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A cure for wind up: NMDA receptor antagonists as potential analgesics

Effective treatment for many pain disorders is still lacking, which is due to the complexity of pain in general and of the underlying pathology of many pain syndromes in particular. This results in the majority of investigational analgesic drugs failing to reach registration, either due to lack of efficacy, or due to the drug's adverse effect profile. To increase the number of analgesics that reach the patient, it is essential to carefully and rationally plan the clinical development program. By including proof-of-mechanism (PoM) and/or proof-of-concept (PoC) methods in early-phase clinical drug studies, the analgesic drug developer will be better informed regarding the key characteristics of the studied drug, which will aid in making crucial decisions during the development process. Here, we describe the top 10 currently most developed analgesic drug classes, link them mechanistically to appropriate methods to demonstrate PoM and PoC in early-phase clinical trials, and include pros and cons of each of the methods described. Lastly, we discuss how each analgesic drug class requires a tailored experimental approach for proper evaluation of PoM and PoC, and how this can contribute to an efficient and question-based approach in early-phase analgesic drug research.

Sensory information stimulates receptors of somatosensory system neurons generating a signal that codifies the characteristics of peripheral stimulation. This information reaches the spinal cord and is relayed to supra-spinal structures through two main systems: the postsynaptic dorsal column-medial lemniscal (DC-ML) and the anterolateral (AL) systems. From the classical point of view, the DC-ML has an ipsilateral ascending pathway to the Gracilis (GRA) or Cuneate (CUN) nuclei and the AL has a contralateral ascending pathway to the ventral posterolateral (VPL) thalamic nucleus. These two systems have been the subject of multiple studies that established their independence and interactions. To analyze the ascending projections of L1–L5 spinal dorsal horn neurons in the rat, two retrograde neuronal tracers were injected into the GRA and the VPL. Additionally, an electrophysiological study was performed by applying electrical stimulation at the GRA or VPL and recording antidromic evoked activity in single unit spinal cord cells. Importantly, a subset of spinal dorsal horn neurons exhibited double staining, indicating that these neurons projected to both the GRA and the VPL. These double-stained neurons were located on both sides of the dorsal horn of the spinal cord. The spinal dorsal horn neurons exhibited antidromic and collision activities in response to both GRA and VPL electrical activation. These results show spinal cord neurons with bifurcated bilateral projections to both the DC-ML and AL systems. Based on these results, we named these neurons bilateral and bifurcated cells.

Upon systemic administration in rats, the prodrug L-4-chlorokynurenine (4-Cl-KYN; AV-101; VistaGen Therapeutics, Inc, South San Francisco, CA) is rapidly absorbed, actively transported across the blood-brain barrier, and converted in astrocytes to 7-chlorokynurenic acid (7-Cl-KYNA), a potent and specific antagonist of the glycine B coagonist site of the N-methyl-D-aspartate (NMDA) receptor. We examined the effects of 4-Cl-KYN in several rat models of hyperalgesia and allodynia and determined the concentrations of 4-Cl-KYN and newly produced 7-Cl-KYNA in serum, brain, and spinal cord. Adult male rats were given 4-Cl-KYN (56, 167, 500 mg/kg), the NMDA receptor antagonist MK-801 (.1, .3, 1.0 mg/kg), or gabapentin (33, 100, 300 mg/kg) intraperitoneally, and were then examined on rotarod, intraplantar formalin-evoked flinching, thermal escape in the normal and carrageenan-inflamed paw, and allodynia after sciatic nerve ligation. Our conclusions show that after systemic delivery, the highest 2 doses (167 and 500 mg/kg) of 4-Cl-KYN yielded brain concentrations of 7-Cl-KYNA exceeding its half maximal inhibitory concentration (IC₅₀) at the glycine B site and resulted in dose-dependent antihyperalgesia in the 4 models of facilitated processing associated with tissue inflammation and nerve injury. On the basis of the relative dose requirements for analgesic actions and side effect profiles from these experiments, 4-Cl-KYN is predicted to have antihyperalgesic efficacy and a therapeutic ratio equal to gabapentin and superior to MK-801.

These studies show that systemic administration of the prodrug 4-Cl-KYN produces high central nervous system levels of 7-Cl-KYNA, a potent and highly selective antagonist of the NMDA receptor. Compared with other drugs tested, 4-Cl-KYN has robust antinociceptive effects with a better side effect profile, highlighting its potential for treating hyperpathic pain states.

We used in vivo electrophysiology and a model of more persistent nociceptive inputs to monitor spinal cord neuronal activity in anaesthetised rats to reveal the pharmacology of enhanced pain signalling. The study showed that all responses were blocked by non-selective antagonism of glutamate receptors but a selective and preferential role of the N-methyl-d-aspartate (NMDA) receptor in the prolonged plastic responses was clearly seen. The work lead to many publications, initially preclinical but increasingly from patient studies, showing the importance of the NMDA receptor in central sensitisation within the spinal cord and how this could relate to persistent pain states.

This article is part of a Special Issue entitled SI:50th Anniversary Issue.

Glutamate transports (GTs), the only vehicle for removal of glutamate from the extracellular fluid, is reported to be related to chronic pain. To investigate whether the glutamate/aspartate transporter (GLAST) and glutamate transporter-1 (GLT-1) participate in electroacupuncture (EA) analgesia, the EA effect was observed with paw withdraw threshold in a rat model of spared nerve injury. The expression levels of GLAST and GLT-1 were determined with Western Blot and RT-PCR. The results showed significantly upregulated GLAST and GLT-1, along with the relieved pain behaviors after EA treatment. In addition, intrathecal injection of GTs inhibitor, l-trans-pyrrolidine-2-4-dicarboxylate, attenuated the EA-induced analgesic effect. The experiment demonstrates that EA can increase the GTs of neuropathic pain rats, which might be one of the mechanisms underlying its effectiveness in the neuropathic pain.

Maladaptive plasticity within the dorsal horn (DH) of the spinal cord is a key substrate for development of neuropathic pain following peripheral nerve injury. Advances in genetic engineering, tracing techniques and opto-genetics are leading to a much better understanding of the complex circuitry of the spinal DH and the radical changes evoked in such circuitry by nerve injury. These changes can be viewed at multiple levels including: synaptic remodeling including enhanced excitatory and reduced inhibitory drive, morphological and electrophysiological changes which are observed both to primary afferent inputs as well as DH neurons, and ultimately circuit-level rewiring which leads to altered connectivity and aberrant processing of sensory inputs in the DH. The DH should not be seen in isolation but is subject to important descending modulation from the brainstem, which is further dysregulated by nerve injury. Understanding which changes relate to specific disease-states is essential, and recent work has aimed to stratify patient populations in a mechanistic fashion. In this review we will discuss how such pathophysiological mechanisms may lead to the distressing sensory phenomena experienced by patients suffering neuropathic pain, and the relationship of such mechanisms to current and potential future treatment modalities.