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Bacq A, Depaulis A, Castagné V, Le Guern ME, Wirrell EC, Verleye M. An Update on Stiripentol Mechanisms of Action: A Narrative Review. Adv Ther 2024; 41:1351-1371. [PMID: 38443647 PMCID: PMC10960919 DOI: 10.1007/s12325-024-02813-0] [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: 01/09/2024] [Accepted: 02/02/2024] [Indexed: 03/07/2024]
Abstract
Stiripentol (Diacomit®) (STP) is an orally active antiseizure medication (ASM) indicated as adjunctive therapy, for the treatment of seizures associated with Dravet syndrome (DS), a severe form of childhood epilepsy, in conjunction with clobazam and, in some regions valproic acid. Since the discovery of STP, several mechanisms of action (MoA) have been described that may explain its specific effect on seizures associated with DS. STP is mainly considered as a potentiator of gamma-aminobutyric acid (GABA) neurotransmission: (i) via uptake blockade, (ii) inhibition of degradation, but also (iii) as a positive allosteric modulator of GABAA receptors, especially those containing α3 and δ subunits. Blockade of voltage-gated sodium and T-type calcium channels, which is classically associated with anticonvulsant and neuroprotective properties, has also been demonstrated for STP. Finally, several studies indicate that STP could regulate glucose energy metabolism and inhibit lactate dehydrogenase. STP is also an inhibitor of several cytochrome P450 enzymes involved in the metabolism of other ASMs, contributing to boost their anticonvulsant efficacy as add-on therapy. These different MoAs involved in treatment of DS and recent data suggest a potential for STP to treat other neurological or non-neurological diseases.
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Affiliation(s)
- Alexandre Bacq
- Biocodex Research and Development Center, Compiègne, France.
| | - Antoine Depaulis
- Univ. Grenoble Alpes, Inserm, U1216, Grenoble Institut Neurosciences, Grenoble, France
| | | | | | - Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Marc Verleye
- Biocodex Research and Development Center, Compiègne, France
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2
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Pierce SR, Germann AL, Xu SQ, Menon SL, Ortells MO, Arias HR, Akk G. Mutational Analysis of Anesthetic Binding Sites and Their Effects on GABA A Receptor Activation and Modulation by Positive Allosteric Modulators of the α7 Nicotinic Receptor. Biomolecules 2023; 13:698. [PMID: 37189445 PMCID: PMC10135968 DOI: 10.3390/biom13040698] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/16/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023] Open
Abstract
The positive allosteric modulators (PAMs) of the α7 nicotinic receptor N-(5-Cl-2-hydroxyphenyl)-N'-[2-Cl-5-(trifluoromethyl)phenyl]-urea (NS-1738) and (E)-3-(furan-2-yl)-N-(p-tolyl)-acrylamide (PAM-2) potentiate the α1β2γ2L GABAA receptor through interactions with the classic anesthetic binding sites located at intersubunit interfaces in the transmembrane domain of the receptor. In the present study, we employed mutational analysis to investigate in detail the involvement and contributions made by the individual intersubunit interfaces to receptor modulation by NS-1738 and PAM-2. We show that mutations to each of the anesthetic-binding intersubunit interfaces (β+/α-, α+/β-, and γ+/β-), as well as the orphan α+/γ- interface, modify receptor potentiation by NS-1738 and PAM-2. Furthermore, mutations to any single interface can fully abolish potentiation by the α7-PAMs. The findings are discussed in the context of energetic additivity and interactions between the individual binding sites.
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Affiliation(s)
- Spencer R. Pierce
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Allison L. Germann
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Sophia Q. Xu
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Saumith L. Menon
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Marcelo O. Ortells
- Facultad de Medicina, Universidad de Morón, CONICET, Morón 1708, Argentina
| | - Hugo R. Arias
- Department of Pharmacology and Physiology, Oklahoma State University College of Osteopathic Medicine, Tahlequah, OK 74464, USA
| | - Gustav Akk
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- The Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, MO 63110, USA
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3
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Seto T. General anesthetic binding mode via hydration with weak affinity and molecular discrimination: General anesthetic dissolution in interfacial water of the common binding site of GABA A receptor. Biophys Physicobiol 2023; 20:e200005. [PMID: 38496235 PMCID: PMC10941959 DOI: 10.2142/biophysico.bppb-v20.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 01/23/2023] [Indexed: 01/25/2023] Open
Abstract
The GABAA receptor (GABAAR) is a target channel for the loss of awareness of general anesthesia. General anesthetic (GA) spans a wide range of chemical structures, such as monatomic molecules, barbital acids, phenols, ethers, and alkanes. GA has a weak binding affinity, and the affinity has a characteristic that correlates with the solubility in olive oil rather than the molecular shape. The GA binding site of GABAAR is common to GAs and exists in the transmembrane domain of the GABAAR intersubunit. In this study, the mechanism of GA binding, which allows binding of various GAs with intersubunit selectivity, was elucidated from the hydration analysis of the binding site. Regardless of the diverse GA chemical structures, a strong correlation was observed between the binding free energy and total dehydration number of the binding process. The GA binding free energy was more involved in the binding dehydration and showed molecular recognition that allowed for the binding of various GA structures via binding site hydration. We regarded the GA substitution for the interfacial water molecule of the binding site as a dissolution into the interfacial hydration layer. The elucidation of the GA binding mechanism mediated by hydration at the GABAAR common binding site provides a rationale for the combined use of anesthetics in medical practice and its combination adjustments via drug interactions.
