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Klein P, Bourikas D. Narrative Review of Brivaracetam: Preclinical Profile and Clinical Benefits in the Treatment of Patients with Epilepsy. Adv Ther 2024; 41:2682-2699. [PMID: 38811492 PMCID: PMC11213745 DOI: 10.1007/s12325-024-02876-z] [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: 03/13/2024] [Accepted: 04/16/2024] [Indexed: 05/31/2024]
Abstract
One third of patients with epilepsy will continue to have uncontrolled seizures despite treatment with antiseizure medications (ASMs). There is therefore a need to develop novel ASMs. Brivaracetam (BRV) is an ASM that was developed in a major drug discovery program aimed at identifying selective, high-affinity synaptic vesicle protein 2A (SV2A) ligands, the target molecule of levetiracetam. BRV binds to SV2A with 15- to 30-fold higher affinity and greater selectivity than levetiracetam. BRV has broad-spectrum antiseizure activity in animal models of epilepsy, a favorable pharmacokinetic profile, few clinically relevant drug-drug interactions, and rapid brain penetration. BRV is available in oral and intravenous formulations and can be initiated at target dose without titration. Efficacy and safety of adjunctive BRV (50-200 mg/day) treatment of focal-onset seizures was demonstrated in three pivotal phase III trials (NCT00490035/NCT00464269/NCT01261325), including in patients who had previously failed levetiracetam. Efficacy and safety of adjunctive BRV were also demonstrated in adult Asian patients with focal-onset seizures (NCT03083665). In several open-label trials (NCT00150800/NCT00175916/NCT01339559), long-term safety and tolerability of adjunctive BRV was established, with efficacy maintained for up to 14 years, with high retention rates. Evidence from daily clinical practice highlights BRV effectiveness and tolerability in specific epilepsy patient populations with high unmet needs: the elderly (≥ 65 years of age), children (< 16 years of age), patients with cognitive impairment, patients with psychiatric comorbid conditions, and patients with acquired epilepsy of specific etiologies (post-stroke epilepsy/brain tumor related epilepsy/traumatic brain injury-related epilepsy). Here, we review the preclinical profile and clinical benefits of BRV from pivotal trials and recently published evidence from daily clinical practice.
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Affiliation(s)
- Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, 6410 Rockledge Dr, Bethesda, MD, 20817, USA.
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Xiong M, Lubberink M, Appel L, Fang XT, Danfors T, Kumlien E, Antoni G. Evaluation of [ 11C]UCB-A positron emission tomography in human brains. EJNMMI Res 2024; 14:56. [PMID: 38884834 PMCID: PMC11183037 DOI: 10.1186/s13550-024-01117-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/02/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND In preclinical studies, the positron emission tomography (PET) imaging with [11C]UCB-A provided promising results for imaging synaptic vesicle protein 2A (SV2A) as a proxy for synaptic density. This paper reports the first-in-human [11C]UCB-A PET study to characterise its kinetics in healthy subjects and further evaluate SV2A-specific binding. RESULTS Twelve healthy subjects underwent 90-min baseline [11C]UCB-A scans with PET/MRI, with two subjects participating in an additional blocking scan with the same scanning procedure after a single dose of levetiracetam (1500 mg). Our results indicated abundant [11C]UCB-A brain uptake across all cortical regions, with slow elimination. Kinetic modelling of [11C]UCB-A PET using various compartment models suggested that the irreversible two-tissue compartment model best describes the kinetics of the radioactive tracer. Accordingly, the Patlak graphical analysis was used to simplify the analysis. The estimated SV2A occupancy determined by the Lassen plot was around 66%. Significant specific binding at baseline and comparable binding reduction as grey matter precludes the use of centrum semiovale as reference tissue. CONCLUSIONS [11C]UCB-A PET imaging enables quantifying SV2A in vivo. However, its slow kinetics require a long scan duration, which is impractical with the short half-life of carbon-11. Consequently, the slow kinetics and complicated quantification methods may restrict its use in humans.
