The Pharmacology of Spinal Opioids and Ziconotide for the Treatment of Non-Cancer Pain

A Systematic Guideline by the ASPN Workgroup on the Evidence, Education, and Treatment Algorithm for Painful Diabetic Neuropathy: SWEET

Introduction

Painful diabetic neuropathy (PDN) is a leading cause of pain and disability globally with a lack of consensus on the appropriate treatment of those suffering from this condition. Recent advancements in both pharmacotherapy and interventional approaches have broadened the treatment options for PDN. There exists a need for a comprehensive guideline for the safe and effective treatment of patients suffering from PDN.

Objective

The SWEET Guideline was developed to provide clinicians with the most comprehensive guideline for the safe and appropriate treatment of patients suffering from PDN.

Methods

The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations for PDN. A multidisciplinary group of international experts developed the SWEET guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Meeting Abstracts, and Scopus to identify and compile the evidence for diabetic neuropathy pain treatments (per section as listed in the manuscript) for the treatment of pain. Manuscripts from 2000-present were included in the search process.

Results

After a comprehensive review and analysis of the available evidence, the ASPN SWEET guideline was able to rate the literature and provide therapy grades for most available treatments for PDN utilizing the United States Preventive Services Task Force criteria.

Conclusion

The ASPN SWEET Guideline represents the most comprehensive review of the available treatments for PDN and their appropriate and safe utilization.

Antimicrobial and anticarcinogenic activity of bioactive peptides derived from abalone viscera (Haliotis fulgens and Haliotis corrugata)

Bioactive peptides have been studied in several sources due to their valuable potential in the pharmaceutical and food industries. Abalone viscera, which are normally discarded as byproducts, are a rich source of protein. Thus, the aim of this study was to explore the potential bioactivity of peptides derived from abalone viscera (Haliotis fulgens and Haliotis corrugata) after hydrolysis with a commercial mixture of enzymes. The hydrolysates obtained were fractionated using gel filtration chromatography. The resulting hydrolysate fractions were investigated for their antimicrobial and cytotoxic activities, including the expression of gelatinases mmp-2 and mmp-9 in human prostate cancer cell lines (PC3). Results showed antimicrobial activity for protein fractions of H. corrugata against Proteus mirabilis and Pseudomona aeuroginosa (66.2-116.25 kDa), Bacillus subtilis (6.5-21.5 kDa), and Aspergillus niger (97.4-116.25 kDa), while H. fulgens peptide fractions (200-31 kDa) displayed activity against six bacterial strains, and fractions from 116.25 to 21.5 kDa had effects on the fungus A. niger, Alternaria alternata, and Aspergillus flavus. Additionally, protein fractions displayed cytotoxic activity, inhibiting 30.4-53.8% of PC3 cellular growth. Selected fractions decreased the PMA-induced and not-induced expressions of mmp-2 and mmp-9 in PC3 cells. Abalone viscera, as byproducts, can be used as a potential source of antimicrobial and anticancer peptides.

Myth and Truth in Opioid Consumption with Intrathecal Morphine Pump Implantation in Chronic Pain: A Retrospective Cohort Study with Claims Database in South Korea

OBJECTIVE

To investigate the opioid consumption and the healthcare resource utilization in patients with the intrathecal drug delivery system (IDDS) therapy and the comprehensive medical management (CMM) alone.

DESIGN

A retrospective cohort study with a customized claims database.

SETTING

In a university-based hospital.

SUBJECTS

Patients with complex regional pain syndrome, post-laminectomy syndrome, and fibromyalgia.

METHODS

Using propensity score matching (1:3), we selected patients with morphine infusion through IDDS (IDDS group) and CMM alone (CMM group). The primary endpoints were comparisons of average morphine equivalents daily dosages (MEDD, mg/day) for 6 and 12 months from an index date. The number of emergency room (ER) visits and hospitalizations and the total medical expenditures were compared as secondary outcomes.

RESULTS

In total, 82 patients (N = 23 in the IDDS group and N = 59 in the CMM group) were analyzed. Although a 6-month average MEDD did not reach statistical significance, a 12-month average MEDD was significantly decreased in the IDDS group compared to the CMM group (53.2 ± 46.3 vs 123.9 ± 176.4, respectively; P = 0.008). ER visits were more frequent in the IDDS group than the CMM group at baseline (5.4 vs 0.5, respectively; P = .002), which was maintained for 12 months (P < 0.001). Otherwise, the number of hospitalization and the medical expenditures for pain management were not different between the groups for 12 months.