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Affiliation(s)
- Tomoyoshi Seto
- Department of Anesthesiology, School of Medicine, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
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4
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Arias HR, Borghese CM, Germann AL, Pierce SR, Bonardi A, Nocentini A, Gratteri P, Thodati TM, Lim NJ, Adron Harris R, Akk G. (+)-Catharanthine potentiates the GABA A receptor by binding to a transmembrane site at the β(+)/α(-) interface near the TM2-TM3 loop. Biochem Pharmacol 2022; 199:114993. [PMID: 35304861 PMCID: PMC9178925 DOI: 10.1016/j.bcp.2022.114993] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 11/17/2022]
Abstract
(+)-Catharanthine, a coronaridine congener, potentiates the γ-aminobutyric acid type A receptor (GABAAR) and induces sedation through a non-benzodiazepine mechanism, but the specific site of action and intrinsic mechanism have not beendefined. Here, we describe GABAAR subtype selectivity and location of the putative binding site for (+)-catharanthine using electrophysiological, site-directed mutagenesis, functional competition, and molecular docking experiments. Electrophysiological and in silico experiments showed that (+)-catharanthine potentiates the responses to low, subsaturating GABA at β2/3-containing GABAARs 2.4-3.5 times more efficaciously than at β1-containing GABAARs. The activity of (+)-catharanthine is reduced by the β2(N265S) mutation that decreases GABAAR potentiation by loreclezole, but not by the β3(M286C) or α1(Q241L) mutations that reduce receptor potentiation by R(+)-etomidate or neurosteroids, respectively. Competitive functional experiments indicated that the binding site for (+)-catharanthine overlaps that for loreclezole, but not those for R(+)-etomidate or potentiating neurosteroids. Molecular docking experiments suggested that (+)-catharanthine binds at the β(+)/α(-) intersubunit interface near the TM2-TM3 loop, where it forms H-bonds with β2-D282 (TM3), β2-K279 (TM2-TM3 loop), and β2-N265 and β2-R269 (TM2). Site-directed mutagenesis experiments supported the in silico results, demonstrating that the K279A and D282A substitutions, that lead to a loss of H-bonding ability of the mutated residue, and the N265S mutation, impair the gating efficacy of (+)-catharanthine. We infer that (+)-catharanthine potentiates the GABAAR through several H-bond interactions with a binding site located in the β(+)/α(-) interface in the transmembrane domain, near the TM2-TM3 loop, where it overlaps with loreclezole binding site.
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Affiliation(s)
- Hugo R Arias
- Department of Pharmacology and Physiology, Oklahoma State University College of Osteopathic Medicine, Tahlequah, OK, USA.
| | - Cecilia M Borghese
- Waggoner Center for Alcohol and Addiction Research, The University of Texas at Austin, Austin, TX, USA.
| | - Allison L Germann
- Department of Anesthesiology, the Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, MO, USA.
| | - Spencer R Pierce
- Department of Anesthesiology, the Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, MO, USA.
| | - Alessandro Bonardi
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), Section of Pharmaceutical and Nutraceutical Sciences, Laboratory of Molecular Modeling Cheminformatics & QSAR, University of Florence, Florence, Italy.
| | - Alessio Nocentini
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), Section of Pharmaceutical and Nutraceutical Sciences, Laboratory of Molecular Modeling Cheminformatics & QSAR, University of Florence, Florence, Italy.
| | - Paola Gratteri
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), Section of Pharmaceutical and Nutraceutical Sciences, Laboratory of Molecular Modeling Cheminformatics & QSAR, University of Florence, Florence, Italy.
| | - Thanvi M Thodati
- Waggoner Center for Alcohol and Addiction Research, The University of Texas at Austin, Austin, TX, USA.
| | - Natalie J Lim
- Waggoner Center for Alcohol and Addiction Research, The University of Texas at Austin, Austin, TX, USA.
| | - R Adron Harris
- Waggoner Center for Alcohol and Addiction Research, The University of Texas at Austin, Austin, TX, USA.
| | - Gustav Akk
- Department of Anesthesiology, the Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, MO, USA.
