Lacosamide

Lacosamide
Systematic (IUPAC) name
N2-acetyl-N-benzyl-D-homoserinamide
Clinical data
Trade names Vimpat
AHFS/Drugs.com monograph
MedlinePlus a609028
Pregnancy
category
  • C
Routes of
administration		 Oral, intravenous
Legal status
Legal status
Pharmacokinetic data
Bioavailability High
Biological half-life 13 hours
Excretion Renal
Identifiers
CAS Number 175481-36-4 N
ATC code N03AX18 (WHO)
PubChem CID 219078
IUPHAR/BPS 7472
ChemSpider 189902 YesY
UNII 563KS2PQY5 YesY
KEGG D07299 YesY
ChEMBL CHEMBL58323 YesY
Synonyms (2R)-2-(acetylamino)-N-benzyl-3-methoxypropanamide
Chemical data
Formula C13H18N2O3
Molar mass 250.294 g/mol
 NYesY (what is this?)  (verify)

Lacosamide (INN, formerly known as erlosamide, harkeroside, SPM 927, or ADD 234037) is a medication discovered by Dr. Harold Kohn while at the University of Houston and developed by Union Chimique Belge (UCB) for the adjunctive treatment of partial-onset seizures and diabetic neuropathic pain marketed under the trade name Vimpat.

Approvals and indications

Lacosamide is an anticonvulsant compound approved for the adjunctive treatment of partial-onset seizures and neuropathic pain (not FDA approved).

The U.S. Food and Drug Administration (FDA) accepted UCB's New Drug Application for lacosamide as of November 29, 2007, beginning the approval process for the drug.[1][2] UCB also filed for marketing approval in the European Union (EU); the European Medicines Agency accepted the marketing application for review in May 2007.[1][3]

The drug was approved in the EU on September 3, 2008.[4] It was approved in the US on October 29, 2008.[5] Lacosamide release was delayed owing to an objection about its placement into schedule V of the Controlled Substances Act. The FDA issued their final rule of placement into Schedule V on June 22, 2009.[6]

Discovery

Lacosamide was discovered by Pr Harold Kohn and colleagues at the University of Houston in 1996.[7] They hypothesized that modified amino acids may be therapeutically useful in the treatment of epilepsy. A few hundred such molecules were synthesized over several years and these were tested phenotypically in an epilepsy disease model performed in rats. N-benzyl-2-acetamido-3-methoxypropionamide was found to be highly efficacious in this model, with the biological activity traced specifically to its R enantiomer.[8] This compound was to become Lacosamide after being licensed by Schwarz Pharma, which completed its pre-clinical and early clinical development. Following its purchase of Schwarz Pharma in 2006, UCB completed the clinical development program and obtained marketing approval for Lacosamide. Interestingly, its precise mechanism of action was unknown at the time of approval.[9]

Mechanism of Action and Pharmacodynamics

Lacosamide is a functionalized amino acid that produces activity in the maximal electroshock seizure (MES) test, that, like some other antiepileptic drugs (AEDs), are believed to act through voltage-gated sodium channels.[10] Lacosamide enhances the slow inactivation of voltage-gated sodium channels without affecting the fast inactivation of voltage-gated sodium channels. This inactivation prevents the channel from opening, helping end the action potential. Many antiepileptic drugs, like carbamazepine or lamotrigine, slow the recovery from inactivation and hence reduce the ability of neurons to fire action potentials. Inactivation only occurs in neurons firing action potentials; this means that drugs that modulate fast inactivation selectively reduce the firing in active cells. Slow inactivation is similar but does not produce complete blockade of voltage gated sodium channels, with both activation and inactivation occurring over hundreds of milliseconds or more. Lacosamide makes this inactivation happen at less depolarized membrane potentials. This means that lacosamide only affects neurons which are depolarized or active for long periods of time, typical of neurons at the focus of epilepsy.[11] Lacosamide administration results in the inhibition of repetitive neuronal firing, the stabilization of hyperexcitable neuronal membranes, and the reduction of long-term channel availability, but does not affect physiological function.[12] Lacosamide has a dual mechanism of action. It also modulates collapsin response mediator protein 2 (CRMP-2), preventing the formation of abnormal neuronal connections in the brain.[13]

