Effectiveness of antiepileptic drug combination therapy for partial-onset seizures based on mechanisms of action.

IMPORTANCE: To our knowledge, the current study is the first to describe antiepileptic drug (AED) combination therapy patterns according to their mechanism of action (MOA) in a real-world setting and to evaluate the differences in outcomes comparing different-MOA combination therapy with same-MOA combination therapy for patients with partial-onset seizure. OBJECTIVE: To compare treatment persistence and health care use with AED combinations categorized by MOA in patients with partial-onset seizures. DESIGN, SETTING, AND PARTICIPANTS: Using the Truven Health MarketScan Commercial Claims Database containing 96 million covered lives from July 1, 2004, through March 31, 2011, adults with concomitant use of 2 different AEDs and a recent partial-onset seizure diagnosis were selected. Antiepileptic drugs were categorized by MOA: sodium channel blockers (SC), gamma-aminobutyric acid analogs (G), synaptic vesicle protein 2A binding (SV2), and multiple mechanisms (M). Patients were assigned a combination category based on their concomitant AED use. MAIN OUTCOMES AND MEASURES: Treatment persistence was measured from the start of AED combination therapy until the end of the combination. Health care resource use was measured during the combination treatment duration. Multivariate analyses evaluated AED discontinuation risk and health care use according to MOA combinations. RESULTS: Distribution of 8615 selected patients by combination was 3.3% for G+G, 7.5% for G+SV2, 8.6% for G+M, 13.9% for SC+SC, 19.0% for G+SC, 21.5% for SC+M, and 26.3% for SC+SV2. The same-MOA (G+G and SC+SC) combinations had the shortest persistence (mean [SD], 344 [345] days and 513 [530] days, respectively) and greater hazard of discontinuation compared with different-MOA combinations. Patients with different-MOA G combinations had a significantly lower risk for inpatient admission (odds ratio, 0.716; 95% CI, 0.539-0.952; P = .02) compared with G+G combinations. Patients with different-MOA SC combinations had significantly lower risks for emergency department visits (odds ratio, 0.853; 95% CI, 0.742-0.980; P = .03) compared with SC+SC combinations. CONCLUSIONS AND RELEVANCE: The findings suggest that AED combinations with different MOAs have greater effectiveness as measured by treatment persistence and lower risks for hospitalization and emergency department visits. Further research is needed to more fully understand the role of the MOA in achieving optimal outcomes.

Activation of mesocorticolimbic reward circuits for assessment of relief of ongoing pain: a potential biomarker of efficacy.

Preclinical assessment of pain has increasingly explored operant methods that may allow behavioral assessment of ongoing pain. In animals with incisional injury, peripheral nerve block produces conditioned place preference (CPP) and activates the mesolimbic dopaminergic reward pathway. We hypothesized that activation of this circuit could serve as a neurochemical output measure of relief of ongoing pain. Medications commonly used clinically, including gabapentin and nonsteroidal anti-inflammatory drugs (NSAIDs), were evaluated in models of post-surgical (1 day after incision) or neuropathic (14 days after spinal nerve ligation [SNL]) pain to determine whether the clinical efficacy profile of these drugs in these pain conditions was reflected by extracellular dopamine (DA) release in the nucleus accumbens (NAc) shell. Microdialysis was performed in awake rats. Basal DA levels were not significantly different between experimental groups, and no significant treatment effects were seen in sham-operated animals. Consistent with clinical observation, spinal clonidine produced CPP and produced a dose-related increase in net NAc DA release in SNL rats. Gabapentin, commonly used to treat neuropathic pain, produced increased NAc DA in rats with SNL but not in animals with incisional, injury. In contrast, ketorolac or naproxen produced increased NAc DA in animals with incisional but not neuropathic pain. Increased extracellular NAc DA release was consistent with CPP and was observed selectively with treatments commonly used clinically for post-surgical or neuropathic pain. Evaluation of NAc DA efflux in animal pain models may represent an objective neurochemical assay that may serve as a biomarker of efficacy for novel pain-relieving mechanisms.

