A Doença de Alzheimer (DA) é uma doença cerebral progressiva que resulta em prejuízos na memória e disfunção cognitiva global. Entre as principais características neuropatológicas associadas a DA estão à presença de placas senis, emaranhados neurofibrilares e a hiperfosforilação da proteína Tau. A hiperativação do sistema glutamatérgico tem sido implicada na fisiopatologia da DA. O excesso de glutamato na fenda sináptica causa hiperativação do seu receptor ionótropico N-metill-D-aspartato (NMDA) o que favorece o aumento do influxo de cálcio e morte neuronal. A administração intracerebral de ácido ocadáico (AO) causa alterações morfológicas e funcionais similares à DA. O AO promove a inibição da proteína fosfatase 2A (PP2A) favorecendo as atividades cinásicas de proteínas como a cinase dependente de ciclina 5 (Cdk5). A memantina (MN) é uma das principais drogas utilizadas no tratamento da DA e o seu mecanismo de ação envolve um antagonismo não competitivo de baixa afinidade pela subunidade NR2B do receptor NMDA. Neste trabalho, foram avaliados efeitos do pré-tratamento com MN em um modelo semelhante a DA induzido pela administração intrahipocampal de AO em ratos. O pré-tratamento com MN preveniu o déficit na memória especial causado pela infusão intrahipocampal de AO. Os mecanismos envolvidos nestes efeitos neuroprotetores envolvem a prevenção do aumento de glutamato no liquido cefalorraquidiano, juntamente com a regulação da expressão de Cdk5 e em conseqüência a prevenção do aumento da fosforilação de Tau. Desta maneira, a MN pode ser um alvo terapêutico para prevenir as alterações comportamentais e neuroquímicas em um modelo similar a DA induzido pelo AO. / Alzheimer's disease (AD) is a progressive brain disease that causes memory loss and global cognitive dysfunction. The neuropathological alterations associated with AD include senile plaques, neurofibrillary tangles and Tau protein hyperphosphorylation. The glutamatergic system is implicated in the pathophysiology of AD. Indeed, the excessive glutamate levels in the synaptic cleft may cause hyperactivation of glutamate ionotropic N-metill-Daspartate (NMDA), which favors increase calcium influx and neuronal death. The intracerebral administration of okadaic acid (OA) causes morphological and functional alterations similar to AD. The OA inhibits the protein phosphatase 2A (PP2A) thus overstimulating the kinases activities. Memantine (MN) is a drug currently used in the treatment of AD, which mechanism involves a noncompetitive low affinity antagonism for NR2B subunit of NMDA receptors. In this work we evaluate the effects of pretreatment with MN in an AD-like model in rats induced by intrahippocampal administration of OA. The pretreatment with MN could prevent the spatial memory deficits caused by OA intrahipocampal administration in rats. The mechanisms underlying this neuroprotective effects involves the prevention of the increase in brain glutamate levels along with regulation of Cdk5 and, in consequence, downstream phosphorylation of Tau (ser199/202) protein. To conclude, MN has potential therapeutic role in preventing behavioral and neurochemical alterations caused by an AD like model induced by OA.