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Sikstus S, Benkherouf AY, Soini SL, Uusi-Oukari M. The Influence of AA29504 on GABA A Receptor Ligand Binding Properties and Its Implications on Subtype Selectivity. Neurochem Res 2022; 47:667-678. [PMID: 34727270 PMCID: PMC8847198 DOI: 10.1007/s11064-021-03475-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/03/2021] [Accepted: 10/27/2021] [Indexed: 10/26/2022]
Abstract
The unique pharmacological properties of δ-containing γ-aminobutyric acid type A receptors (δ-GABAARs) make them an attractive target for selective and persistent modulation of neuronal excitability. However, the availability of selective modulators targeting δ-GABAARs remains limited. AA29504 ([2-amino-4-(2,4,6-trimethylbenzylamino)-phenyl]-carbamic acid ethyl ester), an analog of K+ channel opener retigabine, acts as an agonist and a positive allosteric modulator (Ago-PAM) of δ-GABAARs. Based on electrophysiological studies using recombinant receptors, AA29504 was found to be a more potent and effective agonist in δ-GABAARs than in γ2-GABAARs. In comparison, AA29504 positively modulated the activity of recombinant δ-GABAARs more effectively than γ2-GABAARs, with no significant differences in potency. The impact of AA29504's efficacy- and potency-associated GABAAR subtype selectivity on radioligand binding properties remain unexplored. Using [3H]4'-ethynyl-4-n-propylbicycloorthobenzoate ([3H]EBOB) binding assay, we found no difference in the modulatory potency of AA29504 on GABA- and THIP (4,5,6,7-tetrahydroisoxazolo[5,4-c]pyridin-3-ol)-induced responses between native forebrain GABAARs of wild type and δ knock-out mice. In recombinant receptors expressed in HEK293 cells, AA29504 showed higher efficacy on δ- than γ2-GABAARs in the GABA-independent displacement of [3H]EBOB binding. Interestingly, AA29504 showed a concentration-dependent stimulation of [3H]muscimol binding to γ2-GABAARs, which was absent in δ-GABAARs. This was explained by AA29504 shifting the low-affinity γ2-GABAAR towards a higher affinity desensitized state, thereby rising new sites capable of binding GABAAR agonists with low nanomolar affinity. Hence, the potential of AA29504 to act as a desensitization-modifying allosteric modulator of γ2-GABAARs deserves further investigation for its promising influence on shaping efficacy, duration and plasticity of GABAAR synaptic responses.
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Affiliation(s)
- Sylvia Sikstus
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland
| | - Ali Y Benkherouf
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland
| | - Sanna L Soini
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland
| | - Mikko Uusi-Oukari
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland.
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Kono M, Ozoe F, Asahi M, Ozoe Y. State-dependent inhibition of GABA receptor channels by the ectoparasiticide fluralaner. PESTICIDE BIOCHEMISTRY AND PHYSIOLOGY 2022; 181:105008. [PMID: 35082031 DOI: 10.1016/j.pestbp.2021.105008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/15/2021] [Accepted: 12/07/2021] [Indexed: 06/14/2023]
Abstract
γ-Aminobutyric acid (GABA) receptors (GABARs) are ligand-gated Cl- channels, which cause an influx of Cl- that inhibits excitation in postsynaptic cells upon activation. GABARs are important targets for drugs and pest control chemicals. We previously reported that the isoxazoline ectoparasiticide fluralaner inhibits GABA-induced currents in housefly (Musca domestica) GABARs by binding to the putative binding site in the transmembrane subunit interface. In the present study, we investigated whether fluralaner inhibits the GABA response in the GABAR activated state, the resting state, or both, using two-electrode voltage clamp electrophysiology protocols. We found that inhibition progresses over time to steady-state levels by repeated short applications of GABA during fluralaner perfusion. The GABA response was not impaired by fluralaner treatment in the GABAR resting state. However, once inhibited, the GABA response was not restored by repeated applications of GABA. These findings suggest that fluralaner might reach the binding site of the activated conformation of GABARs in a stepwise fashion and tightly bind to it.
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Affiliation(s)
- Miku Kono
- Faculty of Life and Environmental Sciences, Shimane University, Matsue, Shimane 690-8504, Japan
| | - Fumiyo Ozoe
- Interdisciplinary Institute for Science Research, Organization for Research and Academic Information, Shimane University, Matsue, Shimane 690-8504, Japan
| | - Miho Asahi
- Biological Research Laboratories, Nissan Chemical Corporation, Shiraoka, Saitama 349-0294, Japan
| | - Yoshihisa Ozoe
- Faculty of Life and Environmental Sciences, Shimane University, Matsue, Shimane 690-8504, Japan; Interdisciplinary Institute for Science Research, Organization for Research and Academic Information, Shimane University, Matsue, Shimane 690-8504, Japan.
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7
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Cheng WWL, Arcario MJ, Petroff JT. Druggable Lipid Binding Sites in Pentameric Ligand-Gated Ion Channels and Transient Receptor Potential Channels. Front Physiol 2022; 12:798102. [PMID: 35069257 PMCID: PMC8777383 DOI: 10.3389/fphys.2021.798102] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/02/2021] [Indexed: 12/17/2022] Open
Abstract
Lipids modulate the function of many ion channels, possibly through direct lipid-protein interactions. The recent outpouring of ion channel structures by cryo-EM has revealed many lipid binding sites. Whether these sites mediate lipid modulation of ion channel function is not firmly established in most cases. However, it is intriguing that many of these lipid binding sites are also known sites for other allosteric modulators or drugs, supporting the notion that lipids act as endogenous allosteric modulators through these sites. Here, we review such lipid-drug binding sites, focusing on pentameric ligand-gated ion channels and transient receptor potential channels. Notable examples include sites for phospholipids and sterols that are shared by anesthetics and vanilloids. We discuss some implications of lipid binding at these sites including the possibility that lipids can alter drug potency or that understanding protein-lipid interactions can guide drug design. Structures are only the first step toward understanding the mechanism of lipid modulation at these sites. Looking forward, we identify knowledge gaps in the field and approaches to address them. These include defining the effects of lipids on channel function in reconstituted systems using asymmetric membranes and measuring lipid binding affinities at specific sites using native mass spectrometry, fluorescence binding assays, and computational approaches.