CONCLUSIONS

The combined IDDS therapy had some benefits in reducing opioid consumption for 1-year follow-up compared to the CMM alone in chronic noncancer pain patients.

Brief History of Opioids in Perioperative and Periprocedural Medicine to Inform the Future

Background: Opioids and derivatives of opium had been used as analgesics for thousands of years before the introduction of inhalational anesthetic agents. Once these early volatile agents were in widespread use, opioids were used as part of anesthetic care for premedication, as intraoperative adjuncts to general anesthesia, and for the management of postoperative pain. Evidence of growing dependence on opioids in the perioperative and periprocedural patient is supported by the ongoing research to develop synthetic opioids and to customize the pharmacokinetics and pharmacodynamics to achieve specific therapeutic goals. Methods: We explore the history of opioid use in perioperative care as a means of future management in light of new persistent opioid abuse. Results: As the opium chemical structure has been modified, newer nonopioid analgesics have been approved and brought into clinical practice. Opioid-sparing and opioid-free anesthetic techniques are not only a possibility, but a reality. Conclusion: Continuing research in neurobiology and addiction genetics will ultimately lead to a pharmacogenetic approach to patients at risk for new persistent opioid abuse.

Analgesic effect of recombinant GABAergic precursors releasing MVIIA in a model of peripheral nerve injury in rats

Development of chronic pain has been attributed to dysfunctional GABA signaling in the spinal cord. Direct pharmacological interventions on GABA signaling are usually not very efficient and often accompanied by side effects due to the widespread distribution of GABA receptors in CNS. Transplantation of GABAergic neuronal cells may restore the inhibitory potential in the spinal cord. Grafted cells may also release additional analgesic peptides by means of genetic engineering to further enhance the benefits of this approach. Conopeptides are ideal candidates for recombinant expression using cell-based strategies. The omega-conopeptide MVIIA is in clinical use for severe pain marketed as FDA approved Prialt in the form of intrathecal injections. The goal of this study was to develop transplantable recombinant GABAergic cells releasing conopeptide MVIIA and to evaluate the analgesic effect of the grafts in a model of peripheral nerve injury-induced pain. We have engineered and characterized the GABAergic progenitors expressing MVIIA. Recombinant and nonrecombinant cells were intraspinally injected into animals after the nerve injury. Animals were tested weekly up to 12 weeks for the presence of hypersensitivity, followed by histochemical and biochemical analysis of the tissue. We observed beneficial effects of the grafted cells in reducing hypersensitivity in all grafted animals, especially potent in the recombinant group. The level of pain-related cytokines was reduced in the grafted animals and correlation between these pain markers and actual behavior was indicated. This study demonstrated the feasibility of recombinant cell transplantation in the management of chronic pain.

Suppression of host nocifensive behavior by parasitoid wasp venom

The parasitoid wasp Ampulex compressa envenomates the brain of its host the American cockroach (Periplaneta americana), thereby making it a behaviorally compliant food supply for its offspring. The target of venom injection is a locomotory command center in the brain called the central complex. In this study, we investigate why stung cockroaches do not respond to injuries incurred during the manipulation process by the wasp. In particular, we examine how envenomation compromises nociceptive signaling pathways in the host. Noxious stimuli applied to the cuticle of stung cockroaches fail to evoke escape responses, even though nociceptive interneurons projecting to the brain respond normally. Hence, while nociceptive signals are carried forward to the brain, they fail to trigger robust nocifensive behavior. Electrophysiological recordings from the central complex of stung animals demonstrate decreases in peak firing rate, total firing, and duration of noxious-evoked activity. The single parameter best correlated with altered noxious-evoked behavioral responses of stung cockroaches is reduced duration of the evoked response in the central complex. Our findings demonstrate how the reproductive strategy of a parasitoid wasp is served by venom-mediated elimination of aversive, nocifensive behavior in its host.

Therapeutic peptides: current applications and future directions

Peptide drug development has made great progress in the last decade thanks to new production, modification, and analytic technologies. Peptides have been produced and modified using both chemical and biological methods, together with novel design and delivery strategies, which have helped to overcome the inherent drawbacks of peptides and have allowed the continued advancement of this field. A wide variety of natural and modified peptides have been obtained and studied, covering multiple therapeutic areas. This review summarizes the efforts and achievements in peptide drug discovery, production, and modification, and their current applications. We also discuss the value and challenges associated with future developments in therapeutic peptides.

