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Jones et al., 'Selective Inhibition of NaV1.8 with VX-548 for Acute Pain' NEJM 08.03.2023

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39
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Los Angeles, California
https://www.nejm.org/doi/full/10.1056/NEJMoa2209870

Summary of findings:
https://www.drugs.com/news/research...0.html?hash2=23ebf82608bc6281f942e7b1cf323e06


Link to NEJM podcast (with transcription) including interview with Yale neurologist Stephen Waxman, who was not involved with the research but wrote a review of it:
https://www.nejm.org/doi/full/10.1056/NEJMp2305759


From the original article:

Background​

The NaV1.8 voltage-gated sodium channel, expressed in peripheral nociceptive neurons, plays a role in transmitting nociceptive signals. The effect of VX-548, an oral, highly selective inhibitor of NaV1.8, on control of acute pain is being studied.

Methods​

After establishing the selectivity of VX-548 for NaV1.8 inhibition in vitro, we conducted two phase 2 trials involving participants with acute pain after abdominoplasty or bunionectomy. In the abdominoplasty trial, participants were randomly assigned in a 1:1:1:1 ratio to receive one of the following over a 48-hour period: a 100-mg oral loading dose of VX-548, followed by a 50-mg maintenance dose every 12 hours (the high-dose group); a 60-mg loading dose of VX-548, followed by a 30-mg maintenance dose every 12 hours (the middle-dose group); hydrocodone bitartrate–acetaminophen (5 mg of hydrocodone bitartrate and 325 mg of acetaminophen every 6 hours); or oral placebo every 6 hours. In the bunionectomy trial, participants were randomly assigned in a 2:2:1:2:2 ratio to receive one of the following over a 48-hour treatment period: oral high-dose VX-548; middle-dose VX-548; low-dose VX-548 (a 20-mg loading dose, followed by a 10-mg maintenance dose every 12 hours); oral hydrocodone bitartrate–acetaminophen (5 mg of hydrocodone bitartrate and 325 mg of acetaminophen every 6 hours); or oral placebo every 6 hours. The primary end point was the time-weighted sum of the pain-intensity difference (SPID) over the 48-hour period (SPID48), a measure derived from the score on the Numeric Pain Rating Scale (range, 0 to 10; higher scores indicate greater pain) at 19 time points after the first dose of VX-548 or placebo. The main analysis compared each dose of VX-548 with placebo.


Results​

A total of 303 participants were enrolled in the abdominoplasty trial and 274 in the bunionectomy trial. The least-squares mean difference between the high-dose VX-548 and placebo groups in the time-weighted SPID48 was 37.8 (95% confidence interval [CI], 9.2 to 66.4) after abdominoplasty and 36.8 (95% CI, 4.6 to 69.0) after bunionectomy. In both trials, participants who received lower doses of VX-548 had results similar to those with placebo. Headache and constipation were common adverse events with VX-548.


Conclusions​

As compared with placebo, VX-548 at the highest dose, but not at lower doses, reduced acute pain over a period of 48 hours after abdominoplasty or bunionectomy. VX-548 was associated with adverse events that were mild to moderate in severity. (Funded by Vertex Pharmaceuticals; VX21-548-101 and VX21-548-102 ClinicalTrials.gov numbers, NCT04977336. opens in new tab and NCT05034952. opens in new tab.)
 
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datadragon

Senior Member
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401
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USA
Nav1.8 produces the majority, 70%, of the sodium current that produces nerve impulses in pain-signaling neurons. VX-548, an oral, highly selective inhibitor of Sodium Channel NaV1.8...Overall, only the highest dose of the drug proved better than placebo pills, reducing patients' pain intensity scores to a greater degree over two days. Last posted we had using gene therapy to regulate Sodium Channel NaV1.7. https://theprint.in/science/study-r...-chronic-pain-by-dialing-down-sodium/1690791/ https://www.nyu.edu/about/news-publ...ats-chronic-pain-by-dialing-down-sodium-.html

PAIN;
Sodium channel subtypes have been linked to human pain syndromes through genetic studies. Gain of function mutations in Nav1.7, 1.8 and 1.9 can cause pain, while loss of function Nav1.7 mutations lead to loss of pain in otherwise normal people. https://pubmed.ncbi.nlm.nih.gov/26941184/

SCN9A The human SCN9A gene encodes the pore-forming subunit of Nav1.7, a voltage-gated sodium channel. The SCN9A gene provides instructions for making one part (the alpha subunit) of a sodium channel called NaV1.7. NaV1.7 sodium channels are found in nerve cells called nociceptors that transmit pain signals. Nociceptors are part of the peripheral nervous system, which connects the brain and spinal cord to cells that detect sensations such as touch, smell, and pain. Nociceptors are primarily involved in transmitting pain signals. The centers of nociceptors, known as the cell bodies, are located in a part of the spinal cord called the dorsal root ganglion. Fibers called axons extend from the cell bodies, reaching throughout the body to receive sensory information. Axons transmit the information back to the dorsal root ganglion, which then sends it to the brain. NaV1.7 sodium channels are also found in olfactory sensory neurons, which are nerve cells in the nasal cavity that transmit smell-related signals to the brain.
Mutations in SCN9A channels have been linked to several inherited diseases including erythromelalgia (vasodilation with burning pain), paroxysmal extreme pain disorder, and congenital indifference to pain). Nav1.7, upregulated in prostatic cancer and inflammation, is a cancer biomarker and a therapeutic target in treatment of pain. loss-of-function mutations are linked to complete insensitivity to pain that may be accompanied by anosmia. Other gain-of-function variants in NaV1.7 are risk factors for painful small-fibre neuropathy. https://www.nature.com/articles/nrn3404/