Assessment of paclitaxel induced sensory polyneuropathy with "Catwalk" automated gait analysis in mice.

Neuropathic pain as a symptom of sensory nerve damage is a frequent side effect of chemotherapy. The most common behavioral observation in animal models of chemotherapy induced polyneuropathy is the development of mechanical allodynia, which is quantified with von Frey filaments. The data from one study, however, cannot be easily compared with other studies owing to influences of environmental factors, inter-rater variability and differences in test paradigms. To overcome these limitations, automated quantitative gait analysis was proposed as an alternative, but its usefulness for assessing animals suffering from polyneuropathy has remained unclear. In the present study, we used a novel mouse model of paclitaxel induced polyneuropathy to compare results from electrophysiology and the von Frey method to gait alterations measured with the Catwalk test. To mimic recently improved clinical treatment strategies of gynecological malignancies, we established a mouse model of dose-dense paclitaxel therapy on the common C57Bl/6 background. In this model paclitaxel treated animals developed mechanical allodynia as well as reduced caudal sensory nerve action potential amplitudes indicative of a sensory polyneuropathy. Gait analysis with the Catwalk method detected distinct alterations of gait parameters in animals suffering from sensory neuropathy, revealing a minimized contact of the hind paws with the floor. Treatment of mechanical allodynia with gabapentin improved altered dynamic gait parameters. This study establishes a novel mouse model for investigating the side effects of dose-dense paclitaxel therapy and underlines the usefulness of automated gait analysis as an additional easy-to-use objective test for evaluating painful sensory polyneuropathy.

Assessment of the antinociceptive effects of pregabalin alone or in combination with morphine during acetic acid-induced writhing in mice.

Visceral pain currently represents one of the most important pain treatment challenges in clinical practice, and investigators across the world are continuously designing and conducting numerous studies in search of new analgesics and new combination therapies. The current study assessed the analgesic effects of saline, pregabalin (2, 5, 17, 50, 100, and 200 mg/kg, i.p.) and morphine (0.25, 0.5, 1, 3 and 5 mg/kg) alone or in combination on acetic-acid induced abdominal contractions in mice. The number of writhes and the inhibitory effects (as percentages, %E) were calculated as antinociception indexes. These indexes indicated that both pregabalin (Prg) and morphine (Mrp) produced dose-dependent antinociception. Pregabalin at 5 mg/kg (%E=32.5±4.0) or 2 mg/kg (%E=20.8±4.5) and morphine at 0.25 mg/kg (%E=20.2±7.8) and 0.5 mg/kg (%E=43.6±4.5) exhibited antinociceptive effects, and the combination of pregabalin and morphine produced significantly greater antinociceptive effects (%E=62.4±5.8 for Prg5+Mrp0.25; %E=71.7±4.8 for Prg5+Mrp0.5; and %E=54.1±4.0 for Prg2+Mrp0.25), although this enhancement was not observed when morphine was combined with 17 mg/kg pregabalin. Pre-treatment with 2 mg/kg (i.p.) naloxone did not affect increased analgesia when combined with these drugs. A dose-response curve was established for pregabalin at a fixed morphine dose and revealed that, at low doses, pregabalin dose-dependently enhanced the antinociceptive effects, while the opposite was true at high doses (17 and 25 mg/kg). In conclusion, pregabalin can produce levels of antinociception that are similar to those of morphine in acetic acid-induced viscero-somatic pain. The enhancement of antinociception produced by the co-administration of morphine and pregabalin is termed a supra-additive interaction and occurred at low doses but not at high doses. These findings militate for increased attention and caution in clinical settings.

Pregabalin versus gabapentin in the management of peripheral neuropathic pain associated with post-herpetic neuralgia and diabetic neuropathy: a cost effectiveness analysis for the Greek healthcare setting.