The Options for Neuraxial Drug Administration

Neuraxial drug administration, i.e., the injection of drugs into the epidural or intrathecal space to produce anesthesia or analgesia, is a technique developed more than 120 years ago. Today, it still is widely used in daily practice in anesthesiology and in acute and chronic pain therapy. A multitude of different drugs have been introduced for neuraxial injection, only a part of which have obtained official approval for that indication. A broad understanding of the pharmacology of those agents is essential to the clinician to utilize them in a safe and efficient manner. In the present narrative review, we summarize current knowledge on neuraxial anatomy relevant to clinical practice, including pediatric anatomy. Then, we delineate the general pharmacology of neuraxial drug administration, with particular attention to specific aspects of epidural and intrathecal pharmacokinetics and pharmacodynamics. Furthermore, we describe the most common clinical indications for neuraxial drug administration, including the perioperative setting, obstetrics, and chronic pain. Then, we discuss possible neurotoxic effects of neuraxial drugs, and moreover, we detail the specific properties of the most commonly used neuraxial drugs that are relevant to clinicians who employ epidural or intrathecal drug administration, in order to ensure adequate treatment and patient safety in these techniques. Finally, we give a brief overview on new developments in neuraxial drug therapy.

Comparison of intrathecal bupivacaine-fentanyl and bupivacaine-butorphanol combinations for joint replacement surgeries

Background and Aims:

The objective of the study was to compare duration of analgesia of fentanyl versus butorphanol as adjuvants to bupivacaine in spinal anesthesia.

Material and Methods:

A prospective, randomized, double-blinded study conducted in 80 patients of 18–75 years age group and American Society of Anesthesiologists Grades I and II undergoing joint replacement surgeries. A total of 40 patients in each Group A and Group B received 0.5% bupivacaine 3 ml with 25 mcg fentanyl and 25 mcg butorphanol respectively, in a total volume of 3.5 ml made with saline. Duration of analgesia, number of rescue analgesia, sensory, and motor block characteristics were compared between the two groups. Statistical analysis was done using t test and Chi-square test with SPSS 19.0 software.

Results:

Mean duration of analgesia was found more in Group B in comparison to Group A (P < 0.05). A number of doses of analgesic required postoperatively were more in Group A compared to Group B (P < 0.001). Time required for onset of sensory and motor block was comparable in both the groups. However, two segment regression of sensory block was slower in Group B compared to Group A (P < 0.05).

Conclusion:

We conclude that addition of butorphanol 25 μg as an adjuvant to 0.5% hyperbaric bupivacaine provided prolonged duration of analgesia compared to 25 mg fentanyl.

A safety review of approved intrathecal analgesics for chronic pain management

Introduction: Intrathecal (IT) drug therapy is an effective treatment option for patients with chronic pain of malignant or nonmalignant origin, with an established safety profile and fewer adverse effects compared to oral or parenteral pain medications. Morphine (a μ-opioid receptor agonist) and ziconotide (a non-opioid calcium channel antagonist) are the only IT agents approved by the U.S. Food and Drug Administration for the treatment of chronic pain. Although both are considered first-line IT therapies, each drug has unique properties and considerations.Areas Covered: This review will evaluate the pivotal trials that established the use of morphine and ziconotide as first-line IT therapy for patients with chronic pain, as well as safety and efficacy data generated from various retrospective and prospective studies.Expert Opinion: Morphine and ziconotide are effective IT therapies for patients with chronic malignant or nonmalignant pain that is refractory to other interventions. IT ziconotide is recommended as a first-line therapy due to its efficacy and avoidance of many adverse effects commonly associated with opioids. The use of IT morphine is also considered first-line; however, the risks of respiratory depression, withdrawal with drug discontinuation or pump malfunction, and the development of tolerance require careful patient selection and management.

Intrathecal pain management with ziconotide: Time for consensus?

