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Pigliasco F, Cafaro A, Barco S, Stella M, Mattioli F, Riva A, Mancardi MM, Lattanzi S, Bandettini R, Striano P, Cangemi G. Innovative LC-MS/MS method for therapeutic drug monitoring of fenfluramine and cannabidiol in the plasma of pediatric patients with epilepsy. J Pharm Biomed Anal 2024; 245:116174. [PMID: 38703746 DOI: 10.1016/j.jpba.2024.116174] [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: 02/12/2024] [Revised: 03/25/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
We present a novel liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for quantifying fenfluramine (FFA), its active metabolite norfenfluramine (norFFA), and Epidyolex®, a pure cannabidiol (CBD) oral solution in plasma. Recently approved by the EMA for the adjunctive treatment of refractory seizures in patients with Dravet and Lennox-Gastaut syndromes aged above 2 years, FFA and CBD still do not have established therapeutic blood ranges, and thus need careful drug monitoring to manage potential pharmacokinetic and pharmacodynamic interactions. Our method, validated by ICH guidelines M10, utilizes a rapid extraction protocol from 100 µL of human plasma and a reversed-phase C-18 HPLC column, with deuterated internal standards. The Thermofisher Quantiva triple-quadrupole MS coupled with an Ultimate 3000 UHPLC allowed multiple reaction monitoring detection, ensuring precise analyte quantification. The assay exhibited linear responses across a broad spectrum of concentrations: ranging from 1.64 to 1000 ng/mL for both FFA and CBD, and from 0.82 to 500 ng/mL for norFFA. The method proves accurate and reproducible, free from matrix effect. Additionally, FFA stability in plasma at 4 °C and -20 °C for up to 7 days bolsters its clinical applicability. Plasma concentrations detected in patients samples, expressed as mean ± standard deviation, were 0.36 ± 0.09 ng/mL for FFA, 19.67 ± 1.22 ng/mL for norFFA. This method stands as a robust tool for therapeutic drug monitoring (TDM) of FFA and CBD, offering significant utility in assessing drug-drug interactions in co-treated patients, thus contributing to optimized patient care in complex therapeutic scenarios.
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Affiliation(s)
- Federica Pigliasco
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alessia Cafaro
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Sebastiano Barco
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Manuela Stella
- Gaslini Trial Centre, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Pharmacology and Toxicology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Francesca Mattioli
- Pharmacology and Toxicology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy; Clinical Pharmacology Unit, Ente Ospedaliero Ospedali Galliera, Genoa, Italy
| | - Antonella Riva
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | | | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Roberto Bandettini
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy; Paediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giuliana Cangemi
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Dell'isola GB, Verrotti A, Sciaccaluga M, Roberti R, Parnetti L, Russo E, Costa C. Evaluating bexicaserin for the treatment of developmental epileptic encephalopathies. Expert Opin Pharmacother 2024:1-10. [PMID: 38916481 DOI: 10.1080/14656566.2024.2373350] [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: 05/13/2024] [Accepted: 06/24/2024] [Indexed: 06/26/2024]
Abstract
INTRODUCTION Developmental epileptic encephalopathies (DEEs) pose significant challenges due to their refractory nature and limited treatment options. Despite advancements in genetic understanding, effective therapies targeting underlying pathophysiology are lacking. Serotoninergic dysfunction has been implicated in epilepsy, sparking interest in serotonin as a therapeutic target. AREA COVERED This article explores the potential of bexicaserin, a selective 5-HT2C receptor agonist, as an adjunctive antiseizure medication in DEEs. Bexicaserin is thought to modulate GABAergic neurotransmission, suppressing central hyperexcitability. Preclinical studies demonstrate its efficacy across various seizure models. Clinical trials, including the Pacific Study, reveal promising results in reducing motor seizures. However, challenges such as adverse effects and treatment discontinuation underscore the need for further investigation. EXPERT OPINION The efficacy of 5-HT2C serotoninergic agonists, validated in preclinical and clinical studies, highlights serotonin's role in DEEs. Bexicaserin offers new therapeutic possibilities, potentially synergizing with existing antiseizure medications. Polypharmacotherapy, targeting distinct pathways, may enhance therapeutic outcomes. Monitoring pharmacological interactions and addressing central nervous system comorbidities are crucial for optimizing treatment strategies. Further research is needed to elucidate bexicaserin's mechanisms and potential antiepileptogenic effects.