BACKGROUND: The anticonvulsants pregabalin and gabapentin are both indicated for the treatment of peripheral neuropathic pain. The decision on which treatment provides the best alternative, should take into account all aspects of costs and outcomes associated with the two therapeutic options. The objective of this study was to examine the cost - effectiveness of the two agents in the management of patients with painful diabetic neuropathy or post - herpetic neuralgia, under the third party payer perspective in Greece. METHODS: The analysis was based on a dynamic simulation model which estimated and compared the costs and outcomes of pregabalin and gabapentin in a hypothetical cohort of 1,000 patients suffering from painful Diabetic Peripheral Neuropathy (DPN) or Post-Herpetic Neuralgia (PHN). In the model, each patient was randomly allocated an average pretreatment pain score, measured using an eleven-point visual analogue scale (0 - 10) and was "run through" the model, simulating their daily pain intensity and allowing for stochastic calculation of outcomes, taking into account medical interventions and the effectiveness of each treatment. RESULTS: Pregabalin demonstrated a reduction in days with moderate to severe pain when compared to gabapentin. During the 12 weeks the pregabalin arm demonstrated a 0.1178 (SE 0.0002) QALY gain, which proved to be 0.0063 (SE 0.0003) higher than that in the gabapentin arm. The mean medication cost per patient was higher for the pregabalin arm when compared to the gabapentin arm (i.e. €134.40) over the 12 week treatment period. However, this higher cost was partially offset by the reduced direct medical costs (i.e. the cost of specialist visits, the cost of diagnostic tests and the other applied interventions). Comparing costs with respective outcomes, the ICERs for pregabalin versus gabapentin were €13 (95%CI: 8 - 18) per additional day with no or mild pain and €19,320 (95%CI: 11,743 - 26,755) per QALY gained. CONCLUSIONS: Neuropathic pain carries a great disease burden for patients and society and, is also, associated with a significant economic burden. The treatment of pain associated with DPN and PHN with pregabalin is a cost-effective intervention for the social security in Greece compared to gabapentin. Thus, these findings need to be taken into consideration in the decision - making process when considering which therapy to use for the treatment of neuropathic pain.

Pregabalin effect on steady-state pharmacokinetics of carbamazepine, lamotrigine, phenobarbital, phenytoin, topiramate, valproate, and tiagabine.

By reducing neuronal excitability through selective binding to the α(2)δ subunit of voltage-dependent calcium channels, pregabalin effectively treats epilepsy, chronic pain, and anxiety disorders. To evaluate if pregabalin coadministration affects pharmacokinetics of other antiepileptic drugs, population pharmacokinetic analyses using NONMEM software were performed on data from three epilepsy trials involving seven antiepileptic drugs with pregabalin as add-on therapy. Results demonstrated that pregabalin did not alter the steady-state plasma concentrations of carbamazepine, lamotrigine, phenobarbital, phenytoin, tiagabine, topiramate, and valproate. Furthermore, the small percent change in the population estimate of antiepileptic drug plasma clearance values (-2% to +7%) suggests that pregabalin coadministration exerted no significant effect on the pharmacokinetics of these antiepileptic drugs, with the possible exception of tiagabine (+34.9%). These findings are in agreement with those of previously published reports. A further clarification study is necessary for tiagabine. In conclusion, it appears that pregabalin can be coadministered with other antiepileptic drugs without concern for significantly altering their pharmacokinetic profiles.

Pregabalin: in the treatment of postherpetic neuralgia.

Pregabalin is the pharmacologically active S-enantiomer of 3-aminomethyl-5-methyl-hexanoic acid. It has a similar pharmacological profile to that of its developmental predecessor gabapentin, but had greater analgesic activity in rodent models of neuropathic pain. Pregabalin is thought to act by reducing the excessive release of several excitatory neurotransmitters by binding to the alpha(2)-delta protein subunit of voltage-gated calcium channels. Oral pregabalin 150-600 mg/day, administered in two or three divided doses, was significantly more effective than placebo in relieving pain and improving pain-related sleep interference in four randomized, double-blind, multicentre studies of 4-13 weeks' duration in patients with postherpetic neuralgia (PHN). Pregabalin achieved a faster onset of pain relief than placebo. The median times to the onset of pain relief with fixed and flexible doses of pregabalin were 1.5 and 3.5 days compared with >4 weeks with placebo. Pregabalin was generally well tolerated when titrated over 1 week to fixed dosages (maximum 600 mg/day) in clinical trials in mostly elderly PHN patients. Adverse events were usually mild to moderate in severity.