This article summarizes recommendations made by six pain specialists who discussed the rationale for ziconotide intrathecal analgesia (ITA) and the requirement for evidence-based guidance on its use, from a European perspective. Riemser Pharma GmbH (Greifswald, Germany), which holds the European marketing authorization for ziconotide, hosted the meeting. The group agreed that ITA is under-used in Europe, adding that ziconotide ITA has potential to be a first-line alternative to morphine; both are already first-line options in the USA. Ziconotide ITA (initiated using a low-dose, slow-titration approach) is suitable for many patients with noncancer- or cancer-related chronic refractory pain and no history of psychosis. Adopting ziconotide as first-line ITA could reduce opioid usage in these patient populations. The group advocated a risk-reduction strategy for all candidate patients, including compulsory prescreening for neuropsychosis, and requested US-European alignment of the licensed starting dose for ziconotide: the low-and-slow approach practiced in the USA has a better tolerability profile than the fixed high starting dose licensed in Europe. Of note, an update to the European Summary of Product Characteristics is anticipated in early 2021. The group acknowledged that the Polyanalgesic Consensus Conference (PACC) treatment algorithms for ziconotide ITA provide useful guidance, but recommendations tailored specifically for European settings are required. Before a consensus process can formally begin, the group called for additional European prospective studies to investigate ziconotide in low-and-slow dosing strategies, in different patient settings. Such data would enable European guidance to have the most appropriate evidence at its core.

[What became of Prialt®? : Observational study on the use of ziconotide in the treatment of chronic pain]

Hintergrund

Prialt® ist seit Februar 2005 von der europäischen Arzneimittelbehörde zugelassen und ist neben Morphin das einzige Analgetikum, welches über die offizielle Marktzulassung in der intrathekalen Schmerztherapie verfügt. Da es nicht über Opioidrezeptoren wirkt, galt es zum Zeitpunkt der Markteinführung als nebenwirkungs- und risikoärmer in der Behandlung chronischer Schmerzen als Morphin. Trotzdem gilt es noch heute als Orphan Drug und Studien über den Langzeiteinsatz und hierunter aufgetretene Nebenwirkungen sind rar.

Fragestellung

Welchen Stellenwert nimmt Prialt® verglichen mit anderen intrathekal verabreichten Analgetika ein? Wie wirken sich die Startdosis und die Geschwindigkeit der Aufdosierung auf die schmerzlindernde Wirkung und das Auftreten von Nebenwirkungen in der Langzeittherapie aus?

Material und Methoden

Zum einen wurden anhand von Arztbriefen retrospektiv alle Patienten erfasst, die zwischen Februar 2005 und dem Ende des Beobachtungszeitraums im Oktober 2018 Ziconotid in Monotherapie in der Neurochirurgie des Universitätsklinikums Jena erhielten. Zum anderen wurden diese Patienten anhand eines erstellten Fragebogens hinsichtlich ihrer Erfahrung mit Ziconotid befragt.

Ergebnisse

Bei allen zwölf in die Studie eingeschlossenen Teilnehmern kam es zu mindestens einer Arzneimittelnebenwirkung. Am häufigsten wurde über Vergesslichkeit und Sensibilitätsstörungen mit jeweils 25 % berichtet. Ein Drittel der Patienten musste die Behandlung aufgrund von Nebenwirkungen beenden. Die mittlere Initialdosis betrug 1,98 µg/Tag.

Diskussion

Trotz leitliniengerechter Behandlung hat sich Ziconotid am Universitätsklinikum Jena nicht gegen Morphin und andere Opioidanalgetika in der intrathekalen Schmerztherapie durchgesetzt. Die Gründe hierfür sind vielfältig, wobei die enge therapeutische Breite, das häufige Auftreten von Nebenwirkungen und die schwierige therapeutische Handhabung, vor allem im ambulanten Setting, von besonderer Bedeutung sind.

Efficacy of Simultaneous Usage of Spinal Cord Stimulation and Intrathecal Therapy for Nonmalignant Chronic Neuropathic Pain

BACKGROUND

Some patients with chronic pain and implanted spinal cord stimulators or intrathecal (IT) pumps fail to obtain significant pain relief. The use of dual modality treatment with both therapies is understudied. This study evaluated comprehensive outcomes in this patient population and reported outcomes primarily using IT ziconotide.

METHODS

We retrospectively analyzed 11 patients with chronic pain treated with both spinal cord stimulation and IT therapy. When a primary treatment failed to achieve significant pain relief, a secondary device was trialed and implanted. Pain severity (measured by a numeric rating scale) was assessed by the change from baseline to after the first and second intervention. In a subset of patients (n = 6), quality-of-life metrics were also assessed. Outcome measures were analyzed closest to the 1-year follow-up date after implantation of the first modality and then at the most recent follow-up after implantation of the second modality.