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Affiliation(s)
- Mengfei Xiong
- Molecular Imaging and Medical Physics, Department of Surgical Sciences, Uppsala University, Entrance 70, 75185, Uppsala, Sweden.
| | - Mark Lubberink
- Molecular Imaging and Medical Physics, Department of Surgical Sciences, Uppsala University, Entrance 70, 75185, Uppsala, Sweden
| | - Lieuwe Appel
- Molecular Imaging and Medical Physics, Department of Surgical Sciences, Uppsala University, Entrance 70, 75185, Uppsala, Sweden
| | - Xiaotian Tsong Fang
- Molecular Imaging and Medical Physics, Department of Surgical Sciences, Uppsala University, Entrance 70, 75185, Uppsala, Sweden
- Julius Clinical BV, Zeist, The Netherlands
| | - Torsten Danfors
- Molecular Imaging and Medical Physics, Department of Surgical Sciences, Uppsala University, Entrance 70, 75185, Uppsala, Sweden
| | - Eva Kumlien
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Gunnar Antoni
- Department of Medicinal Chemistry, Uppsala University, Uppsala, Sweden
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Marstrand-Joergensen MR, Laurell GL, Herrmann S, Nasser A, Johansen A, Lund A, Andersen TL, Knudsen GM, Pinborg LH. Assessment of cerebral drug occupancy in humans using a single PET-scan: A [ 11C]UCB-J PET study. Eur J Nucl Med Mol Imaging 2024:10.1007/s00259-024-06759-x. [PMID: 38758370 DOI: 10.1007/s00259-024-06759-x] [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: 01/30/2024] [Accepted: 05/07/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE Here, we evaluate a PET displacement model with a Single-step and Numerical solution in healthy individuals using the synaptic vesicle glycoprotein (SV2A) PET-tracer [11C]UCB-J and the anti-seizure medication levetiracetam (LEV). We aimed to (1) validate the displacement model by comparing the brain LEV-SV2A occupancy from a single PET scan with the occupancy derived from two PET scans and the Lassen plot and (2) determine the plasma LEV concentration-SV2A occupancy curve in healthy individuals. METHODS Eleven healthy individuals (five females, mean age 35.5 [range: 25-47] years) underwent two 120-min [11C]UCB-J PET scans where an LEV dose (5-30 mg/kg) was administered intravenously halfway through the first PET scan to partially displace radioligand binding to SV2A. Five individuals were scanned twice on the same day; the remaining six were scanned once on two separate days, receiving two identical LEV doses. Arterial blood samples were acquired to determine the arterial input function and plasma LEV concentrations. Using the displacement model, the SV2A-LEV target engagement was calculated and compared with the Lassen plot method. The resulting data were fitted with a single-site binding model. RESULTS SV2A occupancies and VND estimates derived from the displacement model were not significantly different from the Lassen plot (p = 0.55 and 0.13, respectively). The coefficient of variation was 14.6% vs. 17.3% for the Numerical and the Single-step solution in Bland-Altman comparisons with the Lassen plot. The average half maximal inhibitory concentration (IC50), as estimated from the area under the curve of the plasma LEV concentration, was 12.5 µg/mL (95% CI: 5-25) for the Single-Step solution, 11.8 µg/mL (95% CI: 4-25) for the Numerical solution, and 6.3 µg/mL (95% CI: 0.08-21) for the Lassen plot. Constraining Emax to 100% did not significantly improve model fits. CONCLUSION Plasma LEV concentration vs. SV2A occupancy can be determined in humans using a single PET scan displacement model. The average concentration of the three computed IC50 values ranges between 6.3 and 12.5 µg/mL. The next step is to use the displacement model to evaluate LEV occupancy and corresponding plasma concentrations in relation to treatment efficacy. CLINICAL TRIAL REGISTRATION NCT05450822. Retrospectively registered 5 July 2022 https://clinicaltrials.gov/ct2/results? term=NCT05450822&Search=Search.