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Affiliation(s)
- Wayland W L Cheng
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, United States
| | - Mark J Arcario
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, United States
| | - John T Petroff
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, United States
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8
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Löscher W. Single-Target Versus Multi-Target Drugs Versus Combinations of Drugs With Multiple Targets: Preclinical and Clinical Evidence for the Treatment or Prevention of Epilepsy. Front Pharmacol 2021; 12:730257. [PMID: 34776956 PMCID: PMC8580162 DOI: 10.3389/fphar.2021.730257] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/04/2021] [Indexed: 01/09/2023] Open
Abstract
Rationally designed multi-target drugs (also termed multimodal drugs, network therapeutics, or designed multiple ligands) have emerged as an attractive drug discovery paradigm in the last 10-20 years, as potential therapeutic solutions for diseases of complex etiology and diseases with significant drug-resistance problems. Such agents that modulate multiple targets simultaneously are developed with the aim of enhancing efficacy or improving safety relative to drugs that address only a single target or to combinations of single-target drugs. Although this strategy has been proposed for epilepsy therapy >25 years ago, to my knowledge, only one antiseizure medication (ASM), padsevonil, has been intentionally developed as a single molecular entity that could target two different mechanisms. This novel drug exhibited promising effects in numerous preclinical models of difficult-to-treat seizures. However, in a recent randomized placebo-controlled phase IIb add-on trial in treatment-resistant focal epilepsy patients, padsevonil did not separate from placebo in its primary endpoints. At about the same time, a novel ASM, cenobamate, exhibited efficacy in several randomized controlled trials in such patients that far surpassed the efficacy of any other of the newer ASMs. Yet, cenobamate was discovered purely by phenotype-based screening and its presumed dual mechanism of action was only described recently. In this review, I will survey the efficacy of single-target vs. multi-target drugs vs. combinations of drugs with multiple targets in the treatment and prevention of epilepsy. Most clinically approved ASMs already act at multiple targets, but it will be important to identify and validate new target combinations that are more effective in drug-resistant epilepsy and eventually may prevent the development or progression of epilepsy.
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Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany, and Center for Systems Neuroscience Hannover, Hannover, Germany
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9
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Abstract
A 60-year-old woman with a 5-year history of anxiolytic use, a diazepam-equivalent daily dose of 15 mg, was scheduled for esophageal stent removal. She was given remimazolam (0.5 mg/kg) but remained fully alert. She only lost consciousness with propofol (40 mg). A 61-year-old man with a 1-year history of anxiolytic use, diazepam-equivalent daily dose of 20 mg, was scheduled for hand tumor resection. He was given remimazolam (0.3 mg/kg) but remained fully alert. He only lost consciousness after desflurane inhalation. In a patient with a history of long-term benzodiazepine use, anesthetic or sedative agents aside from remimazolam should be considered.
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10
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Kim JJ, Hibbs RE. Direct Structural Insights into GABA A Receptor Pharmacology. Trends Biochem Sci 2021; 46:502-517. [PMID: 33674151 DOI: 10.1016/j.tibs.2021.01.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/08/2021] [Accepted: 01/25/2021] [Indexed: 12/18/2022]
Abstract
GABAA receptors are pentameric ligand-gated ion channels that mediate most fast neuronal inhibition in the brain. In addition to their important physiological roles, they are noteworthy in their rich pharmacology; prominent drugs used for anxiety, insomnia, and general anesthesia act through positive modulation of GABAA receptors. Direct structural information for how these drugs work was absent until recently. Efforts in structural biology over the past few years have revealed how important drug classes and natural products interact with the GABAA receptor, providing a foundation for studies in dynamics and structure-guided drug design. Here, we review recent developments in GABAA receptor structural pharmacology, focusing on subunit assemblies of the receptor found at synapses.
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Affiliation(s)
- Jeong Joo Kim
- Department of Neuroscience, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Ryan E Hibbs
- Department of Neuroscience, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA.
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11
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Borghese CM, Wang HYL, McHardy SF, Messing RO, Trudell JR, Harris RA, Bertaccini EJ. Modulation of α1β3γ2 GABA A receptors expressed in X. laevis oocytes using a propofol photoswitch tethered to the transmembrane helix. Proc Natl Acad Sci U S A 2021; 118:e2008178118. [PMID: 33593898 PMCID: PMC7923644 DOI: 10.1073/pnas.2008178118] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Tethered photoswitches are molecules with two photo-dependent isomeric forms, each with different actions on their biological targets. They include reactive chemical groups capable of covalently binding to their target. Our aim was to develop a β-subunit-tethered propofol photoswitch (MAP20), as a tool to better study the mechanism of anesthesia through the GABAA α1β3γ2 receptor. We used short spacers between the tether (methanethiosulfonate), the photosensitive moiety (azobenzene), and the ligand (propofol), to allow a precise tethering adjacent to the putative propofol binding site at the β+α- interface of the receptor transmembrane helices (TMs). First, we used molecular modeling to identify possible tethering sites in β3TM3 and α1TM1, and then introduced cysteines in the candidate positions. Two mutant subunits [β3(M283C) and α1(V227C)] showed photomodulation of GABA responses after incubation with MAP20 and illumination with lights at specific wavelengths. The α1β3(M283C)γ2 receptor showed the greatest photomodulation, which decreased as GABA concentration increased. The location of the mutations that produced photomodulation confirmed that the propofol binding site is located in the β+α- interface close to the extracellular side of the transmembrane helices. Tethering the photoswitch to cysteines introduced in the positions homologous to β3M283 in two other subunits (α1W288 and γ2L298) also produced photomodulation, which was not entirely reversible, probably reflecting the different nature of each interface. The results are in agreement with a binding site in the β+α- interface for the anesthetic propofol.
