the prothrombin time. Liver biopsy showed extensive hepatocellular necrosis. The patient recovered slowly after discontinuation of the drug. The finding of eosinophilia and increased serum IgE suggests an immunologically mediated mechanism for the Progabide-induced hepatic injury. Alternatively, the lipophilic moiety of Progabide may interact with hepatocyte cell membrane lipids leading to toxic injury. We conclude that Progabide may occasionally cause severe hepatic injury.

Progabide for previously untreated absence epilepsy

Ten patients suffering from absence epilepsy and showing generalized spike-wave paroxysms in the EEG were treated by progabide monotherapy. Findings concerning clinical data and serial 24 h long-term EEG recordings were compared for the pre-treatment and treatment period. The average total spike-wave duration in 24 h decreased slightly from 810 sec to 699 sec; at follow-up, in 4 cases this trend was found to have reversed. Concerning seizure frequency, a marked anticonvulsant effect could not be confirmed; an initial slight anti-absence activity in some cases seemed to be subjected to the development of tolerance. Side effects were rarely observed and if so were not severe.

Pharmacokinetic interactions of progabide with other antiepileptic drugs

The influence of progabide, a new antiepileptic drug, on the pharmacokinetic profiles of phenobarbital, phenytoin, carbamazepine, and valproic acid was evaluated in four separate studies, each including six young healthy volunteers. The pharmacokinetic parameters of the associated antiepileptic drugs were measured before and after repeated administration of progabide (600 mg t.i.d.) for 15 days. A significant reduction of the total body clearance of both phenytoin and phenobarbital and a higher Cmax value of carbamazepine epoxide and phenobarbital were observed. No modifications were noticed for the kinetic profiles of carbamazepine and valproic acid. These modifications may be of clinical relevance and suggest that, as a general rule, when progabide is added to an established treatment with phenobarbital or phenytoin or carbamazepine, an adjustment of previous posology may be necessary.

Differential effect of gamma-vinyl GABA and valproate on GABA-transaminase from cultured neurones and astrocytes

A preferential effect of valproate on gamma-aminobutyric acid (GABA) in the nerve terminal compartment has been proposed. Gamma-vinyl GABA, an irreversible inhibitor of GABA-transaminase (GABA-T) causes a preferential increase in the GABA compartment of the non-nerve terminal. The aim of the present study was to investigate further this apparent differential effect on GABA-T of these compounds in neurones and glia. The investigations were undertaken in neurones and astrocytes, cultured separately. After incubation with valproate, the IC50 value for astrocytes was found to be 1202 microM of valproate and for neurones 634 microM. Assuming regional differences of concentrations of valproate in the brain, the observed IC50 values might be clinically relevant. Culturing the cells in the presence of gamma-vinyl GABA demonstrated IC50 values for astrocytes and neurones of 89 and 24 microM, respectively. The (S)isomer of gamma-vinyl GABA was the most active inhibitor of GABA-T in both glia and neurones. After withdrawal of gamma-vinyl GABA from the culture media of the cells, in neurones 50% of the activity of GABA-T was regained within 2-4 days. In astrocytes a similar time course was observed. These findings are in agreement with clinical data: the IC50 values correspond to clinically-relevant serum levels of gamma-vinyl GABA in humans only the (S)isomer showed an antiepileptic effect in animal models of epilepsy a delayed antiepileptic effect, after withdrawal of gamma-vinyl GABA, has been established in clinical studies.

gamma-Vinyl GABA: a double-blind placebo-controlled trial in partial epilepsy

The antiepileptic effect of gamma-vinyl gamma-aminobutyric acid (GABA), an irreversible GABA-transaminase inhibitor, was investigated in an add-on, placebo-controlled, double-blind, cross-over, fixed-dose trial. Twenty-one patients suffering from difficult to control complex partial seizures participated; 18 patients completed the trial. Serum levels of concomitant antiepileptic drugs were kept constant throughout the trial. Three patients (17%) experienced a 75% reduction in seizure frequency and in 8 (44%) the seizures were reduced by at least 50%. Two patients developed a moderate and 1 patient a marked increase in seizure frequency during treatment with gamma-vinyl GABA. Except for 2 patients who had to discontinue the trial because of adverse effects of gamma-vinyl GABA, the participants were unable to discriminate between treatment regimens with regard to side effects. gamma-vinyl GABA seems to be a promising new antiepileptic drug, and the first one to present convincing evidence of a GABAergic mechanism of action.

Epileptic seizure disorders. Developments in diagnosis and therapy

There has been considerable progress in various segments of epileptology over the past two to three decades. The diagnostic sector has benefited from more advanced and sophisticated EEG-related techniques. The advent of computerized tomography has expedited the clinical evaluation of epileptic patients and new high-technology methods have been introduced. A new type of diagnostic subdivision (based on age-determined epileptic conditions and certain epileptic syndromes) is of great practical significance because of its prognostic implications (distinction of basically benign and severe forms of epileptic seizure disorders). The therapeutic sector has been stimulated by the introduction of new antiepileptic medications and particularly by profound insights into metabolic and pharmacokinetic characteristics of anticonvulsants; this has resulted in the introduction of techniques for serum level determinations. There have been new developments in the field of neurosurgical treatment of epileptic seizure disorders.

Penicillin spikes in rats. Limitations of a simple model for the study of anticonvulsants

Direct GABA agonists that suppress spikes induced by penicillin in cats failed to do so in rats. Phenytoin and large doses of THIP increased the rate of spiking activity of the penicillin focus. Only progabide caused marked, initial, short-lasting suppression and a modest reduction of frequency of spikes for 1 hr. Homotaurine (3APS) reduced the amplitude and changed the morphology of the contralateral "mirror" spike. Antagonism of penicillin-induced spikes in rats is considered to be an unsuitable parameter for the screening of anticonvulsant agents.

THIP: a single-blind controlled trial in patients with epilepsy

In an early phase-2 study, THIP (4,5,6,7-tetrahydroisoxazolo(5,4-c)pyridin-3-ol) was investigated in a single-blind controlled trial comprising 9 outpatients suffering from epilepsy. THIP was added to the concomitant antiepileptic treatment with increasing doses (15 to 120 mg/day) based on therapeutic effect or side-effects. The blood levels of concomitant therapy were kept constant. No significant difference was established between the number of seizures during treatment with maximal doses of THIP and placebo. A trend was observed for lower seizure frequency during a period on submaximal dose of THIP.