RESULTS

Spinal cord stimulation leads were percutaneous (n = 2) or paddles (n = 9) and commonly covered T8-10. IT medication included ziconotide (n = 8), baclofen (n = 1), hydromorphone (n = 1), and morphine/clonidine (n = 1). There was a mean of 19.64 ± 3.17 months between primary and secondary intervention. There was a significant improvement in pain severity from baseline to implantation of the second modality (P = 0.032) at a mean follow-up of 50.18 ± 11.83 months.

CONCLUSIONS

Dual modality therapy is a potential treatment option in patients who have lost efficacy with a single neuromodulation modality. Further study is required to identify potential responders and nonresponders.

Why behavioral neuroscience still needs diversity?: A curious case of a persistent need

In the past few decades, a substantial portion of neuroscience research has moved from studies conducted across a spectrum of animals to reliance on a few species. While this undoubtedly promotes consistency, in-depth analysis, and a better claim to unraveling molecular mechanisms, investing heavily in a subset of species also restricts the type of questions that can be asked, and impacts the generalizability of findings. A conspicuous body of literature has long advocated the need to expand the diversity of animal systems used in neuroscience research. Part of this need is utilitarian with respect to translation, but the remaining is the knowledge that historically, a diverse set of species were instrumental in obtaining transformative understanding. We argue that diversifying matters also because the current approach limits the scope of what can be discovered. Technological advancements are already bridging several practical gaps separating these two worlds. What remains is a wholehearted embrace by the community that has benefitted from past history. We suggest the time for it is now.

Analgesic and side effects of intravenous recombinant Phα1β

Background

Intrathecal injection of voltage-sensitive calcium channel blocker peptide toxins exerts analgesic effect in several animal models of pain. Upon intrathecal administration, recombinant Phα1β exerts the same analgesic effects as the those of the native toxin. However, from a clinical perspective, the intrathecal administration limits the use of anesthetic drugs in patients. Therefore, this study aimed to investigate the possible antinociceptive effect of intravenous recombinant Phα1β in rat models of neuropathic pain, as well as its side effects on motor, cardiac (heart rate and blood pressure), and biochemical parameters.

Methods

Male Wistar rats and male Balb-C mice were used in this study. Giotto Biotech® synthesized the recombinant version of Phα1β using Escherichia coli expression. In rats, neuropathic pain was induced by chronic constriction of the sciatic nerve and paclitaxel-induced acute and chronic pain. Mechanical sensitivity was evaluated using von Frey filaments. A radiotelemeter transmitter (TA11PA-C10; Data Sciences, St. Paul, MN, USA) was placed on the left carotid of mice for investigation of cardiovascular side effects. Locomotor activity data were evaluated using the open-field paradigm, and serum CKMB, TGO, TGP, LDH, lactate, creatinine, and urea levels were examined.

Results

Intravenous administration of recombinant Phα1β toxin induced analgesia for up to 4 h, with ED₅₀ of 0.02 (0.01-0.03) mg/kg, and reached the maximal effect (E_max = 100% antinociception) at a dose of 0.2 mg/kg. No significant changes were observed in any of the evaluated motor, cardiac or biochemical parameters.

Conclusion

Our data suggest that intravenous administration of recombinant Phα1β may be feasible for drug-induced analgesia, without causing any severe side effects.

Cancer- and Non-cancer Related Chronic Pain: From the Physiopathological Basics to Management

The prevalence of chronic pain is between 33% to 64% and is due to cancer pain, but it has also been observed in non-cancer patients. Chronic pain is associated with lower quality of life and higher psychological distress and depressive/anxiety disorders in patients without a history of disorder. In this study we evaluated in clinical practice the effectiveness of the intrathecal pump in 140 patients who underwent pain therapy at our Center. These patients were consecutively enrolled from January 2010 to July 2018. Follow-up was carried out over these eight years regarding the infusion modalities. Pain relief was obtained in 71 (50,7%) patients out of the 140 that experienced satisfactory pain control globally. Intrathecal therapy is one of the best options for chronic severe refractory pain. The greatest advantage of this therapy is due to the possibility of treating the pain with minimal dosages of the drug, avoiding the appearance of troublesome side effects.