TRPV1 channels and the progesterone receptor Sig-1R interact to regulate pain. Here we show that TRPV1 physically interacts with the Sigma 1 Receptor (Sig-1R), a chaperone that binds progesterone, an antagonist of Sig-1R and an important neurosteroid associated to the modulation of pain. Antagonism of Sig-1R by progesterone results in the down-regulation of TRPV1 expression in the plasma membrane of sensory neurons and, consequently, a decrease in capsaicin-induced nociceptive responses. This is observed both in males treated with a synthetic antagonist of Sig-1R and in pregnant females where progesterone levels are elevated. https://www.pnas.org/doi/10.1073/pnas.1715972115

Functional and biochemical interaction between PPARα receptors and TRPV1 channels: Potential role in PPARα agonists-mediated analgesia. Collectively, these results provide evidence for a PPARα-mediated pathway triggering TRPV1 channel activation and desensitization, and highlight a novel mechanism which might contribute to the analgesic effects shown by PPARα agonists in vivo. https://pubmed.ncbi.nlm.nih.gov/25014183/ administration of PPAR ligands reduces inflammatory pain and neuropathic pain. https://pubmed.ncbi.nlm.nih.gov/19607969/

Palmitoylethanolamide which activates PPAR-a was used successfully for chronic and neuropathic pain and inflammation, as demonstrated in clinical trials (and further may have benefits with ME/CFS). These include peripheral neuropathies such as diabetic neuropathy, chemotherapy-induced peripheral neuropathy, carpal tunnel syndrome, sciatic pain, osteoarthritis, low-back pain, failed back surgery syndrome, dental pains, neuropathic pain in stroke and multiple sclerosis, chronic pelvic pain, postherpetic neuralgia, and vaginal pains. https://pubmed.ncbi.nlm.nih.gov/23166447/

Life extension mentioned it also as safer pain alternative https://www.lifeextension.com/magazine/2019/3/turn-off-the-pain-signal https://www.lifeextension.com/magazine/2022/9/turn-off-pain-signals

CB1-cannabinoid-, TRPV1-vanilloid- and NMDA-glutamatergic-receptor-signalling systems interact in the prelimbic cerebral cortex to control neuropathic pain symptoms https://www.sciencedirect.com/science/article/abs/pii/S0361923020306353 Targeting the Glutamate NMDA receptor subunit NR2B for the treatment of neuropathic pain https://pubmed.ncbi.nlm.nih.gov/19789073/

Mutations in these genes, such as SCN9A, SHANK3, and CNTNAP2, lead to altered neuronal function that produce different responses to pain, shown in both mouse and human models. https://pubmed.ncbi.nlm.nih.gov/33987518/

SHANK3 Deficiency Impairs Heat Hyperalgesia and TRPV1 Signaling in Primary Sensory Neurons. Homozygous and heterozygous Shank3 complete knockout results in impaired heat hyperalgesia in inflammatory and neuropathic pain. TRPV1 modulates glutamate release from nociceptor afferents in the spinal cord, and the authors found that loss of SHANK3 impaired this function. loss of SHANK3 impairs TRPV1 signalling in human neurons. Biochemical experiments showed that SHANK3 and TRPV1 can physically interact and that SHANK3 regulates the surface expression and trafficking of TRPV1 in cell culture. Further analysis showed that the proline-rich domain of SHANK3 is responsible for mediating these interactions and regulating TRPV1 function. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5182147/

Since SHANK3 is concentrated in glutamatergic synapses, it interacts with all prominent glutamate receptors, such as NMDA, AMPA, and mGlu receptors. SHANK3 also indirectly interacts with Neuroligins (NLGN), a family of post-synaptic adhesion molecules. Most of these interactions are indirect and mediated by post-synaptic proteins such as GKAP, Homer PSD95 etc. InsG3680 Shank3 mutant mice show disruptions of glutamatergic signaling as compared to WT controls. https://www.nature.com/articles/s41398-021-01612-3

Specific deletion of Shank3 in Sodium Nav1.8-expressing sensory neurons also impairs heat hyperalgesia in homozygous and heterozygous mice. Human genetics strongly suggests that SCN9A, the human gene encoding sodium channel subunit Nav1.7, critically regulates pain sensitivity Interestingly, transient sodium currents, as well as Nav1.7-mediated sodium currents (isolated by Protoxin-II) were normal in Shank3-deficient DRG neurons compared with WT neurons. Neither did we find changes in neuronal excitability in Shank3−/− mice: Shank3-deficient neurons and WT neurons fired action potentials at the same rate. Thus, sodium channels such as Nav1.7 may not contribute to pain defects in Shank3−/− mice.
https://www.nature.com/articles/nrn.2016.179

TNFalpha may have a significant impact on nociceptive signaling at the spinal cord level that could be mediated by increased responsiveness of presynaptic TRPV1 receptors to endogenous agonists. https://pubmed.ncbi.nlm.nih.gov/20796308/ and https://pubmed.ncbi.nlm.nih.gov/22189061/

Shank3 levels are also lowered via zinc deficiency that regulates Shank levels as well as NLRP3 over activation as being discussed in relation to ME/CFS. https://forums.phoenixrising.me/thr...s-chronic-fatigue-syndrome.90582/post-2442240
 
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