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Affiliation(s)
- Cecilia M Borghese
- Waggoner Center for Alcohol and Addiction Research, The University of Texas at Austin, Austin, TX 78712;
- Department of Neuroscience, The University of Texas at Austin, Austin, TX 78712
| | - Hua-Yu L Wang
- Center for Innovative Drug Discovery, University of Texas at San Antonio, San Antonio, TX 78249
| | - Stanton F McHardy
- Center for Innovative Drug Discovery, University of Texas at San Antonio, San Antonio, TX 78249
| | - Robert O Messing
- Waggoner Center for Alcohol and Addiction Research, The University of Texas at Austin, Austin, TX 78712
- Department of Neuroscience, The University of Texas at Austin, Austin, TX 78712
| | - James R Trudell
- Department of Anesthesia, Stanford University, Palo Alto, CA 94305
- Beckman Program for Molecular and Genetic Medicine, Stanford University, Palo Alto, CA 94305
| | - R Adron Harris
- Waggoner Center for Alcohol and Addiction Research, The University of Texas at Austin, Austin, TX 78712
- Department of Neuroscience, The University of Texas at Austin, Austin, TX 78712
| | - Edward J Bertaccini
- Department of Anesthesia, Stanford University, Palo Alto, CA 94305
- Department of Anesthesia, Palo Alto VA Health Care System, Palo Alto Division, Palo Alto, CA 94304
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12
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Löscher W, Sills GJ, White HS. The ups and downs of alkyl-carbamates in epilepsy therapy: How does cenobamate differ? Epilepsia 2021; 62:596-614. [PMID: 33580520 DOI: 10.1111/epi.16832] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 12/13/2022]
Abstract
Since 1955, several alkyl-carbamates have been developed for the treatment of anxiety and epilepsy, including meprobamate, flupirtine, felbamate, retigabine, carisbamate, and cenobamate. They have each enjoyed varying levels of success as antiseizure drugs; however, they have all been plagued by the emergence of serious and sometimes life-threatening adverse events. In this review, we compare and contrast their predominant molecular mechanisms of action, their antiseizure profile, and where possible, their clinical efficacy. The preclinical, clinical, and mechanistic profile of the prototypical γ-aminobutyric acidergic (GABAergic) modulator phenobarbital is included for comparison. Like phenobarbital, all of the clinically approved alkyl-carbamates share an ability to enhance inhibitory neurotransmission through modulation of the GABAA receptor, although the specific mechanism of interaction differs among the different drugs discussed. In addition, several alkyl-carbamates have been shown to interact with voltage-gated ion channels. Flupirtine and retigabine share an ability to activate K+ currents mediated by KCNQ (Kv7) K+ channels, and felbamate, carisbamate, and cenobamate have been shown to block Na+ channels. In contrast to other alkyl-carbamates, cenobamate seems to be unique in its ability to preferentially attenuate the persistent rather than transient Na+ current. Results from recent randomized controlled clinical trials with cenobamate suggest that this newest antiseizure alkyl-carbamate possesses a degree of efficacy not witnessed since felbamate was approved in 1993. Given that ceno-bamate's mechanistic profile is unique among the alkyl-carbamates, it is not clear whether this impressive efficacy reflects an as yet undescribed mechanism of action or whether it possesses a unique synergy between its actions at the GABAA receptor and on persistent Na+ currents. The high efficacy of cenobamate is, however, tempered by the risk of serious rash and low tolerability at higher doses, meaning that further safety studies and clinical experience are needed to determine the true clinical value of cenobamate.
