Gabapentinoids, also known as α2δ ligands, are a class of drugs that are chemically derivatives of the inhibitory neurotransmitter gamma-Aminobutyric acid (GABA) (i.e., GABA analogues) which bind selectively to the α2δ protein that was first described as an auxiliary subunit of voltage-gated calcium channels (VGCCs). Clinically used gabapentinoids include gabapentin, pregabalin, baclofen and mirogabalin, as well as a gabapentin prodrug, gabapentin enacarbil. Further analogues like imagabalin and atagabalin have been tested in clinical trials but their development has been halted. Other gabapentinoids which are used in scientific research but have not been approved for medical use include 4-methylpregabalin and PD-217,014. Additionally, phenibut and baclofen have been found to act as very low affinity gabapentinoid in addition to their action as GABAB receptor agonist.
Medical uses Gabapentinoids are approved for the treatment of epilepsy, postherpetic neuralgia, neuropathic pain associated with diabetic neuropathy, fibromyalgia, generalized anxiety disorder, and restless legs syndrome. Some off-label uses of gabapentinoids include the treatment of insomnia, migraine, social phobia, panic disorder, mania, bipolar disorder, and alcohol withdrawal. Existing evidence on the use of gabapentinoids in chronic lower back pain is limited, and demonstrates significant risk of adverse effects, without any demonstrated benefit. The main side-effects include: a feeling of sleepiness and tiredness, decreased blood pressure, nausea, vomiting and also glaucomatous visual hallucinations. In a systematic review analysing data from 5 cohort studies having 10,85,488 patients, use of gabapentinoids (pregabalin and gabapentin) was associated with an increased risks of thrombotic events (deep venous thrombosis and pulmonary thrombo-embolism) as early as three months of use, and with increased risk of cardiovascular events on prolonged use of more than a year duration. Heart failure was not increased with the use of gabapentinoids.
Side effects
Pharmacology
Pharmacodynamics Gabapentinoids are high affinity ligands of the α2δ protein that was first described as an auxiliary subunit of certain voltage-gated calcium channels (VGCC). All of the known pharmacological actions of gabapentinoids require binding at this site. There are two drug-binding α2δ subunits, α2δ-1 and α2δ-2, and most gabapentinoids show similar affinity for (and hence lack of selectivity between) these two sites. In most cases, gabapentinoid drugs do not seem to directly alter the action of VGCC and instead reduce the release of certain excitatory neurotransmitters. (However, see). The gabapentinoid drugs do not bind significantly to other known drug receptors and so the α2δ VGCC subunit has been called the gabapentin receptor. Recently, the same α2δ-1 protein has been found closely associated not with VGCCs but with other proteins such as presynaptic NMDA-type glutamate receptors, cell adhesion molecules such as thrombospondin and others. Gabapentinoids alter the function of these additional α2δ binding proteins, and these have been proposed as mediators of drug actions. Despite the fact that gabapentinoids are GABA analogues, gabapentin and pregabalin do not bind to GABA receptors, do not convert into GABATooltip γ-aminobutyric acid or GABA receptor agonists in vivo, and do not modulate GABA transport or metabolism. Conversely, GABA does not bind appreciably to the α2δ protein. Furthermore, gabapentinoids do not act directly as inhibitors or blockers of VGCC. Instead, they reduce the release of excitatory neurotransmitters including glutamate, monoamine neurotransmitters and Substance P. Although not thought to be a major site of action, gabapentinoids such as gabapentin, but not pregabalin, have been found to activate Kv voltage-gated potassium channels (KCNQ). The endogenous α-amino acids L-leucine and L-isoleucine, which resemble the gabapentinoids in chemical structure (see figure) are ligands of the α2δ VDCC subunit with similar affinity as gabapentin and pregabalin (e.g., IC50 = 71 nM for L-isoleucine), and are present in human cerebrospinal fluid at micromolar concentrations (e.g., 12.9 μM for L-leucine, 4.8 μM for L-isoleucine). It has been hypothesized that they may be endogenous ligands of the subunit and that they may competitively antagonize the effects of gabapentinoids in brain tissues. In accordance, while gabapentin and pregabalin have nanomolar binding affinities for the α2δ subunit, their potencies in vivo are in the low micromolar range, and competition for binding by endogenous L-amino acids is likely responsible for this discrepancy. In one study, the affinity (Ki) values of gabapentinoids for the α2δ subunit expressed in rat brain were found to be 0.05 μM for gabapentin, 23 μM for (R)-phenibut, 39 μM for (S)-phenibut, and 156 μM for baclofen. Their affinities (Ki) for the GABAB receptor were >1 mM for gabapentin, 92 μM for (R)-phenibut, >1 mM for (S)-phenibut, 6 μM for Baclofen. Pregabalin has demonstrated significantly greater potency (about 2.5-fold) than gabapentin in clinical studies and mirogabalin is even more potent in vivo.
Pharmacokinetics
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