Lacosamide does not affect AMPA, kainate, NMDA, GABAA, GABAB or a variety of dopaminergic, serotonergic, adrenergic, muscarinic or cannabinoid receptors and does not block potassium or calcium currents.[14] Lacosamide does not modulate the reuptake of neurotransmitters including norepinephrine, dopamine, and serotonin.[15] In addition, it does not inhibit GABA transaminase.[16]

Pharmacokinetics

When administered orally in healthy individuals, lacosamide is rapidly absorbed from the gastrointestinal tract. Little of the drug is lost via the first pass effect, and thus has an oral bioavailability of nearly 100%.[17] In adults, lacosamide demonstrates a low plasma protein binding of <15, which reduces the potential for interaction with other drugs. Lacosamide is at its highest concentration in blood plasma approximately 1 to 4 hours after oral administration. Lacosamide has a half life of about 12–16 hours, which remains unchanged if the patients is also taking enzyme inducers. Consequently, the drug is administered twice per day at 12-hour intervals. Lacosamide is excreted renally, with 95% of the drug eliminated in the urine.[18] 40% of the compound remains unchanged from its original structure, while the rest of the elimination product consists of metabolites of lacosamide. Just 0.5% of the drug is eliminated in the feces.[19] The major metabolic pathway of lacosamide is CYP2C9, CY2C19, and CYP3A4-mediated demethylation.[20]

The dose-response curve for lacosamide is linear and proportional for oral doses of up to 800 mg and intravenous doses of up to 300 mg.[21] Lacosamide has low potential for drug-drug interactions, and no pharmacokinetic interactions have been found to occur with other (AEDs) that act on sodium channels.[22] A study on the binding of lacosamide to CRMP-2 in Xenopus oocytes showed both competitive and specific binding. Lacosamide has a Kd value just under 5μM and a Bmax of about 200 pM/mg.[23] The volume of distribution (Vd) of lacosamide in plasma is 0.6 L/kg, which is close to the total volume of water. Lacosamide is ampiphilic and is thus hydrophilic while also lipophilic enough to cross the blood-brain barrier.[24]

Dosage

Lacosamide is initially prescribed in oral doses of 50 mg twice per day, with a total dose of 100 mg/day.The dosing can be increased by 100 mg/day following a twice-daily dose up to a total dose of 200–400 mg/day. Clinical trials showed that a dose of 600 mg/day was not more effective than a dose of 400 mg/day, but resulted in more adverse reactions. Lacosamide is administered orally through film-coated tablets of 50 mg (pink), 100 mg (dark yellow), 150 mg (salmon), and 200 mg (blue). It can also be administered by injection at a concentration of 200 mg/20 mL or by oral solution at a concentration of 10 mg/mL.[25]

Preclinical trials

In preclinical trials, the effect of lacosamide administration on animal models of epilepsy was tested using the Frings audiogenic seizures (AGS)-susceptible mouse model of seizure activity with an effective dose (ED50) of 0.63 mg/kg, i.p.[26] The effect of lacosamide was also assessed using the MES test to detect inhibition of seizure spread.[27][28] Lacosamide administration was successful in preventing the spread of seizures induced by MES in mice (ED50 = 4.5 mg/kg, i.p.) and rats (ED50 = 3.9 mg/kg, p.o.).[26] In preclinical trials, administration of lacosamide in combination with other AEDs resulted in synergistic anticonvulsant effects. Lacosamide produced effects in animal models of essential tremor, tardive dyskinesia, schizophrenia, and anxiety.[29] Preclinical trials found the S-stereoisomer to be less potent than the R-stereoisomer in the treatment of seizures.[30]

Clinical trials

Partial-onset seizures

Lacosamide was tested in three placebo-controlled, double-blind, randomized trials of at least 1300 patients.[31] In a multi center, multinational, placebo-controlled, double-blind, randomized clinical trial conducted to determine the efficacy and safety of different doses of lacosamide on individuals with poorly controlled partial-onset seizures, lacosamide was found to significantly reduce seizure frequency when given in addition to other antiepileptics, at doses of 400 and 600 milligrams a day.[32]