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Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Hannover, Germany.,Center for Systems Neuroscience Hannover, Hannover, Germany
| | - Graeme J Sills
- School of Life Sciences, University of Glasgow, Glasgow, UK
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
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13
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Competitive Antagonism of Etomidate Action by Diazepam: In Vitro GABAA Receptor and In Vivo Zebrafish Studies. Anesthesiology 2020; 133:583-594. [PMID: 32541553 DOI: 10.1097/aln.0000000000003403] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recent cryo-electron microscopic imaging studies have shown that in addition to binding to the classical extracellular benzodiazepine binding site of the α1β3γ2L γ-aminobutyric acid type A (GABAA) receptor, diazepam also binds to etomidate binding sites located in the transmembrane receptor domain. Because such binding is characterized by low modulatory efficacy, the authors hypothesized that diazepam would act in vitro and in vivo as a competitive etomidate antagonist. METHODS The concentration-dependent actions of diazepam on 20 µM etomidate-activated and 6 µM GABA-activated currents were defined (in the absence and presence of flumazenil) in oocyte-expressed α1β3γ2L GABAA receptors using voltage clamp electrophysiology. The ability of diazepam to inhibit receptor labeling of purified α1β3γ2L GABAA receptors by [H]azietomidate was assessed in photoaffinity labeling protection studies. The impact of diazepam (in the absence and presence of flumazenil) on the anesthetic potencies of etomidate and ketamine was compared in a zebrafish model. RESULTS At nanomolar concentrations, diazepam comparably potentiated etomidate-activated and GABA-activated GABAA receptor peak current amplitudes in a flumazenil-reversible manner. The half-maximal potentiating concentrations were 39 nM (95% CI, 27 to 55 nM) and 26 nM (95% CI, 16 to 41 nM), respectively. However, at micromolar concentrations, diazepam reduced etomidate-activated, but not GABA-activated, GABAA receptor peak current amplitudes in a concentration-dependent manner with a half-maximal inhibitory concentration of 9.6 µM (95% CI, 7.6 to 12 µM). Diazepam (12.5 to 50 µM) also right-shifted the etomidate-concentration response curve for direct activation without reducing the maximal response and inhibited receptor photoaffinity labeling by [H]azietomidate. When administered with flumazenil, 50 µM diazepam shifted the etomidate (but not the ketamine) concentration-response curve for anesthesia rightward, increasing the etomidate EC50 by 18-fold. CONCLUSIONS At micromolar concentrations and in the presence of flumazenil to inhibit allosteric modulation via the classical benzodiazepine binding site of the GABAA receptor, diazepam acts as an in vitro and in vivo competitive etomidate antagonist.
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14
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Sugasawa Y, Cheng WW, Bracamontes JR, Chen ZW, Wang L, Germann AL, Pierce SR, Senneff TC, Krishnan K, Reichert DE, Covey DF, Akk G, Evers AS. Site-specific effects of neurosteroids on GABA A receptor activation and desensitization. eLife 2020; 9:55331. [PMID: 32955433 PMCID: PMC7532004 DOI: 10.7554/elife.55331] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 09/20/2020] [Indexed: 12/16/2022] Open
Abstract
This study examines how site-specific binding to three identified neurosteroid-binding sites in the α1β3 GABAA receptor (GABAAR) contributes to neurosteroid allosteric modulation. We found that the potentiating neurosteroid, allopregnanolone, but not its inhibitory 3β-epimer epi-allopregnanolone, binds to the canonical β3(+)–α1(-) intersubunit site that mediates receptor activation by neurosteroids. In contrast, both allopregnanolone and epi-allopregnanolone bind to intrasubunit sites in the β3 subunit, promoting receptor desensitization and the α1 subunit promoting effects that vary between neurosteroids. Two neurosteroid analogues with diazirine moieties replacing the 3-hydroxyl (KK148 and KK150) bind to all three sites, but do not potentiate GABAAR currents. KK148 is a desensitizing agent, whereas KK150 is devoid of allosteric activity. These compounds provide potential chemical scaffolds for neurosteroid antagonists. Collectively, these data show that differential occupancy and efficacy at three discrete neurosteroid-binding sites determine whether a neurosteroid has potentiating, inhibitory, or competitive antagonist activity on GABAARs.
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Affiliation(s)
- Yusuke Sugasawa
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, United States
| | - Wayland Wl Cheng
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, United States
| | - John R Bracamontes
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, United States
| | - Zi-Wei Chen
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, United States.,Taylor Family Institute for Innovative Psychiatric Research, Washington University in St. Louis, St. Louis, United States
| | - Lei Wang
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, United States
| | - Allison L Germann
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, United States
| | - Spencer R Pierce
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, United States
| | - Thomas C Senneff
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, United States
| | - Kathiresan Krishnan
- Department of Developmental Biology, Washington University in St. Louis, St. Louis, United States
| | - David E Reichert
- Taylor Family Institute for Innovative Psychiatric Research, Washington University in St. Louis, St. Louis, United States.,Department of Radiology, Washington University in St. Louis, St. Louis, United States
| | - Douglas F Covey
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, United States.,Taylor Family Institute for Innovative Psychiatric Research, Washington University in St. Louis, St. Louis, United States.,Department of Developmental Biology, Washington University in St. Louis, St. Louis, United States.,Department of Psychiatry, Washington University in St. Louis, St. Louis, United States
| | - Gustav Akk
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, United States.,Taylor Family Institute for Innovative Psychiatric Research, Washington University in St. Louis, St. Louis, United States
| | - Alex S Evers
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, United States.,Taylor Family Institute for Innovative Psychiatric Research, Washington University in St. Louis, St. Louis, United States.,Department of Developmental Biology, Washington University in St. Louis, St. Louis, United States
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15
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Kim JJ, Gharpure A, Teng J, Zhuang Y, Howard RJ, Zhu S, Noviello CM, Walsh RM, Lindahl E, Hibbs RE. Shared structural mechanisms of general anaesthetics and benzodiazepines. Nature 2020; 585:303-308. [PMID: 32879488 PMCID: PMC7486282 DOI: 10.1038/s41586-020-2654-5] [Citation(s) in RCA: 171] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 06/01/2020] [Indexed: 01/17/2023]
Abstract
Most general anaesthetics and classical benzodiazepine drugs act through positive modulation of γ-aminobutyric acid type A (GABAA) receptors to dampen neuronal activity in the brain1-5. However, direct structural information on the mechanisms of general anaesthetics at their physiological receptor sites is lacking. Here we present cryo-electron microscopy structures of GABAA receptors bound to intravenous anaesthetics, benzodiazepines and inhibitory modulators. These structures were solved in a lipidic environment and are complemented by electrophysiology and molecular dynamics simulations. Structures of GABAA receptors in complex with the anaesthetics phenobarbital, etomidate and propofol reveal both distinct and common transmembrane binding sites, which are shared in part by the benzodiazepine drug diazepam. Structures in which GABAA receptors are bound by benzodiazepine-site ligands identify an additional membrane binding site for diazepam and suggest an allosteric mechanism for anaesthetic reversal by flumazenil. This study provides a foundation for understanding how pharmacologically diverse and clinically essential drugs act through overlapping and distinct mechanisms to potentiate inhibitory signalling in the brain.