Attenuation of hemodynamic responses following laryngoscopy and tracheal intubation -- comparative assessment of clonidine and gabapentin premedication.

OBJECTIVE: The present study was conducted to compare the effect of clonidine and gabapentin premedication in modifying the hyperdynamic response following laryngoscopy and tracheal intubation. METHODS AND MATERIALS: Seventy-five ASA I-II patients of both sexes (37 males (49.3%), 38 females (50.7%)) 18 to 45 years (mean 32.8 +/- 8.65 yr.) were randomly allocated into three equal groups (25 each). Group-1 received 0.2 mg clonidine, Group-2 received placebo and Group-3 received 900 mg gabapentin, 120 minute before operation. Heart rate, systolic, diastolic and mean arterial blood pressure were measured before induction of anesthesia, before laryngoscopy, and 1, 3, 5, 10 min after intubation. RESULTS: Analysis revealed that the heart rate, systolic, diastolic and mean arterial blood pressure significantly differed between groups (p<0.001, p = 0.003, p<0.001, p<0.001, respectively). The highest rates of heart rate, systolic, diastolic and mean arterial blood pressure were in the placebo group and in one minute after laryngoscopy, and the lowest rate were in the gabapentin group at the time of 1, 3, 5 and 10 after laryngoscopy, except that the lowest rate of heart rate in 10 min after laryngoscopy was in clonidine group. CONCLUSION: The data propose that both clonidine and gabapentin have effective role in blunting hyperdynamic responses after laryngoscopy, more so with gabapentin.

Medicinal chemistry strategies in follow-on drug discovery.

Drug discovery targeting novel mechanisms has become extremely expensive and risky. The annual first-in-class drug approvals have not been satisfactory in the past decade (two to six per year) despite an increased R&D budget. Follow-on programs targeting proven mechanisms are less risky and costly but can produce drugs with meaningful differentiations and thus can play an important supporting role. This article will discuss the medicinal chemistry strategies that have been utilized by the pharmaceutical industry to exploit validated therapeutic targets.

Transient allodynia pain models in mice for early assessment of analgesic activity.

BACKGROUND AND PURPOSE: The most common preclinical models of neuropathic pain involve surgical ligation of sensory nerves, which is especially difficult in mice. Transient models of chemically sensitized allodynia are potentially useful for rapidly characterizing the analgesic profile of compounds and conducting mechanistic studies. EXPERIMENTAL APPROACH: Increasing doses of NMDA, sulprostone (an EP1/EP3 prostaglandin receptor agonist) or phenylephrine (an alpha (1) adrenoceptor agonist) were injected intrathecally (i.t.) or i.p., and animals were subsequently assessed for allodynia. The effects of receptor antagonists and analgesic compounds on allodynia were also assessed. KEY RESULTS: A comparison of total body doses that cause allodynia following spinal or systemic administration indicated that NMDA induces allodynia in the spinal cord while sulprostone and phenylephrine act through a peripheral mechanism. Inhibition of the allodynia with receptor antagonists indicated that each agent induces allodynia by a distinct mechanism. The three models were benchmarked using compounds known to be active in neuropathic pain patients and nerve injury animal models, including gabapentin, amitriptyline and clonidine. CONCLUSIONS AND IMPLICATIONS: These transient allodynia models are a useful addition to the toolbox of preclinical pain models. They are simple, rapid and reproducible, and will be especially useful for characterizing the pain phenotype of knockout mice.

Pregabalin (lyrica) for neuropathic pain and epilepsy.

A new drug similar to gabapentin (Neurontin, and others).

GABA uptake into astrocytes is not associated with significant metabolic cost: implications for brain imaging of inhibitory transmission.