Diabetic neuropathy

In a smaller trial of patients with diabetic neuropathy, lacosamide also provided significantly better pain relief when compared to placebo.[33] Lacosamide administration in combination with 1-3 other AEDs was well-tolerated in patients. Lacosamide administered at 400 mg/day was found to significantly reduce pain in patients with diabetic neuropathy in a multi center, double-blind, placebo-controlled Phase III trial with a treatment duration of 18 weeks.[34]

Treatment

Lacosamide is an anticonvulsant compound approved for the adjunctive treatment of partial-onset seizures and neuropathic pain. Clinical trials are currently underway for the use of lacosamide as monotherapy for partial onset seizures.[31] There is no evidence that lacosamide provides additional value over current AEDs for the treatment of partial-onset seizures, but it may offer a safety advantage.[22] Newer AEDs, including lacosamide, vigabatrin, felbamate, gabapentin, tiagabine, and rufinamide have been found to be more tolerable and safer than older drugs such as carbamazepine, phenytoin, and valproate.[35]

Side-effects and Tolerability

Lacosamide was generally well tolerated in adult patients with partial-onset seizures.[36] The side-effects most commonly leading to discontinuation were dizziness, ataxia, vomiting, diplopia (double vision), nausea, vertigo, and blurred vision. These adverse reactions were observed in at least 10% of patients.[25] Less common side-effects include forgetfulness, discouragement, feelings of sadness, and lack of appetite.

Gastrointestinal

Nausea, vomiting, diarrhea.

Central Nervous system

Dizziness was the most common treatment-related adverse event. Other CNS effects are headache, drowsiness, blurred vision, involuntary movements, weakness, tiredness, memory problems, diplopia, trembling or shaking of the hands, unsteadiness, ataxia.

Psychology

Panic attacks; agitation or restlessness; irritability and aggression, anxiety, or depression; suicidality; insomnia and mania; altered mood; false and unusual sense of well-being.

Cardiovascular

Postural hypotension, arrhythmias.

Allergies

Itching, rash,[37] pruritus

Warnings

Suicidal behavior and ideation have been observed as early as one week after starting treatment with lacosamide, and is an adverse reaction from use of most AEDs. In clinical trials with a medial treatment duration of 12 weeks, the incidence of suicidal ideation was 0.43% among 27,863 patients as opposed to 0.24% among 16,029 placebo-treated patients. Suicidal behavior was observed in 1 of every 530 patients treated.[25]>

In Pregnancy

In a study conducted to assess the teratogenic potential of AEDs in the zebrafish embryo, the teratogenicity index of lacosamide was found to be higher than that of lamotigrine, levetiracetam, and ethosuximide. Lacosamide administration resulted in different malformations in the neonatal zebrafish depending on dosage.[38]

The FDA has assigned lacosamide to pregnancy category C. Animal studies have reported incidences of fetal mortality and growth deficit. Lacosamide has not been tested during human pregnancy, and should be administered with caution. In addition, it has not been determined whether the excretion of lacosamide occurs in breast milk.[39]

Off-label use

Lacosamide may have a variety of off-label uses, including for pain management and treatment of mental health disorders. Lacosamide and other AEDs have been used off-label in the management of bipolar disorder, cocaine addiction, dementia, depression, diabetic peripheral neuropathy, fibromyalgia, headache, hiccoughs, Huntington's disease, mania, migraine, obsessive-compulsive disorder, panic disorder, restless leg syndrome, and tinnitus. Combinations of AEDs are often employed for seizure reduction. Studies are underway for the use of lacosamide as a monotherapy for partial onset seizures, diabetic neuropathy, and fibromyalgia.[22]

Chemistry

Lacosamide is a powdery, white to light yellow crystalline compound. The chemical name of lacosamide is (R)-2-acetamido-N-benzyl-3-methoxypropionamide and the systemic name is N2-Acetyl-N-benzyl-O-methyl-D-serinamide.[15][40] Lacosamide is a functionalized amino acid molecule that has high solubility in water and DMSO, with a solubility of 20.1 mg/mL in phosphate-buffered saline (PBS, pH 7.5, 25 °C).[15][41] The molecule has six rotatable bonds and one aromatic ring. Lacosamide melts at 143-144 °C and boils at 536.447 °C at a pressure of 760 mmHg.[42][43]

Synthesis

The following three-step synthesis of lacosamide was proposed in 1996.