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Affiliation(s)
| | | | - Miriam Sciaccaluga
- Section of Neurology, Laboratory of Experimental Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Mauro Baschirotto Rare Disease Foundation BIRD Onlus, Longare, VI, Italy
| | - Roberta Roberti
- Science of Health Department, University Magna Grecia of Catanzaro, Catanzaro, Italy
| | - Lucilla Parnetti
- Section of Neurology, Laboratory of Experimental Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Emilio Russo
- Science of Health Department, University Magna Grecia of Catanzaro, Catanzaro, Italy
| | - Cinzia Costa
- Section of Neurology, Laboratory of Experimental Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Okanari K, Teranishi H, Umeda R, Shikano K, Inoue M, Hanada T, Ihara K, Hanada R. Behavioral and neurotransmitter changes on antiepileptic drugs treatment in the zebrafish pentylenetetrazol-induced seizure model. Behav Brain Res 2024; 464:114920. [PMID: 38403178 DOI: 10.1016/j.bbr.2024.114920] [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: 12/27/2023] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 02/27/2024]
Abstract
Epilepsy, a recurrent neurological disorder involving abnormal neurotransmitter kinetics in the brain, has emerged as a global health concern. The mechanism of epileptic seizures is thought to involve a relative imbalance between excitatory and inhibitory neurotransmitters. Despite the recent advances in clinical and basic research on the pathogenesis of epilepsy, the complex relationship between the neurotransmitter changes and behavior with and without antiepileptic drugs (AEDs) during seizures remains unclear. To investigate the effects of AEDs such as levetiracetam (LEV), carbamazepine (CBZ), and fenfluramine (FFR) on key neurotransmitters in the pentylenetetrazol (PTZ)-induced seizures in adult zebrafish, we examined the changes in glutamic acid, gamma-aminobutyric acid (GABA), serotonin (5-HT), 5-hydroxyindoleacetic acid (5-HIAA), choline, acetylcholine, norepinephrine, dopamine (DA), 3,4-dihydroxyphenylacetic acid (DOPAC), and adenosine. In this study, we observed that 5-HT and DA levels in the brain increased immediately after PTZ-induced seizures. Behavioral tests clearly showed that all of these AEDs suppressed the PTZ-induced seizures. Upon treatment of PTZ-induced seizures with these AEDs, CBZ decreased the glutamic acid and FFR increased the GABA levels; however, no neurotransmitter changes were observed in the brain after LEV administration. Thus, we demonstrated a series of neurotransmitter changes linked to behavioral changes during PTZ-induced epileptic seizures when LEV, CBZ, or FFR were administered. These findings will lead to a more detailed understanding of the pathogenesis of epilepsy associated with behavioral and neurotransmitter changes under AED treatment.
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Affiliation(s)
- Kazuo Okanari
- Department of Pediatrics, Faculty and Medicine, Oita University, Oita, Japan
| | - Hitoshi Teranishi
- Department of Neurophysiology, Faculty and Medicine, Oita University, Oita, Japan
| | - Ryohei Umeda
- Department of Neurophysiology, Faculty and Medicine, Oita University, Oita, Japan
| | - Kenshiro Shikano
- Department of Neurophysiology, Faculty and Medicine, Oita University, Oita, Japan
| | - Masanori Inoue
- Department of Pediatrics, Faculty and Medicine, Oita University, Oita, Japan
| | - Toshikatsu Hanada
- Department of Cell Biology, Faculty and Medicine, Oita University, Oita, Japan
| | - Kenji Ihara
- Department of Pediatrics, Faculty and Medicine, Oita University, Oita, Japan
| | - Reiko Hanada
- Department of Neurophysiology, Faculty and Medicine, Oita University, Oita, Japan.