Synaptically released glutamate has been identified as a signal coupling excitatory neuronal activity to increased glucose utilization. The proposed mechanism of this coupling involves glutamate uptake into astrocytes resulting in increased intracellular Na+ (Nai+) and activation of the Na+/K+-ATPase. Increased metabolic demand linked to disruption of Nai+ homeostasis activates glucose uptake and glycolysis in astrocytes. Here, we have examined whether a similar neurometabolic coupling could operate for the inhibitory neurotransmitter gamma-aminobutyric acid (GABA), also taken up by Na+-dependent transporters into astrocytes. Thus, we have compared the Nai+ response to GABA and glutamate in mouse astrocytes by microspectrofluorimetry. The Nai+ response to GABA consisted of a rapid rise of 4-6 mM followed by a plateau that did not, however, significantly activate the pump. Indeed, the GABA transporter-evoked Na+ influxes are transient in nature, almost totally shutting off within approximately 30 sec of GABA application. The metabolic consequences of the GABA-induced Nai+ response were evaluated by monitoring cellular ATP changes indirectly in single cells and measuring 2-deoxyglucose uptake in astrocyte populations. Both approaches showed that, whereas glutamate induced a robust metabolic response in astrocytes (decreased ATP levels and glucose uptake stimulation), GABA did not cause any measurable metabolic response, consistent with the Nai+ measurements. Results indicate that GABA does not couple inhibitory neuronal activity with glucose utilization, as does glutamate for excitatory neurotransmission, and suggest that GABA-mediated synaptic transmission does not contribute directly to brain imaging signals based on deoxyglucose.

GABAB receptor-mediated presynaptic potentiation of ATP ionotropic receptors in rat midbrain synaptosomes.

Nucleotides can activate ionotropic P2X receptors that induce calcium-responses in rat midbrain synaptosomes. In this report, we show that ATP elicits Ca(2+) responses producing a monophasic dose-response curve with an EC(50) value of 24.24+/-1.42 micro M. In the presence of gamma-aminobutyric acid (GABA), the ATP dose-response curve becomes biphasic with EC(50) values of 3.69+/-0.44 nM and 59.65+/-8.32 micro M. Moreover, the maximal calcium response induced by ATP is 52.1% higher than the control. This effect is mimicked or blocked by the specific GABA(B) receptor agonist and antagonist, baclofen and saclofen, respectively. Presynaptic GABA(B) receptors, identified by immunocytochemistry are present in 62% of the total synaptosomal population. Adenylate cyclase and protein kinase A cascades are involved in the potentiatory effects mediated by baclofen and their activation or inhibition modifies calcium signalling and synaptosomal cAMP levels. The potentiatory action of baclofen was confirmed by microfluorimetry performed on single synaptic terminals. In its presence, 86% of the terminals responding to 100 micro M ATP, are also able to respond to nanomolar concentrations (100 nM) of this nucleotide. This potentiatory effect is reduced to 32% in the presence of pertussis toxin. Our data suggest that the activity of P2X receptors is modulated by GABA(B) receptors in midbrain synaptosomes.

An electrogenic ionic pump derived from an ionotropic receptor: assessment of a candidate.

1. Data obtained studying permeability characteristics of single Deiters' membranes in a microchamber system show that intracellular GABA can activate chloride in-->out passage with a GABAA pharmacology. 2. The overall data suggest the presence of a chloride extrusion pump in these neurons based on intracellular GABA activated chloride channels. 3. This conclusion takes up a previous theoretical suggestion that ionic channels could work as ionic pumps provided an energy input modifies the energy profile along the permeation path. 4. According to our quantitative evaluation, this pumping mechanism works with a low yield and along a cycle with a strongly asymmetric behavior, being far from equilibrium due to powerful "leakage" pathways for chloride in these neurons.

A novel methodology for simultaneous assessment of the effects of 5-hydroxytryptamine on primary afferent polarisation and synaptic transmission in rat dorsal horn neurones in vitro.

