Current Clinical Trials for Tinnitus: Drugs and Biologics.

Despite recent, major steps forward in our understanding of tinnitus pathophysiology and improved research methodology, tinnitus remains a clear unmet clinical need. Here, the authors identify current active clinical and preclinical development programs of tinnitus drug candidates using publications, databases, and company communications. The current drug development programs hold promise for new therapeutic options for tinnitus patients, but further fundamental research is needed to validate additional targets for treating tinnitus.

Effect of the novel histamine H4 receptor antagonist SENS-111 on spontaneous nystagmus in a rat model of acute unilateral vestibular loss.

BACKGROUND AND PURPOSE: Histamine H4 receptors are expressed in the peripheral vestibular system, and their selective inhibition improves vertigo symptoms in rats with unilateral vestibular lesions. The effects of SENS-111, a selective oral H4 receptor antagonist with high affinity to both animal and human receptors, on vertigo symptoms was evaluated in a translational in vivo model of unilateral vestibular loss. EXPERIMENTAL APPROACH: Pharmacokinetics of SENS-111 in rats was determined to aid dose selection for efficacy testing. Vestibular lesions were induced in rats by unilateral transtympanic injection of kainic acid. The effect of SENS-111 (10 or 20 mg·kg-1 ) on spontaneous nystagmus was evaluated compared with placebo vehicle using video-nystagmography, and the effective dose was compared with those of similar drugs used clinically, as single agents or combined with SENS-111. KEY RESULTS: Doses were selected for plasma exposure were consistent with published phase 1 results from healthy volunteers. SENS-111 of 10 mg·kg-1 gave a 21-22% reduction in nystagmus at 1 hr post-administration, whereas a loss of efficacy was seen with 20 mg·kg-1 . Compared with SENS-111, meclizine and methylprednisolone had minimal effects on nystagmus as single agents, and meclizine abolished the effect of SENS-111 when combined with SENS-111. All evaluated drugs were well tolerated. CONCLUSIONS AND IMPLICATIONS: The exposure-efficacy relationship for improved spontaneous nystagmus seen with SENS-111 in this in vivo model is consistent with phase 1 clinical results and provides preclinical support for pharmacokinetic/pharmacodynamic modelling and selection of effective clinical drug concentrations. LINKED ARTICLES: This article is part of a themed section on New Uses for 21st Century. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.3/issuetoc.

Medicine in the Fourth Dimension.

The importance of circadian biology has rarely been considered in pre-clinical studies, and even more when translating to the bedside. Circadian biology is becoming a critical factor for improving drug efficacy and diminishing drug toxicity. Indeed, there is emerging evidence showing that some drugs are more effective at nighttime than daytime, whereas for others it is the opposite. This suggests that the biology of the target cell will determine how an organ will respond to a drug at a specific time of the day, thus modulating pharmacodynamics. Thus, it is now time that circadian factors become an integral part of translational research.

Management of peripheral vertigo with antihistamines: New options on the horizon.

Vertigo is associated with a wide range of vestibular pathologies. It increasingly affects the elderly, with a high cost to society. Solutions include vestibular suppressants and vestibular rehabilitation, which form the mainstay of therapy. Antihistamines represent the largest class of agents used to combat vestibular vertigo symptoms. Agents targeting the H1 and H3 receptors have been in clinical use for several decades as single agents. Nonetheless, effective management of vertigo proves elusive as many treatments largely address only associated symptoms, and with questionable efficacy. Additionally, the primary and limiting side effect of sedation is counterproductive to normal functioning and the natural recovery process occurring via central compensation. To address these issues, the timing of administration of betahistine, the mainstay H3 antihistamine, can be fine-tuned, while bioavailability is also being improved. Other approaches include antihistamine combination studies, devices, physical therapy and behavioural interventions. Recently demonstrated expression of H4 receptors in the peripheral vestibular system represents a new potential drug target for treating vestibular disorders. A number of novel selective H4 antagonists are active in vestibular models in vivo. The preclinical potential of SENS-111 (Seliforant), an oral first-in-class selective H4 antagonist is the only such molecule to date to be translated into the clinical setting. With an excellent safety profile and notable absence of sedation, encouraging outcomes in an induced vertigo model in healthy volunteers have led to ongoing clinical studies in acute unilateral vestibulopathy, with the hope that H4 antagonists will offer new effective therapeutic options to patients suffering from vertigo.

