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Pharmacology of Cenobamate: Mechanism of Action, Pharmacokinetics, Drug–Drug Interactions and Tolerability

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Abstract

Cenobamate is one of the latest antiseizure medications (ASMs) developed for the treatment of focal onset seizures in adult patients. The recommended starting dose is 12.5 mg/day, titrated gradually to the target daily dose of 200 mg, which may be increased to a maximum of 400 mg/day based on clinical response. Although the high rate of seizure freedom observed in randomized, placebo-controlled clinical trials has resulted in exciting expectations, further clinical studies are needed to better define its clinical profile. Cenobamate is characterized by a peculiar pharmacology regarding both pharmacodynamics and pharmacokinetics. The mechanism of action has only partly been described, with the drug acting on voltage-gated sodium channels through a pronounced action on persistent rather than transient currents. Cenobamate also acts as a positive allosteric modulator of GABAA receptors independently from the benzodiazepine binding site. The bioavailability of cenobamate is not influenced by other drugs, except phenytoin; it can inhibit cytochrome P450 (CYP) 2C19 and induce CYP3A4 and 2B6, and hence can potentially interact with many drugs (e.g. dose adjustments may be required for lamotrigine, carbamazepine and clobazam). The pharmacokinetics of cenobamate are not linear and dosage increases imply a disproportional increase in plasma levels, particularly at doses higher than 300 mg. The most common and dose-related adverse effects associated with cenobamate include central nervous system-related symptoms, mainly somnolence, dizziness, diplopia, and disturbances in gait and coordination. A somewhat higher incidence of adverse events has been observed in patients concomitantly treated with sodium channel blockers. The most relevant safety issues are currently represented by the risk of severe skin reactions (apparently avoidable by a slow titration) and QT shortening (the drug is contraindicated in patients with familial short QT syndrome or taking QT-shortening drugs). Overall, cenobamate is a promising ASM with an intriguing and not fully understood mechanism of action; pharmacokinetic issues need to be considered in clinical practice.

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Acknowledgements

The Italian Medicine Agency (AIFA) and Regione Calabria are kindly acknowledged for their financial support of the pharmacovigilance project AIFA 2012-2014 entitled “Studio regionale di farmacovigilanza attiva per valutazione di sicurezza, appropriatezza prescrittiva, efficacia ed aderenza alla terapia con i nuovi antiepilettici”. These funders had no active role in the data collection and analysis, decision to publish or preparation of this manuscript.

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Authors and Affiliations

  1. Science of Health Department, University Magna Grecia of Catanzaro, Via T. Campanella, 115, 88100, Catanzaro, Italy

    Roberta Roberti, Carmen De Caro, Luigi Francesco Iannone & Emilio Russo

  2. Regional Health Agency of Tuscany, Florence, Italy

    Gaetano Zaccara

  3. Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy

    Simona Lattanzi

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  1. Roberta Roberti
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  2. Carmen De Caro
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Correspondence to Emilio Russo.

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This manuscript was not funded.

Conflict of interest

Emilio Russo has received speaker fees or funding from, and has participated in advisory boards for, Arvelle Therapeutics, Eisai, Pfizer, GW Pharmaceuticals, UCB and Lundbeck. Gaetano Zaccara has received speaker’s or consultancy fees from Eisai, UCB Pharma and Jazz Pharmaceuticals, and has served on the advisory board for GW Pharmaceuticals. Simona Lattanzi has received speaker’s or consultancy fees from Eisai, UCB Pharma, and GW Pharmaceuticals, and has served on advisory boards for GW Pharmaceuticals and Arvelle Therapeutics. Roberta Roberti, Carmen De Caro, Luigi F. Iannone have no conflicts of interest to declare.

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All authors participated equally in the conceptualization of the manuscript and in the writing up of the manuscript, from the initial draft to the final version. All authors have read and approved the final version.

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Roberti, R., De Caro, C., Iannone, L.F. et al. Pharmacology of Cenobamate: Mechanism of Action, Pharmacokinetics, Drug–Drug Interactions and Tolerability. CNS Drugs 35, 609–618 (2021). https://doi.org/10.1007/s40263-021-00819-8

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