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Affiliation(s)
- Maja R Marstrand-Joergensen
- Epilepsy Clinic, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, Copenhagen O, 2100, Denmark
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Rigshospitalet, Building 8057, Blegdamsvej 9, Copenhagen, 8057, DK-2100, Denmark
- Department of Neurology, Copenhagen University Hospital Rigshospitalet, Copenhagen, 2100, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Gjertrud L Laurell
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Rigshospitalet, Building 8057, Blegdamsvej 9, Copenhagen, 8057, DK-2100, Denmark
- Molecular Imaging and Neuropathology Area, New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | - Susan Herrmann
- Department of Clinical Biochemistry, Copenhagen University Hospital Rigshospitalet, Glostrup, Denmark
| | - Arafat Nasser
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Rigshospitalet, Building 8057, Blegdamsvej 9, Copenhagen, 8057, DK-2100, Denmark
| | - Annette Johansen
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Rigshospitalet, Building 8057, Blegdamsvej 9, Copenhagen, 8057, DK-2100, Denmark
- Department of Neurology, Copenhagen University Hospital Rigshospitalet, Copenhagen, 2100, Denmark
| | - Anton Lund
- Department of Neuroanaesthesiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, 2100, Denmark
| | - Thomas L Andersen
- Department of Clinical Physiology & Nuclear Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, 2100, Denmark
- Department of Clinical Medicine, Faculty of Health and Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Gitte M Knudsen
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Rigshospitalet, Building 8057, Blegdamsvej 9, Copenhagen, 8057, DK-2100, Denmark
- Department of Neurology, Copenhagen University Hospital Rigshospitalet, Copenhagen, 2100, Denmark
- Department of Clinical Medicine, Faculty of Health and Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars H Pinborg
- Epilepsy Clinic, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, Copenhagen O, 2100, Denmark.
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Rigshospitalet, Building 8057, Blegdamsvej 9, Copenhagen, 8057, DK-2100, Denmark.
- Department of Neurology, Copenhagen University Hospital Rigshospitalet, Copenhagen, 2100, Denmark.
- Department of Clinical Medicine, Faculty of Health and Medicine, University of Copenhagen, Copenhagen, Denmark.
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Zwierzyńska E, Pietrzak B. The impact of brivaracetam on cognitive processes and anxiety in various experimental models. Pharmacol Rep 2024; 76:86-97. [PMID: 38182968 PMCID: PMC10830775 DOI: 10.1007/s43440-023-00564-3] [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: 08/23/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Memory deficits and anxiety symptoms are undesirable effects that occur in epilepsy patients. They may be associated with the pathophysiology of the disease but also with anticonvulsant therapy. Brivaracetam (BRV) is one of the newest antiseizure drugs. It acts as a ligand for synaptic vesicle glycoprotein 2A (SV2A), which may play a significant role in cognitive processes. Although BRV has a favorable safety profile, its central side effects remain unclear. Hence, this study aimed to evaluate the effect of BRV on various types of memory and anxiety in rats. METHODS BRV was given to adult male Wistar rats (n = 80) via gastric tube as a single dose (6 mg/kg or 20 mg/kg) or chronically (6 mg/kg). The effect of the drug on spatial memory was evaluated in the Morris water maze (MWM), fear-learning by passive avoidance (PA), and recognition memory with novel object recognition (NOR). The elevated plus maze (EPM) was used to assess anxiety-like behaviors. RESULTS The impact of BRV on memory is dose-dependent and mainly high doses may alter retrieval memory and fear-learning. Sub-chronic administration also impaired retrieval and spatial memory in animals. Moreover, chronic BRV may increase anxiety levels in rats but did not affect recognition memory. CONCLUSIONS BRV may cause transient memory deficits as well as anxiety disturbances. However, the results are varied and depend on the type of memory, used dose, and duration of administration.
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Affiliation(s)
- Ewa Zwierzyńska
- Department of Pharmacodynamics, Medical University of Lodz, Muszyńskiego 1, 90-151, Łódź, Poland.