(R)-2-amino-3-hydroxypropanoic acid is treated with acetic anhydride and acetic acid. The product is treated first with N-methylmorpholine, isobutyl chloroformate, and benzylamine, next with methyl iodide and silver oxide, forming lacosamide.[44]

More efficient routes to synthesis have been proposed in recent years, including the following.[45][46]

Available brands in other countries

In Pakistan, it is marketed by The Searle Company Limited as Lacolit.

See also

References

  1. 1 2 "UCB Announces FDA Filing for lacosamide in the Treatment of Diabetic Neuropathic Pain" (Press release). UCB. 2007-11-29. Retrieved 2007-11-29.
  2. ↑ "UCB Announces FDA Filing for lacosamide in the Treatment of Partial Onset Seizures in Adults with Epilepsy" (Press release). UCB. 2007-11-29. Retrieved 2007-11-29.
  3. ↑ Wan, Yuet (August 17, 2007). "Marketing application for lacosamide (Vimpat) filed in EU for treatment of diabetic neuropathic pain". PharmaTimes through the UK National electronic Library for Medicines. Retrieved 2007-11-30.
  4. ↑ "Vimpat Approved in Europe" (Press release). UCB. 2008-09-03. Retrieved 2008-09-17.
  5. ↑ "UCB's Vimpat approved by U.S. FDA as adjunctive therapy for partial onset seizures in adults" (Press release). UCB. 2008-10-29. Retrieved 2008-11-25.
  6. ↑ "FDA places lacosamide in Schedule V" (Press release). FDA. 2009-06-22. Retrieved 2009-06-28.
  7. ↑ Choi, D; Stables, JP; Kohn, H (Apr 26, 1996). "Synthesis and anticonvulsant activities of N-Benzyl-2-acetamidopropionamide derivatives.". Journal of Medicinal Chemistry 39 (9): 1907–16. doi:10.1021/jm9508705. PMID 8627614.
  8. ↑ Choi, D; Stables, JP; Kohn, H (Apr 26, 1996). "Synthesis and anticonvulsant activities of N-Benzyl-2-acetamidopropionamide derivatives.". Journal of Medicinal Chemistry 39 (9): 1907–16. doi:10.1021/jm9508705. PMID 8627614.
  9. ↑ Michael A. Rogawski, Azita Tofighy, H. Steve White,Alain Matagne, Christian Wolff (2015). "Current understanding of the mechanism of action of the antiepileptic drug lacosamide". Epilepsy Research 110: 189–205. doi:10.1016/j.eplepsyres.2014.11.021. PMID 25616473.
  10. ↑ Michael A. Rogawski, Azita Tofighy, H. Steve White,Alain Matagne, Christian Wolff (2015). "Current understanding of the mechanism of action of the antiepileptic drug lacosamide". Epilepsy Research 110: 189–205. doi:10.1016/j.eplepsyres.2014.11.021. PMID 25616473.
  11. ↑ Errington AC, Stöhr T, Heers C, Lees G (January 2008). "The investigational anticonvulsant lacosamide selectively enhances slow inactivation of voltage-gated sodium channels". Molecular Pharmacology 73 (1): 157–69. doi:10.1124/mol.107.039867. PMID 17940193.
  12. ↑ Doty, P; Hebert D; Mathy FX; Byrnes W; Zackheim J; Simontacchi K (2013). "Development of lacosamide for the treatment of partial-onset seizures". Ann N Y Acad Sci 1291: 56–68. doi:10.1111/nyas.12213. PMC 3759704. PMID 23859801.
  13. ↑ "SCHWARZ PHARMA Highlights the Results of 13 Lacosamide Data Presentations at North American Regional Epilepsy Congress in San Diego". Schwarz Pharma. 5 December 1996. Retrieved 2 April 2014.