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Xu Y, Chen D, Liu L. Optimal dose of fenfluramine in adjuvant treatment of drug-resistant epilepsy: evidence from randomized controlled trials. Front Neurol 2024; 15:1371704. [PMID: 38590719 PMCID: PMC10999678 DOI: 10.3389/fneur.2024.1371704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/08/2024] [Indexed: 04/10/2024] Open
Abstract
Objective Several clinical trials have suggested that fenfluramine (FFA) is effective for the treatment of epilepsy in Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS). However, the exploration of its optimal target dose is ongoing. This study aimed to summarize the best evidence to inform this clinical issue. Materials and methods We searched PubMed, Embase (via Ovid), and Web of Science for relevant literature published before December 1st, 2023. Randomized, double-blind, placebo-controlled studies that evaluated the efficacy, safety, and tolerability of FFA in DS and LGS were identified and meta-analysis was performed according to doses. The study was registered with PROSPERO (CRD42023392454). Results Six hundred and twelve patients from four randomized controlled trials were enrolled. The results demonstrated that FFA at 0.2, 0.4, or 0.7 mg/kg/d showed significantly greater efficacy compared to placebo in terms of at least 50% reduction (p < 0.001, p < 0.001, p < 0.001) and at least 75% reduction (p < 0.001, p = 0.007, p < 0.001) in monthly seizure frequency from baseline. Moreover, significantly more patients receiving FFA than placebo were rated as much improved or very much improved in CGI-I by both caregivers/parents and investigators (p < 0.001). The most common treatment-emergent adverse events were decreased appetite, diarrhea, fatigue, and weight loss, with no valvular heart disease or pulmonary hypertension observed in any participant. For dose comparison, 0.7 mg/kg/d group presented higher efficacy on at least 75% reduction in seizure (p = 0.006) but not on at least 50% reduction. Weight loss (p = 0.002), decreased appetite (p = 0.04), and all-cause withdrawal (p = 0.036) were more common in 0.7 mg/kg/d group than 0.2 mg/kg/d. There was no statistical difference in other safety parameters between these two groups. Conclusion The higher range of the licensed dose achieves the optimal balance between efficacy, safety, and tolerability in patients with DS and LGS. Clinical trial registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023392454.
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Affiliation(s)
| | | | - Ling Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Dell’Isola GB, Portwood KE, Consing K, Fattorusso A, Bartocci A, Ferrara P, Di Cara G, Verrotti A, Lodolo M. Current Overview of CDKL-5 Deficiency Disorder Treatment. Pediatr Rep 2024; 16:21-25. [PMID: 38251311 PMCID: PMC10801578 DOI: 10.3390/pediatric16010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/15/2023] [Indexed: 01/23/2024] Open
Abstract
CDKL5 deficiency disorder (CDD) is a complex of clinical symptoms resulting from the presence of non-functional or absent CDKL5 protein, a serine-threonine kinase involved in neural maturation and synaptogenesis [...].
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Affiliation(s)
| | - Katherin Elizabeth Portwood
- Shands Children’s Hospital, Department of Child Neurology, University of Florida, Gainesville, FL 32608, USA; (K.E.P.); (K.C.); (M.L.)
| | - Kirsten Consing
- Shands Children’s Hospital, Department of Child Neurology, University of Florida, Gainesville, FL 32608, USA; (K.E.P.); (K.C.); (M.L.)
| | - Antonella Fattorusso
- Department of Pediatrics, University of Perugia, 06129 Perugia, Italy; (A.F.); (G.D.C.); (A.V.)
| | - Arnaldo Bartocci
- Neurophysipathology Service, Villa Margherita, 01027 Montefiascone, Italy;
| | - Pietro Ferrara
- Unit of Pediatrics, Campus Bio-Medico University, 00128 Rome, Italy;
| | - Giuseppe Di Cara
- Department of Pediatrics, University of Perugia, 06129 Perugia, Italy; (A.F.); (G.D.C.); (A.V.)
| | - Alberto Verrotti
- Department of Pediatrics, University of Perugia, 06129 Perugia, Italy; (A.F.); (G.D.C.); (A.V.)
| | - Mauro Lodolo
- Shands Children’s Hospital, Department of Child Neurology, University of Florida, Gainesville, FL 32608, USA; (K.E.P.); (K.C.); (M.L.)
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Dini G, Di Cara G, Ferrara P, Striano P, Verrotti A. Reintroducing Fenfluramine as a Treatment for Seizures: Current Knowledge, Recommendations and Gaps in Understanding. Neuropsychiatr Dis Treat 2023; 19:2013-2025. [PMID: 37790801 PMCID: PMC10543412 DOI: 10.2147/ndt.s417676] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/19/2023] [Indexed: 10/05/2023] Open
Abstract
Despite the introduction of new anti-seizure medications in recent years, approximately one-third of the epileptic population continues to experience seizures. Recently, the anti-obesity medication fenfluramine (FFA) has been successfully repurposed, and it has received approval from various regulatory agencies for the treatment of seizures associated with Dravet syndrome and Lennox-Gastaut syndrome. The potential antiseizure effects of FFA were initially observed in patients with photosensitive epilepsy in the 1980s but it was not rigorously explored as a treatment option until 30 years later. This narrative review aims to provide an overview of the historical progression of FFA's use, starting from initial clinical observations to preclinical studies and, ultimately, successful clinical trials in the field of epilepsy.