Morphological and functional correlates of vestibular synaptic deafferentation and repair in a mouse model of acute-onset vertigo.

Damage to cochlear primary afferent synapses has been shown to be a key factor in various auditory pathologies. Similarly, the selective lesioning of primary vestibular synapses might be an underlying cause of peripheral vestibulopathies that cause vertigo and dizziness, for which the pathophysiology is currently unknown. To thoroughly address this possibility, we selectively damaged the synaptic contacts between hair cells and primary vestibular neurons in mice through the transtympanic administration of a glutamate receptor agonist. Using a combination of histological and functional approaches, we demonstrated four key findings: (1) selective synaptic deafferentation is sufficient to generate acute vestibular syndrome with characteristics similar to those reported in patients; (2) the reduction of the vestibulo-ocular reflex and posturo-locomotor deficits mainly depends on spared synapses; (3) damaged primary vestibular synapses can be repaired over the days and weeks following deafferentation; and (4) the synaptic repair process occurs through the re-expression and re-pairing of synaptic proteins such as CtBP2 and SHANK-1. Primary synapse repair might contribute to re-establishing the initial sensory network. Deciphering the molecular mechanism that supports synaptic repair could offer a therapeutic opportunity to rescue full vestibular input and restore gait and balance in patients.

5-HT3 Receptor Antagonists in Neurologic and Neuropsychiatric Disorders: The Iceberg Still Lies beneath the Surface.

5-HT3 receptor antagonists, first introduced to the market in the mid-1980s, are proven efficient agents to counteract chemotherapy-induced emesis. Nonetheless, recent investigations have shed light on unappreciated dimensions of this class of compounds in conditions with an immunoinflammatory component as well as in neurologic and psychiatric disorders. The promising findings from multiple studies have unveiled several beneficial effects of these compounds in multiple sclerosis, stroke, Alzheimer disease, and Parkinson disease. Reports continue to uncover important roles for 5-HT3 receptors in the physiopathology of neuropsychiatric disorders, including depression, anxiety, drug abuse, and schizophrenia. This review addresses the potential of 5-HT3 receptor antagonists in neurology- and neuropsychiatry-related disorders. The broad therapeutic window and high compliance observed with these agents position them as suitable prototypes for the development of novel pharmacotherapeutics with higher efficacy and fewer adverse effects.

Noise-induced trauma produces a temporal pattern of change in blood levels of the outer hair cell biomarker prestin.

Biomarkers in easy-to-access body fluid compartments, such as blood, are commonly used to assess health of various organ systems in clinical medicine. At present, no such biomarkers are available to inform on the health of the inner ear. Previously, we proposed the outer-hair-cell-specific protein prestin, as a possible biomarker and provided proof of concept in noise- and cisplatin-induced hearing loss. Our ototoxicity data suggest that circulatory prestin changes after inner ear injury are not static and that there is a temporal pattern of change that needs to be further characterized before practical information can be extracted. To achieve this goal, we set out to 1) describe the time course of change in prestin after intense noise exposure, and 2) determine if the temporal patterns and prestin levels are sensitive to severity of injury. After assessing auditory brainstem thresholds and distortion product otoacoustic emission levels, rats were exposed to intense octave band noise for 2 h at either 110 or 120 dB SPL. Auditory function was re-assessed 1 and 14 days later. Blood samples were collected at baseline, 4, 24, 48, 72 h and 7 and 14 days post exposure and prestin concentrations were measured using enzyme-linked immunosorbent assay (ELISA). Functional measures showed temporary hearing loss 1 day after exposure in the 110 dB SPL group, but permanent loss through Day 14 in the 120 dB SPL group. Prestin levels temporarily increased 5% at 4 h after 120 dB SPL exposure, but not in the 110 dB SPL group. There was a gradual decline in prestin levels in both groups thereafter, with prestin being below baseline on Day 14 by 5% in the 110 dB group (NS) and more than 10% in the 120 dB SPL group (p = 0.043). These results suggest that there is a temporal pattern of change in serum prestin level after noise-induced hearing loss that is related to severity of hearing loss. Circulatory levels of prestin may be able to act as surrogate biomarker for hearing loss involving OHC loss.

