Utilizing an acute hyperthermia-induced seizure test and pharmacokinetic studies to establish optimal dosing regimens in a mouse model of Dravet syndrome

Abstract Objective The current standard of care for Dravet Syndrome includes polytherapy after inadequate seizure control with one or more monotherapy approaches. Treatment guidelines are often based on expert opinions, and finding an optimal balance between seizure control and adverse drug effects can be challenging. This study utilizes efficacy and pharmacokinetic analysis of a second-line treatment regimen that combines clobazam and sodium valproate with an add-on drug as a proof-of-principle approach to establish an effective therapeutic regimen in a preclinical mouse model of Dravet Syndrome. Method We evaluated the efficacy of add-on therapies stiripentol, cannabidiol, lorcaserin, or fenfluramine to clobazam and sodium valproate against hyperthermia-induced seizures in Scn1a A1783V/WT mice. Clobazam, N-desmethyl clobazam (an active metabolite of clobazam), sodium valproate, stiripentol, and cannabidiol concentrations were quantified in plasma and brain using liquid chromatography-tandem mass spectrometry for the combinations deemed effective against hyperthermia-induced seizures. The concentration data were used to calculate pharmacokinetic parameters via non-compartmental analysis in Phoenix WinNonLin. Results Higher doses of stiripentol or cannabidiol, in combination with clobazam and sodium valproate, were effective against hyperthermia-induced seizures in Scn1a A1783V/WT mice. In Scn1a WT/WT mice, brain clobazam and N-desmethyl clobazam concentrations were higher in the triple-drug combinations than in the clobazam monotherapy. Stiripentol and cannabidiol brain concentrations were greater in the triple-drug therapy than when given alone. Interpretation A polypharmacy strategy may be a practical preclinical approach to identifying efficacious compounds for Dravet Syndrome. The drug-drug interactions between compounds used in this study may explain the potentiated efficacy of some combination therapies. Graphical Abstract Key findings The hyperthermia-induced seizure assay in Scn1a A1783V/WT mice can identify efficacious antiseizure medications. A triple-drug administration paradigm was designed that mimics clinical standards for add-on therapies in DS. Stiripentol and cannabidiol were effective against hyperthermia-induced seizures when co-administered with clobazam and sodium valproate. Potential drug-drug interactions between compounds may explain the potentiated antiseizure effect in triple-drug therapies. The triple-drug “add-on” therapy approach may be a valuable preclinical strategy for screening investigational compounds for DS, an assay offered at the ETSP.