Marine Ligands of the Pregnane X Receptor (PXR): An Overview

Pregnane X Receptor (PXR) is a ligand-activated transcription factor which binds many structurally different molecules. The receptor is able to regulate the expression of a wide array of genes and is involved in cancer and different key physiological processes such as the metabolism of drugs/xenobiotics and endogenous compounds including lipids and carbohydrates, and inflammation. Algae, sponges, sea squirts, and other marine organisms are some of the species from which structurally new molecules have been isolated that have been subsequently identified in recent decades as ligands for PXR. The therapeutic potential of these natural compounds is promising in different areas and has recently resulted in the registration of trabectedin by the FDA as a novel antineoplastic drug. Apart from being potentially novel drugs, these compounds can also serve as models for the development of new molecules with improved activity. The aim of this review is to succinctly summarize the currently known natural molecules isolated from marine organisms with a proven ability to interact with PXR.

Intrathecal Therapy for Chronic Pain: A Review of Morphine and Ziconotide as Firstline Options

Objectives

To evaluate the evidence for morphine and ziconotide as firstline intrathecal (IT) analgesia agents for patients with chronic pain.

Methods

Medline was searched (through July 2017) for “ziconotide” or “morphine” AND “intrathecal” AND “chronic pain,” with results limited to studies in human populations.

Results

The literature supports the use of morphine (based primarily on noncontrolled, prospective, and retrospective studies) and ziconotide (based on randomized controlled trials and prospective observational studies) as first-choice IT therapies. The 2016 Polyanalgesic Consensus Conference (PACC) guidelines recommended both morphine and ziconotide as firstline IT monotherapy for localized and diffuse chronic pain of cancer-related and non–cancer-related etiologies; however, one consensus point emphasized ziconotide use, unless contraindicated, as firstline IT therapy in patients with chronic non–cancer-related pain. Initial IT therapy choice should take into consideration individual patient characteristics (e.g., pain location, response to previous therapies, comorbid medical conditions, psychiatric history). Trialing is recommended to assess medication efficacy and tolerability. For both morphine and ziconotide, the PACC guidelines recommend conservative initial dosing strategies. Due to its narrow therapeutic window, ziconotide requires careful dose titration. Ziconotide is contraindicated in patients with a history of psychosis. IT morphine administration may be associated with serious side effects (e.g., respiratory depression, catheter tip granuloma), require dose increases, and cause dependence over time.

Conclusion

Based on the available evidence, morphine and ziconotide are recommended as firstline IT monotherapy for cancer-related and non–cancer-related pain. The choice of first-in-pump therapy should take into consideration patient characteristics and the advantages and disadvantages of each medication.

Advances in Pain Management: Palliative Care Applications

One of the most important goals of palliative medicine and hospice care is pain relief. Although great strides have been made in veterinary analgesia, severe pain, especially at home, is still difficult to control. Pain control in the context of palliative medicine and hospice care is far more advanced in human medicine. Many modalities used in chronically or terminally ill humans might be adapted to animals to better manage severe pain. This article discusses drugs and procedures used to control pain in humans that are relatively nascent or unavailable in veterinary medicine and deserve further attention.

Structure-Activity Analysis of N-Type Calcium Channel Inhibitor SO-3

As an ω-conopeptide originally discovered from Conus striatus, SO-3 contains 25 amino acid residues and three disulfide bridges. Our previous study has shown that this peptide possesses potent analgesic activity in rodent pain models (mouse and rat), and it specifically inhibits an N-type calcium ion channel (Cav2.2). In the study presented here, we investigated the key amino acid residues for their inhibitory activity against Cav2.2 expressed in HEK 293 cells and analgesic activity in mice. To improve the inhibitory activity of SO-3, we also evaluated the effects of some amino acid residues derived from the corresponding residues of ω-peptide MVIIA, CVID, or GVIA. Our data reveal that Lys6, Ile11, and Asn14 are the important functional amino acid residues for SO-3. The replacement of some amino acid residues of SO-3 in loop 1 with the corresponding residues of CVID and GVIA improved the inhibitory activity of SO-3. The binding mode of Cav2.2 with SO-3 amino acids in loop 1 and loop 2 may be somewhat different from that of MVIIA. This study expanded our knowledge of the structure-activity relationship of ω-peptides and provided a new strategy for improving the potency of Cav2.2 inhibitors.