The rat hemisected spinal cord in vitro preparation was used to test simultaneously the effects of 5-hydroxytryptamine (5-HT) on primary afferent polarisation and synaptic transmission onto dorsal horn (DH) neurons. Primary afferent polarisation was measured from the cut end of a transected lumbar dorsal root (DR; L3-L6) using tight suction electrodes coupled to a D.C. amplifier. Conventional sharp microelectrodes were used to record intracellularly the excitatory postsynaptic potential (EPSP) evoked by high intensity electrical stimulation (100 microA, 100 microseconds) of another DR contiguous to that used for the suction electrode recording. Superfusion of 5-HT (5-10 microM) caused primary afferent depolarisations (PAD) of 227.5 +/- 26.5 microV (mean +/- SEM) and 221 +/- 32 microV, respectively, values comparable to the PAD caused by 10-100 microM gamma-aminobutyric acid (GABA) superfusion. 5-HT-induced PAD was tetrodotoxin (TTX) resistant and non-additive to capsaicin-induced PAD suggesting a direct depolarising action of 5-HT on a population of primary afferents which may include a high proportion of unmyelinated fibres. Simultaneous intracellular recordings showed that 5-HT, in addition to generating PAD, depressed primary afferent-evoked synaptic transmission to DH neurons reflected by a significant reduction (p < 0.05) in the amplitude and duration of the EPSP. In contrast, GABA, despite producing a PAD of similar amplitude, failed to depress synaptic transmission. These data suggest that PAD alone may be insufficient to account for the 5-HT-induced depression of synaptic transmission. This novel experimental approach offers a means to explore further the possible causal relationship between pre- and post-synaptic effects of 5-HT in the DH and its ability to modulate somatosensory processing and nociception.

Characterization of single channel currents using digital signal processing techniques based on Hidden Markov Models.

Techniques for extracting small, single channel ion currents from background noise are described and tested. It is assumed that single channel currents are generated by a first-order, finite-state, discrete-time, Markov process to which is added 'white' background noise from the recording apparatus (electrode, amplifiers, etc). Given the observations and the statistics of the background noise, the techniques described here yield a posteriori estimates of the most likely signal statistics, including the Markov model state transition probabilities, duration (open- and closed-time) probabilities, histograms, signal levels, and the most likely state sequence. Using variations of several algorithms previously developed for solving digital estimation problems, we have demonstrated that: (1) artificial, small, first-order, finite-state, Markov model signals embedded in simulated noise can be extracted with a high degree of accuracy, (2) processing can detect signals that do not conform to a first-order Markov model but the method is less accurate when the background noise is not white, and (3) the techniques can be used to extract from the baseline noise single channel currents in neuronal membranes. Some studies have been included to test the validity of assuming a first-order Markov model for biological signals. This method can be used to obtain directly from digitized data, channel characteristics such as amplitude distributions, transition matrices and open- and closed-time durations.

Assessment of some transmitter actions in rat cerebellar slices.

The effects of 100 microM norepinephrine (NE), GABA, aspartate, glutamate, and carbachol on the release of endogenous NE, GABA, aspartate, and glutamate from slices of rat cerebellum were examined. The 35 mM K+-stimulated release of NE was potentiated by GABA (136% of control), glutamate (123%), and carbachol (123%); aspartate had no effect. Glutamate increased the release of GABA to 250% of control levels, while neither NE nor carbachol exerted any effect. Glutamate and GABA increased aspartate release to 260% and 300% of control values, respectively. NE decreased the release of aspartate to 86% of control levels while carbachol had no effect. The stimulated release of glutamate was increased by GABA (166% of control) but was unaffected by NE and carbachol. All of these effects were observed only under depolarizing conditions and in the presence of extracellular Ca2+. These data suggest a cholinergic, GABAergic and glutamatergic control of the noradrenergic system in the cerebellum; the presence of a specific aspartergic system in the cerebellum; and a net excitatory action of GABA may be present within the cerebellum.

An assessment of the effect of hormone and neurotransmitters on adenine and guanine derivatives simultaneously in rat brain cortical slices.

A A 2-dimensional thin-layer method has been developed for the separation on cellulose of adenine and guanine derivatives. Using incubated rat cerebral cortex slices it was shown that noradrenaline and acetylcholine stimulated cAMP and cGMP production respectively but glutamate and gamma-aminobutyric acid stimulated production of both cyclic nucleotides.