  14. ↑ Errington AC, Coyne L, Stöhr T, Selve N, Lees G (June 2006). "Seeking a mechanism of action for the novel anticonvulsant lacosamide". Neuropharmacology 50 (8): 1016–29. doi:10.1016/j.neuropharm.2006.02.002. PMID 16620882.
  15. 1 2 3 Beyreuther, BK; Freitag, J; Heers, C; Krebsfänger, N; Scharfenecker, U; Stöhr, T (Spring 2007). "Lacosamide: a review of preclinical properties.". CNS Drug Reviews 13 (1): 21–42. doi:10.1111/j.1527-3458.2007.00001.x. PMID 17461888.
  16. ↑ Errington, AC; Coyne, L; Stöhr, T; Selve, N; Lees, G (Jun 2006). "Seeking a mechanism of action for the novel anticonvulsant lacosamide.". Neuropharmacology 50 (8): 1016–29. doi:10.1016/j.neuropharm.2006.02.002. PMID 16620882.
  17. ↑ Hovinga, CA (2003). "SPM-927 (Schwarz Pharma)". IDrugs 6 (5): 479–85. PMID 12789603. Retrieved 2 April 2014.
  18. ↑ Italiano, D; Perucca E (2013). "Clinical pharmacokinetics of new-generation antiepileptic drugs at the extremes of age: an update". Clin Pharmacokinet 52 (8): 627–45. doi:10.1007/s40262-013-0067-4. PMID 23640503. Retrieved 2 April 2014.
  19. ↑ "Lacosamide". DrugBank. Retrieved 2 April 2014.
  20. ↑ Abou-Khalil, BW (2009). "Lacosamide: what can be expected from the next new antiepileptic drug?". Epilepsy Curr 9 (5): 133–4. doi:10.1111/j.1535-7511.2009.01317.x. PMC 2759042. PMID 19826503. Retrieved 2 April 2014.
  21. ↑ Bialer, M; Johannessen SI; Kupferberg HJ; Levy RH; Perucca E; Tomson T (2004). "Progress report on new antiepileptic drugs: a summary of the Seventh Eilat Conference (EILAT VII)". Epilepsy Res 61 (1-3): 1–48. doi:10.1016/j.eplepsyres.2004.07.010. PMID 15570674.
  22. 1 2 3 "Therapeutic Class Review" (PDF). RegenceRx. Retrieved 2 April 2014.
  23. ↑ "Method for identifying CRMP modulators". Retrieved 2 April 2014.
  24. ↑ Stoht, T; Kupferberg HJ; Stables JP; Choi D; Kohn H; Walton N; White HS (2007). "Lacosamide, a novel anti-convulsant drug, shows efficacy with a wide safety margin in rodent models for epilepsy". Epilepsy Res 74 (2-3): 147–54. doi:10.1016/j.eplepsyres.2007.03.004. PMID 17433624. Retrieved 2 April 2014.
  25. 1 2 3 "Highlights of Prescribing Information" (PDF). Vimpat. Retrieved 2 April 2014.
  26. 1 2 Beyreuther, BK; Freitag J; Heers C; Krebsfanger N; Scharfenecker U; Stohr T (2007). "Lacosamide: a review of preclinical properties". CNS Drug Rev 13 (1): 21–42. doi:10.1111/j.1527-3458.2007.00001.x. PMID 17461888. Retrieved 2 April 2014.
  27. ↑ Borowicz, KK; Gaisor M; Kleinrok Z; Czuczwar SJ (1997). "Influence of isradipine, niguldipine and dantrolene on the anticonvulsive action of conventional antiepileptics in mice". Eur J Pharmacol 323 (1): 45–51. doi:10.1016/s0014-2999(97)00020-4. PMID 9105875. Retrieved 2 April 2014.
  28. ↑ Swinyard, EA; Brown WC; Godman LS (1952). "Comparative assays of antiepileptic drugs in mice and rats". J Pharmacol Exp Ther 106 (3): 319–20. PMID 13000628.
  29. ↑ "SCHWARZ PHARMA Highlights the Results of 13 Lacosamide Data Presentations at North American Regional Epilepsy Congress in San Diego". Schwarz Pharma. 5 December 2006. Retrieved 2 April 2014.