SENS-401 Effectively Reduces Severe Acoustic Trauma-Induced Hearing Loss in Male Rats With Twice Daily Administration Delayed up to 96 hours.

HYPOTHESIS: SENS-401 (R-azasetron besylate) is effective against severe acoustic trauma-induced hearing loss. BACKGROUND: SENS-401 has calcineurin inhibiting properties and attenuates cisplatin-induced hearing loss in a rat model. Cisplatin-induced and acoustic trauma-induced hearing loss share common apoptotic pathways. METHODS: The dose-response relationship of SENS-401 (6.6 mg/kg BID, 13.2 mg/kg BID, 26.4 mg/kg QD) and treatment time-window (13.2 mg/kg BID starting 24, 72, and 96 h posttrauma) versus placebo for 28 days were evaluated in a male rat model of severe acoustic trauma-induced hearing loss (120 dB SPL, 2 h) using auditory brainstem response (ABR) and distortion product otoacoustic emissions (DPOAE) measures followed by cochlear outer hair cell (OHC) counting with myosin-VIIa immunolabeling. RESULTS: All SENS-401 doses improved ABR threshold shift and recovery, reaching statistical significance (p < 0.05) for ABR threshold recoveries after 28-days treatment. DPOAE amplitude loss and recovery improved markedly for 13.2 mg/kg BID SENS-401, reaching significance after 14 days (p < 0.05). Significant improvements in ABR threshold shifts/recovery and DPOAE amplitude loss occurred with up to 96-hours delay in initiating SENS-401 (p < 0.05), and in DPOAE amplitude recovery with up to 72-hours delay (p < 0.05). Significantly more surviving OHCs were present after SENS-401 treatment compared with placebo after 24 to 96-hours delay posttrauma, with up to 5.3-fold more cells in the basal cochlea turn. CONCLUSIONS: In vivo data support the otoprotective potential of twice daily oral SENS-401. Improvements in hearing loss recovery make SENS-401 a promising clinical candidate for acoustic trauma-induced hearing loss, including when treatment is not initiated immediately.

An update: emerging drugs for tinnitus.

Introduction: During the last decade, a number of candidate drugs for the treatment of tinnitus have emerged with the hope of alleviating the burden of millions of sufferers with a persisting ringing in their ears. Knowledge of the pathophysiologic mechanisms has progressed remarkably in the recent years, which has led to the identification of potential new drug targets for the treatment of tinnitus. However, pharmacologic interventions are still limited. Areas covered: In this editorial results from recent Phase 3 and Phase 2a trials investigating the NMDA receptor antagonist AM-101 from Auris Medical, the AMPA receptor antagonist BGG492 from Novartis and the Kv3 modulator AUT00063 from Autifony Therapeutics will be discussed. In this context, we will reevaluate the translational development approach from animal models to clinical trials and seize this opportunity to debate and improve future R&D in tinnitus pipeline. Expert opinion: In spite of huge advances in pathophysiologic knowledge and research methodology in the last decades, pharmaceutical research in tinnitus still represents a high-risk field. Important research directions include the identification of potential therapeutic targets and the development of objective outcome measurements to facilitate translational research.

Oral Administration of Clinical Stage Drug Candidate SENS-401 Effectively Reduces Cisplatin-induced Hearing Loss in Rats.

HYPOTHESIS: SENS-401, an oral clinical-stage drug, may reduce cisplatin-induced hearing loss and cochlear damage in an in vivo model. BACKGROUND: Cisplatin is commonly associated with hearing loss, causing significant learning and behavioral difficulties in the pediatric cancer population, and for which there are currently no clinical solutions. SENS-401 has previously been shown to improve acoustic trauma-induced hearing loss in vivo. METHODS: The effect of SENS-401 (R-azasetron besylate) on cisplatin IC50 values was evaluated in a panel of cisplatin-sensitive cell lines (NIH:OVCAR-3, SK-N-AS, NCI-H460, FaDu). Auditory brainstem response and distortion product otoacoustic emission tests were performed in a rat model of cisplatin-induced hearing-loss (8 mg/kg, day 1) at baseline, and after 14 days of SENS-401 (6.6, 13.2, 26.4 mg/kg/d). Cochlear outer hair cells were counted after immunolabeling for myosin-VIIa. RESULTS: Cisplatin cytotoxicity was not impacted by the addition of SENS-401 (up to 10 µM) in any of the cell types evaluated. In vivo, all SENS-401 doses significantly improved auditory brainstem response threshold shift (up to 30 dB) and distortion product otoacoustic emission amplitude loss (up to 19 dB) over placebo. Body weight and survival were not significantly different between rats receiving placebo and those receiving 26.4 mg/kg SENS-401. Significantly more surviving outer hair cells were present after SENS-401 treatment compared with placebo (p < 0.001), with up to 11-fold more in the basal turn of the cochlea. CONCLUSION: In vivo and in vitro data support the otoprotective potential and tolerability of SENS-401 without impacting chemotherapeutic potential. Oral SENS-401 is a promising candidate for treating cisplatin-induced ototoxicity.