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Affiliation(s)
- Jeong Joo Kim
- Department of Neuroscience, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anant Gharpure
- Department of Neuroscience, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jinfeng Teng
- Department of Neuroscience, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yuxuan Zhuang
- Department of Biochemistry and Biophysics, Science for Life Laboratory, Stockholm University, Solna, Sweden
| | - Rebecca J Howard
- Department of Biochemistry and Biophysics, Science for Life Laboratory, Stockholm University, Solna, Sweden
| | - Shaotong Zhu
- Department of Neuroscience, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Colleen M Noviello
- Department of Neuroscience, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Richard M Walsh
- Department of Biological Chemistry and Molecular Pharmacology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
| | - Erik Lindahl
- Department of Biochemistry and Biophysics, Science for Life Laboratory, Stockholm University, Solna, Sweden
- Department of Applied Physics, Swedish e-Science Research Center, KTH Royal Institute of Technology, Solna, Sweden
| | - Ryan E Hibbs
- Department of Neuroscience, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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16
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Jayakar SS, Chiara DC, Zhou X, Wu B, Bruzik KS, Miller KW, Cohen JB. Photoaffinity labeling identifies an intersubunit steroid-binding site in heteromeric GABA type A (GABA A) receptors. J Biol Chem 2020; 295:11495-11512. [PMID: 32540960 DOI: 10.1074/jbc.ra120.013452] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/09/2020] [Indexed: 12/11/2022] Open
Abstract
Allopregnanolone (3α5α-P), pregnanolone, and their synthetic derivatives are potent positive allosteric modulators (PAMs) of GABAA receptors (GABAARs) with in vivo anesthetic, anxiolytic, and anti-convulsant effects. Mutational analysis, photoaffinity labeling, and structural studies have provided evidence for intersubunit and intrasubunit steroid-binding sites in the GABAAR transmembrane domain, but revealed only little definition of their binding properties. Here, we identified steroid-binding sites in purified human α1β3 and α1β3γ2 GABAARs by photoaffinity labeling with [3H]21-[4-(3-(trifluoromethyl)-3H-diazirine-3-yl)benzoxy]allopregnanolone ([3H]21-pTFDBzox-AP), a potent GABAAR PAM. Protein microsequencing established 3α5α-P inhibitable photolabeling of amino acids near the cytoplasmic end of the β subunit M4 (β3Pro-415, β3Leu-417, and β3Thr-418) and M3 (β3Arg-309) helices located at the base of a pocket in the β+-α- subunit interface that extends to the level of αGln-242, a steroid sensitivity determinant in the αM1 helix. Competition photolabeling established that this site binds with high affinity a structurally diverse group of 3α-OH steroids that act as anesthetics, anti-epileptics, and anti-depressants. The presence of a 3α-OH was crucial: 3-acetylated, 3-deoxy, and 3-oxo analogs of 3α5α-P, as well as 3β-OH analogs that are GABAAR antagonists, bound with at least 1000-fold lower affinity than 3α5α-P. Similarly, for GABAAR PAMs with the C-20 carbonyl of 3α5α-P or pregnanolone reduced to a hydroxyl, binding affinity is reduced by 1,000-fold, whereas binding is retained after deoxygenation at the C-20 position. These results provide a first insight into the structure-activity relationship at the GABAAR β+-α- subunit interface steroid-binding site and identify several steroid PAMs that act via other sites.