  30. ↑ LeTiran, A; Stables, JP; Kohn, H (Oct 2001). "Functionalized amino acid anticonvulsants: synthesis and pharmacological evaluation of conformationally restricted analogues.". Bioorganic & Medicinal Chemistry 9 (10): 2693–708. doi:10.1016/s0968-0896(01)00204-8. PMID 11557357.
  31. 1 2 Doty, P; Hebert, D; Mathy, FX; Byrnes, W; Zackheim, J; Simontacchi, K (Jul 2013). "Development of lacosamide for the treatment of partial-onset seizures.". Annals of the New York Academy of Sciences 1291: 56–68. doi:10.1111/nyas.12213. PMC 3759704. PMID 23859801.
  32. ↑ Ben-Menachem E, Biton V, Jatuzis D, Abou-Khalil B, Doty P, Rudd GD (2007). "Efficacy and safety of oral lacosamide as adjunctive therapy in adults with partial-onset seizures". Epilepsia 48 (7): 1308–17. doi:10.1111/j.1528-1167.2007.01188.x. PMID 17635557.
  33. ↑ Rauck RL, Shaibani A, Biton V, Simpson J, Koch B (2007). "Lacosamide in painful diabetic peripheral neuropathy: a phase 2 double-blind placebo-controlled study". Clin J Pain 23 (2): 150–8. doi:10.1097/01.ajp.0000210957.39621.b2. PMID 17237664.
  34. ↑ "SCHWARZ PHARMA Highlights the Results of 13 Lacosamide Data Presentations at North American Regional Epilepsy Congress in San Diego". Schwarz Pharma. Retrieved 2 April 2014.
  35. ↑ "Antiepileptic drugs". Retrieved 2 April 2014.
  36. ↑ Cross SA, Curran MP.. Drugs 2009;69(4):449-459. doi:10.2165/00003495-200969040-00005.
  37. ↑ Vimpat Side Effects Center http://www.rxlist.com/vimpat-side-effects-drug-center.html
  38. ↑ Lee, SH; Kang, JW; Lin, T; Lee, JE; Jin, DI (2013). "Teratogenic potential of antiepileptic drugs in the zebrafish model.". BioMed research international 2013: 726478. doi:10.1155/2013/726478. PMC 3845484. PMID 24324971.
  39. ↑ "Lacosamide Pregnancy and Breastfeeding Warnings". Drugs.com. Retrieved 2 April 2014.
  40. ↑ "Lacosamide". ChemSpider. Retrieved 2 April 2014.
  41. ↑ Biton, V; Rosenfeld, WE; Whitesides, J; Fountain, NB; Vaiciene, N; Rudd, GD (Mar 2008). "Intravenous lacosamide as replacement for oral lacosamide in patients with partial-onset seizures.". Epilepsia 49 (3): 418–24. doi:10.1111/j.1528-1167.2007.01317.x. PMID 17888078.
  42. ↑ "Lacosamide". Retrieved 2 April 2014.
  43. ↑ Kellinghaus, C (2009). "Lacosamide as treatment for partial epilepsy: mechanisms of action, pharmacology, effects, and safety.". Therapeutics and clinical risk management 5: 757–66. doi:10.2147/tcrm.s5189. PMC 2754090. PMID 19816574.
  44. ↑ Choi, D; Stables, JP; Kohn, H (Apr 26, 1996). "Synthesis and anticonvulsant activities of N-Benzyl-2-acetamidopropionamide derivatives.". Journal of Medicinal Chemistry 39 (9): 1907–16. doi:10.1021/jm9508705. PMID 8627614.
  45. ↑ Morieux, P; Stables, JP; Kohn, H (Oct 1, 2008). "Synthesis and anticonvulsant activities of N-benzyl-(2R)-2-acetamido-3-oxysubstituted propionamide derivatives.". Bioorganic & Medicinal Chemistry 16 (19): 8968–75. doi:10.1016/j.bmc.2008.08.055. PMC 2701728. PMID 18789868.
  46. ↑ McIntyre, J.A.; Castaner, J. "2004". Drugs Future 29 (992).
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