| | - Bogusława Pietrzak
- Department of Pharmacodynamics, Medical University of Lodz, Muszyńskiego 1, 90-151, Łódź, Poland
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Stockis A, Nicolas JM, Sargentini-Maier ML, Krauwinkel W. Pharmacokinetics, Safety, and Tolerability of Brivaracetam in Healthy Elderly Participants. Clin Pharmacol Drug Dev 2023; 12:1121-1127. [PMID: 37212183 DOI: 10.1002/cpdd.1264] [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: 02/20/2023] [Accepted: 04/17/2023] [Indexed: 05/23/2023]
Abstract
The pharmacokinetics, metabolism, safety, and tolerability of the antiseizure medication brivaracetam (BRV) were characterized in 16 healthy elderly participants (8 men/8 women) aged 65-78 years who received a single 200-mg oral dose of BRV on day 1, followed by 200 mg twice daily from day 3 until day 12. BRV and three metabolites were determined in plasma and urine. Adverse events, vital signs, electrocardiograms, laboratory tests, general and neurological examinations, and psychometric rating scales were recorded at regular intervals. No clinically relevant changes or abnormalities were detected. The adverse events were similar to those observed in pivotal trials. Rating scales indicated transiently increased sedation and decreased alertness. BRV pharmacokinetics and metabolism were unchanged relative to younger populations. Based on our observations in this healthy elderly population receiving oral BRV 200 mg twice daily (twice the maximum recommended dose), dose reductions are not warranted relative to other, younger populations. Further investigations may be necessary in frail elderly populations aged >80 years.
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Laurell GL, Plavén-Sigray P, Johansen A, Raval NR, Nasser A, Aabye Madsen C, Madsen J, Hansen HD, Donovan LL, Knudsen GM, Lammertsma AA, Ogden RT, Svarer C, Schain M. Kinetic models for estimating occupancy from single-scan PET displacement studies. J Cereb Blood Flow Metab 2023; 43:1544-1556. [PMID: 37070382 PMCID: PMC10414003 DOI: 10.1177/0271678x231168591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/01/2023] [Accepted: 03/05/2023] [Indexed: 04/19/2023]
Abstract
The traditional design of PET target engagement studies is based on a baseline scan and one or more scans after drug administration. We here evaluate an alternative design in which the drug is administered during an on-going scan (i.e., a displacement study). This approach results both in lower radiation exposure and lower costs. Existing kinetic models assume steady state. This condition is not present during a drug displacement and consequently, our aim here was to develop kinetic models for analysing PET displacement data. We modified existing compartment models to accommodate a time-variant increase in occupancy following the pharmacological in-scan intervention. Since this implies the use of differential equations that cannot be solved analytically, we developed instead one approximate and one numerical solution. Through simulations, we show that if the occupancy is relatively high, it can be estimated without bias and with good accuracy. The models were applied to PET data from six pigs where [11C]UCB-J was displaced by intravenous brivaracetam. The dose-occupancy relationship estimated from these scans showed good agreement with occupancies calculated with Lassen plot applied to baseline-block scans of two pigs. In summary, the proposed models provide a framework to determine target occupancy from a single displacement scan.
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Affiliation(s)
- Gjertrud Louise Laurell
- Neurobiology Research Unit, Copenhagen University Hospital, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | | | - Annette Johansen
- Neurobiology Research Unit, Copenhagen University Hospital, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Nakul Ravi Raval
- Neurobiology Research Unit, Copenhagen University Hospital, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Arafat Nasser
- Neurobiology Research Unit, Copenhagen University Hospital, Copenhagen, Denmark
| | - Clara Aabye Madsen
- Neurobiology Research Unit, Copenhagen University Hospital, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Jacob Madsen
- Department of Clinical Physiology, Nuclear Medicine & PET, Copenhagen University, Copenhagen, Denmark
| | - Hanne Demant Hansen
- Neurobiology Research Unit, Copenhagen University Hospital, Copenhagen, Denmark
- A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Lene Lundgaard Donovan
- Neurobiology Research Unit, Copenhagen University Hospital, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Gitte Moos Knudsen
- Neurobiology Research Unit, Copenhagen University Hospital, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Adriaan A Lammertsma
- Neurobiology Research Unit, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - R Todd Ogden
- Neurobiology Research Unit, Copenhagen University Hospital, Copenhagen, Denmark
- Molecular Imaging and Neuropathology Division, The New York State Psychiatric Institute, New York, USA
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, USA
| | - Claus Svarer
- Neurobiology Research Unit, Copenhagen University Hospital, Copenhagen, Denmark
| | - Martin Schain
- Neurobiology Research Unit, Copenhagen University Hospital, Copenhagen, Denmark
- Antaros Medical, Mölndal, Sweden
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