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Affiliation(s)
- Gianluca Dini
- Department of Pediatrics, University of Perugia, Perugia, Italy
| | | | - Pietro Ferrara
- Department of Pediatrics, Campus Bio-Medico University, Rome, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto “G. Gaslini”, Genoa, Italy
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Vavers E, Zvejniece L, Dambrova M. Sigma-1 receptor and seizures. Pharmacol Res 2023; 191:106771. [PMID: 37068533 PMCID: PMC10176040 DOI: 10.1016/j.phrs.2023.106771] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/03/2023] [Accepted: 04/13/2023] [Indexed: 04/19/2023]
Abstract
Over the last decade, sigma-1 receptor (Sig1R) has been recognized as a valid target for the treatment of seizure disorders and seizure-related comorbidities. Clinical trials with Sig1R ligands are underway testing therapies for the treatment of drug-resistant seizures, developmental and epileptic encephalopathies, and photosensitive epilepsy. However, the direct molecular mechanism by which Sig1R modulates seizures and the balance between excitatory and inhibitory pathways has not been fully elucidated. This review article aims to summarize existing knowledge of Sig1R and its involvement in seizures by focusing on the evidence obtained from Sig1R knockout animals and the anti-seizure effects of Sig1R ligands. In addition, this review article includes a discussion of the advantages and disadvantages of the use of existing compounds and describes the challenges and future perspectives on the use of Sig1R as a target for the treatment of seizure disorders.
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Affiliation(s)
- Edijs Vavers
- Latvian Institute of Organic Synthesis, Laboratory of Pharmaceutical Pharmacology, Aizkraukles 21, LV-1006, Riga, Latvia; University of Tartu, Faculty of Science and Technology, Institute of Chemistry, Ravila 14a, 50411, Tartu, Estonia.
| | - Liga Zvejniece
- Latvian Institute of Organic Synthesis, Laboratory of Pharmaceutical Pharmacology, Aizkraukles 21, LV-1006, Riga, Latvia
| | - Maija Dambrova
- Latvian Institute of Organic Synthesis, Laboratory of Pharmaceutical Pharmacology, Aizkraukles 21, LV-1006, Riga, Latvia; Riga Stradiņš University, Faculty of Pharmacy, Konsula 21, LV-1007, Riga, Latvia
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Voronkova KV, Alieva AM, Nikitin IG, Musina GM, Surskaya EV, Zaitseva OS, Mashkevich NG, Gomonova LV, Petrukhin AS. [The role of the phenosanic acid in the combined treatment of patients with epilepsy]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:151-157. [PMID: 36843473 DOI: 10.17116/jnevro2023123021151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
Epilepsy is one of the most studied chronic neurological disorders in the world. Despite significant progress in epilepsy research, some patients continue to experience recurrent seizures. It has been proven that oxidative stress plays an important role in epilepsy. Targeting oxidative stress may provide a novel therapeutic intervention to attenuate epileptogenesis as well as cognitive and psychiatric impairment in patients with epilepsy. One of the promising directions in the search for new strategies for the treatment of epilepsy is the combined use of antiepileptic drugs with antioxidants that affect the pathogenetic links of this disease. The new Russian antiepileptic drug fenosanoic acid (Dibufelon) has an anticonvulsant effect due to the inhibition of lipid peroxidation of brain cells and the reconstruction of cell membranes. This mechanism of action also paves the way for an increase in the effectiveness of co-administered drugs with phenosanoic acid. The effect of the drug on the cognitive and mental functions of patients, the regression of asthenia phenomena is also observed. The clinical efficacy and safety of the combination of this drug with other antiepileptic drugs in epilepsy has been demonstrated in experimental and clinical studies.
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Affiliation(s)
- K V Voronkova
- Pirogov Russian National Research Medical University, Moscow, Russia.,Petrovsky Russian Scientific Center for Surgery, Moscow, Russia
| | - A M Alieva
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - I G Nikitin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - G M Musina
- Medical Center NORIS, Sterlitamak, Russia
| | - E V Surskaya
- Petrovsky Russian Scientific Center for Surgery, Moscow, Russia
| | - O S Zaitseva
- Petrovsky Russian Scientific Center for Surgery, Moscow, Russia
| | - N G Mashkevich
- Petrovsky Russian Scientific Center for Surgery, Moscow, Russia
| | - L V Gomonova
- Petrovsky Russian Scientific Center for Surgery, Moscow, Russia
| | - A S Petrukhin
- Pirogov Russian National Research Medical University, Moscow, Russia
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