Outer Hair Cell Molecular Protein, Prestin, as a Serum Biomarker for Hearing Loss: Proof of Concept.

HYPOTHESIS: At present there are no serum biomarkers available to monitor cochlear health in those at risk of hearing loss. Outer hair cells (OHCs) play an important role in cochlear function and are one of the cellular elements most vulnerable to damage, such as acoustic trauma. We hypothesized that an OHC-specific protein can serve as a biomarker for OHC damage in circulation. METHODS: After assessing auditory function, rats were exposed to intense octave band noise for 2 to 3 hours. Auditory function was assessed 14 days after trauma. Blood samples were collected and prestin concentration was measured using enzyme-linked immunosorbent assay. RESULTS: Circulating prestin was detectable in all control and noise-exposed animals. At 14 days after trauma, however, noise-exposed rats demonstrated statistically significant decrease in prestin concentrations compared with control animals. CONCLUSION: This work, for the first time, provides proof of concept that an otologic serum biomarker level can change after acoustic trauma and hearing loss. Our approach represents an entirely novel strategy in hearing diagnostics and has both research and clinical potential. Further work is needed to map out the temporal course of change in serum prestin concentrations after inner ear trauma, better define the relationship of serological and functional changes, and explore application to other etiologies of hearing loss (e.g., ototoxins).

Ondansetron reduces lasting vestibular deficits in a model of severe peripheral excitotoxic injury.

Vestibular neuritis is a neuroinflammatory, peripheral vestibular pathology leading to chronic deficits and long-term disability. While current corticosteroid-based therapy does not appear to positively influence the long term outcome for the patient, a recent clinical pilot study suggested a functional vestibuloprotective effect of the anti-emetic ondansetron in the treatment of vestibular neuritis. We here demonstrate that systemic post-insult administration of ondansetron in a novel rat model of severe excitotoxic vestibular insult reproduces the clinically demonstrated functional benefits. This ondansetron-conferred reduction of functional deficits stems from the protection of synapses between sensory hair cells and primary neurons from excitotoxically induced lesion.

Double Trouble? Potential for Hyperexcitability Following Both Channelopathic up- and Downregulation of I(h) in Epilepsy.

Studies of pathological ion channel regulation as an underlying mechanism of epilepsy have revealed alterations in the h-current in several animal models. While earlier reports indicate that downregulation of the h-current is pro-excitatory on the single neuron level, we found an upregulation of I(h) in hyperexcitable CA1 pyramidal neuron dendrites following experimental febrile seizures. In addition, in several CA1 pyramidal neuron computational models of different complexity, h-current upregulation has been shown to lead to pro-excitable effects. This focused review examines the complex impact of altered h-current on neuronal resting membrane potential (RMP) and input resistance (R(in)), as well as reported interactions with other ionic conductances.

Upregulated H-current in hyperexcitable CA1 dendrites after febrile seizures.

Somatic recordings from CA1 pyramidal cells indicated a persistent upregulation of the h-current (I(h)) after experimental febrile seizures. Here, we examined febrile seizure-induced long-term changes in I(h) and neuronal excitability in CA1 dendrites. Cell-attached recordings showed that dendritic I(h) was significantly upregulated, with a depolarized half-activation potential and increased maximal current. Although enhanced I(h) is typically thought to be associated with decreased dendritic excitability, whole-cell dendritic recordings revealed a robust increase in action potential firing after febrile seizures. We turned to computational simulations to understand how the experimentally observed changes in I(h) influence dendritic excitability. Unexpectedly, the simulations, performed in three previously published CA1 pyramidal cell models, showed that the experimentally observed increases in I(h) resulted in a general enhancement of dendritic excitability, primarily due to the increased I(h)-induced depolarization of the resting membrane potential overcoming the excitability-depressing effects of decreased dendritic input resistance. Taken together, these experimental and modeling results reveal that, contrary to the exclusively anti-convulsive role often attributed to increased I(h) in epilepsy, the enhanced I(h) can co-exist with, and possibly even contribute to, persistent dendritic hyperexcitability following febrile seizures in the developing hippocampus.