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Affiliation(s)
- Selwyn S Jayakar
- Department of Neurobiology, Harvard Medical School, Boston, Massachusetts
| | - David C Chiara
- Department of Neurobiology, Harvard Medical School, Boston, Massachusetts
| | - Xiaojuan Zhou
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Bo Wu
- Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, Chicago, Illinois
| | - Karol S Bruzik
- Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, Chicago, Illinois
| | - Keith W Miller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan B Cohen
- Department of Neurobiology, Harvard Medical School, Boston, Massachusetts
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17
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Shalabi AR, Yu Z, Zhou X, Jounaidi Y, Chen H, Dai J, Kent DE, Feng HJ, Forman SA, Cohen JB, Bruzik KS, Miller KW. A potent photoreactive general anesthetic with novel binding site selectivity for GABA A receptors. Eur J Med Chem 2020; 194:112261. [PMID: 32247113 DOI: 10.1016/j.ejmech.2020.112261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 12/27/2022]
Abstract
The pentameric γ-aminobutyric acid type A receptors (GABAARs) are the major inhibitory ligand-gated ion channels in the central nervous system. They mediate diverse physiological functions, mutations in them are associated with mental disorders and they are the target of many drugs such as general anesthetics, anxiolytics and anti-convulsants. The five subunits of synaptic GABAARs are arranged around a central pore in the order β-α-β-α-γ. In the outer third of the transmembrane domain (TMD) drugs may bind to five homologous intersubunit binding sites. Etomidate binds between the pair of β - α subunit interfaces (designated as β+/α-) and R-mTFD-MPAB binds to an α+/β- and an γ+/β- subunit interface (a β- selective ligand). Ligands that bind selectively to other homologous sites have not been characterized. We have synthesized a novel photolabel, (2,6-diisopropyl-4-(3-(trifluoromethyl)-3H-diazirin-3-yl)phenyl)methanol or pTFD-di-iPr-BnOH). It is a potent general anesthetic that positively modulates agonist and benzodiazepine binding. It enhances GABA-induced currents, shifting the GABA concentration-response curve to lower concentrations. Photolabeling-protection studies show that it has negligible affinity for the etomidate sites and high affinity for only one of the two R-mTFD-MPAB sites. Exploratory site-directed mutagenesis studies confirm the latter conclusions and hint that pTFD-di-iPr-BnOH may bind between the α+/β- and α+/γ- subunits in the TMD, making it an α+ ligand. The latter α+/γ- site has not previously been implicated in ligand binding. Thus, pTFD-di-iPr-BnOH is a promising new photolabel that may open up a new pharmacology for synaptic GABAARs.
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Affiliation(s)
- Abdelrahman R Shalabi
- Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, 833 South Wood Street, Chicago, IL, 60612, USA
| | - Zhiyi Yu
- Department of Neurobiology, Harvard Medical School, 220 Longwood Avenue, Boston, MA, 02115, USA.
| | - Xiaojuan Zhou
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 32 Fruit Street, Boston, MA, 02114, USA
| | - Youssef Jounaidi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 32 Fruit Street, Boston, MA, 02114, USA
| | - Hanwen Chen
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 32 Fruit Street, Boston, MA, 02114, USA.
| | - Jiajia Dai
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 32 Fruit Street, Boston, MA, 02114, USA.
| | - Daniel E Kent
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 32 Fruit Street, Boston, MA, 02114, USA; Department of Health Science, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA
| | - Hua-Jun Feng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 32 Fruit Street, Boston, MA, 02114, USA
| | - Stuart A Forman
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 32 Fruit Street, Boston, MA, 02114, USA
| | - Jonathan B Cohen
- Department of Neurobiology, Harvard Medical School, 220 Longwood Avenue, 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
| | - Keith W Miller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 32 Fruit Street, Boston, MA, 02114, USA.
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18
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Sills GJ, Rogawski MA. Mechanisms of action of currently used antiseizure drugs. Neuropharmacology 2020; 168:107966. [PMID: 32120063 DOI: 10.1016/j.neuropharm.2020.107966] [Citation(s) in RCA: 230] [Impact Index Per Article: 57.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/09/2020] [Accepted: 01/12/2020] [Indexed: 02/08/2023]
Abstract
Antiseizure drugs (ASDs) prevent the occurrence of seizures; there is no evidence that they have disease-modifying properties. In the more than 160 years that orally administered ASDs have been available for epilepsy therapy, most agents entering clinical practice were either discovered serendipitously or with the use of animal seizure models. The ASDs originating from these approaches act on brain excitability mechanisms to interfere with the generation and spread of epileptic hyperexcitability, but they do not address the specific defects that are pathogenic in the epilepsies for which they are prescribed, which in most cases are not well understood. There are four broad classes of such ASD mechanisms: (1) modulation of voltage-gated sodium channels (e.g. phenytoin, carbamazepine, lamotrigine), voltage-gated calcium channels (e.g. ethosuximide), and voltage-gated potassium channels [e.g. retigabine (ezogabine)]; (2) enhancement of GABA-mediated inhibitory neurotransmission (e.g. benzodiazepines, tiagabine, vigabatrin); (3) attenuation of glutamate-mediated excitatory neurotransmission (e.g. perampanel); and (4) modulation of neurotransmitter release via a presynaptic action (e.g. levetiracetam, brivaracetam, gabapentin, pregabalin). In the past two decades there has been great progress in identifying the pathophysiological mechanisms of many genetic epilepsies. Given this new understanding, attempts are being made to engineer specific small molecule, antisense and gene therapies that functionally reverse or structurally correct pathogenic defects in epilepsy syndromes. In the near future, these new therapies will begin a paradigm shift in the treatment of some rare genetic epilepsy syndromes, but targeted therapies will remain elusive for the vast majority of epilepsies until their causes are identified. This article is part of the special issue entitled 'New Epilepsy Therapies for the 21st Century - From Antiseizure Drugs to Prevention, Modification and Cure of Epilepsy'.
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Affiliation(s)
- Graeme J Sills
- School of Life Sciences, University of Glasgow, Glasgow, UK.
| | - 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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