Topological determinants of epileptogenesis in large-scale structural and functional models of the dentate gyrus derived from experimental data.

In temporal lobe epilepsy, changes in synaptic and intrinsic properties occur on a background of altered network architecture resulting from cell loss and axonal sprouting. Although modeling studies using idealized networks indicated the general importance of network topology in epilepsy, it is unknown whether structural changes that actually take place during epileptogenesis result in hyperexcitability. To answer this question, we built a 1:1 scale structural model of the rat dentate gyrus from published in vivo and in vitro cell type-specific connectivity data. This virtual dentate gyrus in control condition displayed globally and locally well connected ("small world") architecture. The average number of synapses between any two neurons in this network of over one million cells was less than three, similar to that measured for the orders of magnitude smaller C. elegans nervous system. To study how network architecture changes during epileptogenesis, long-distance projecting hilar cells were gradually removed in the structural model, causing massive reductions in the number of total connections. However, as long as even a few hilar cells survived, global connectivity in the network was effectively maintained and, as a result of the spatially restricted sprouting of granule cell axons, local connectivity increased. Simulations of activity in a functional dentate network model, consisting of over 50,000 multicompartmental single-cell models of major glutamatergic and GABAergic cell types, revealed that the survival of even a small fraction of hilar cells was enough to sustain networkwide hyperexcitability. These data indicate new roles for fractionally surviving long-distance projecting hilar cells observed in specimens from epilepsy patients.

Optical release of caged glutamate for stimulation of neurons in the in vitro slice preparation.

Optical stimulation techniques prove useful to map functional inputs in the in vitro brain slice preparation: Glutamate released by a focused beam of UV light induces action potentials, which can be detected in postsynaptic neurons. The direct activation effect is influenced by factors such as compound concentration, focus depth, light absorption in the tissue, and sensitivity of different neuronal domains. We analyze information derived from direct stimulation experiments in slices from rat barrel cortex and construct a computational model of a layer V pyramidal neuron that reproduces the experimental findings. The model predictions concerning the influence of focus depth on input maps and action potential generation are investigated further in subsequent experiments where the focus depth of a high-numerical-aperture lens is systematically varied. With our setup flashes from a xenon light source can activate neuronal compartments to a depth of 200 mum below the surface of the slice. The response amplitude is influenced both by tissue depth and focus plane. Specific somatodendritic structures can be targeted as the probability of action potential induction falls off exponentially with distance. Somata and primary apical dendrites are most sensitive to uncaged glutamate with locally increased sensitivity on proximal apical dendrites. We conclude that optical stimulation can be targeted with high precision.

Structure of cortical microcircuit theory.

Recent experimental and theoretical investigations have made considerable advances in three major areas relating to the structural basis of quantitative cortical microcircuit theory. The first concerns the nature of the cellular units, encompassing the increasingly precise identification and progressively more complete listing of the individual cellular species that constitute the various cortical networks. The second element addresses the problem of heterogeneity, including the demonstration of the importance of cell to cell variability within defined interneuronal populations and the application of the Shannon-Wiener diversity index for the quantitative assessment of the number and relative abundance of interneuronal species. The third component relates to the discovery of basic topological principles underlying the circuit wiring, revealing a surprising order in the architectural design of networks. These new advances deepen our understanding of the computational principles embedded in cortical microcircuits, and they also provide novel opportunities for building realistic models of mammalian cortical microcircuits.

Dendritic h channelopathy in epileptogenesis.

Recent work has suggested a link between h channels and epilepsy. In this issue of Neuron, Shah et al. demonstrate that a robust, postseizure decrease in h channels during a critical phase of epileptogenesis mechanistically underlies dendritic hyperexcitability in entorhinal-hippocampal pyramidal cells.