A Doença de Alzheimer (DA) é uma doença cerebral progressiva que resulta em prejuízos na memória e disfunção cognitiva global. Entre as principais características neuropatológicas associadas a DA estão à presença de placas senis, emaranhados neurofibrilares e a hiperfosforilação da proteína Tau. A hiperativação do sistema glutamatérgico tem sido implicada na fisiopatologia da DA. O excesso de glutamato na fenda sináptica causa hiperativação do seu receptor ionótropico N-metill-D-aspartato (NMDA) o que favorece o aumento do influxo de cálcio e morte neuronal. A administração intracerebral de ácido ocadáico (AO) causa alterações morfológicas e funcionais similares à DA. O AO promove a inibição da proteína fosfatase 2A (PP2A) favorecendo as atividades cinásicas de proteínas como a cinase dependente de ciclina 5 (Cdk5). A memantina (MN) é uma das principais drogas utilizadas no tratamento da DA e o seu mecanismo de ação envolve um antagonismo não competitivo de baixa afinidade pela subunidade NR2B do receptor NMDA. Neste trabalho, foram avaliados efeitos do pré-tratamento com MN em um modelo semelhante a DA induzido pela administração intrahipocampal de AO em ratos. O pré-tratamento com MN preveniu o déficit na memória especial causado pela infusão intrahipocampal de AO. Os mecanismos envolvidos nestes efeitos neuroprotetores envolvem a prevenção do aumento de glutamato no liquido cefalorraquidiano, juntamente com a regulação da expressão de Cdk5 e em conseqüência a prevenção do aumento da fosforilação de Tau. Desta maneira, a MN pode ser um alvo terapêutico para prevenir as alterações comportamentais e neuroquímicas em um modelo similar a DA induzido pelo AO. / Alzheimer's disease (AD) is a progressive brain disease that causes memory loss and global cognitive dysfunction. The neuropathological alterations associated with AD include senile plaques, neurofibrillary tangles and Tau protein hyperphosphorylation. The glutamatergic system is implicated in the pathophysiology of AD. Indeed, the excessive glutamate levels in the synaptic cleft may cause hyperactivation of glutamate ionotropic N-metill-Daspartate (NMDA), which favors increase calcium influx and neuronal death. The intracerebral administration of okadaic acid (OA) causes morphological and functional alterations similar to AD. The OA inhibits the protein phosphatase 2A (PP2A) thus overstimulating the kinases activities. Memantine (MN) is a drug currently used in the treatment of AD, which mechanism involves a noncompetitive low affinity antagonism for NR2B subunit of NMDA receptors. In this work we evaluate the effects of pretreatment with MN in an AD-like model in rats induced by intrahippocampal administration of OA. The pretreatment with MN could prevent the spatial memory deficits caused by OA intrahipocampal administration in rats. The mechanisms underlying this neuroprotective effects involves the prevention of the increase in brain glutamate levels along with regulation of Cdk5 and, in consequence, downstream phosphorylation of Tau (ser199/202) protein. To conclude, MN has potential therapeutic role in preventing behavioral and neurochemical alterations caused by an AD like model induced by OA.

No description available.

Abstract Ischaemic cerebral injury follows a well attested sequence of events including three phases, i.e. depolarization, biochemical cascade and reperfusion injury. Glutamate excitotoxicity plays an important role in the development of ischaemic brain injury following prolonged hypothermic circulatory arrest (HCA), and leukocyte infiltration and a cytokine-mediated inflammatory reaction are known to play a pivotal role in the reperfusion phase. The aim of this series of experimental studies was to develop biochemical and reperfusion-related strategies to improve brain protection. We tested the hypotheses that the Na+ channel blocker lamotrigine (I) or the N-Methyl-D-Aspartate-receptor antagonist memantine (III) could improve the cerebral outcome after HCA and studied whether a leukocyte-depletion filter (L-DF; LeukoGuard LG6®, Pall Biomedical, Portsmouth, U.K) could mitigate brain injury (II). The aim of the fourth study was to find out whether lamotrigine combined with the leukocyte-depleting filter can potentiate cerebral protection (IV). A chronic porcine model was used, in which haemodynamic, electrophysiological, metabolic and temperature monitoring were performed for four hours after the instigation of rewarming and S-100β measured up to 20 hours. Cytokines were measured, microdialysis was performed, and daily behavioural assessments were made until death or elective sacrifice on the seventh postoperative day, upon which a histopathological analysis of the brain was carried out. The rate of EEG burst recovery was higher in the lamotrigine-treated animals, the median being 40% of the baseline compared with 17% in the placebo group at 4 hours after the start of rewarming (p = 0.02) and 80% compared with 20% at 4 hours (p = 0.01). Complete behavioural recovery was seen in 5/8 of cases (63%) after lamotrigine administration, compared with 1/8 (13%) in the placebo group (p = 0.02). The median behavioural score among the animals that survived for 7 days was higher in the lamotrigine group (8) than in the controls (7) (p = 0.02). Mortality was 2/10 in the L-DF group and 5/10 in the controls, the median behavioural score on day 7 being higher in the L-DF group (8.5 vs. 3.5 p = 0.04). The median of the total histopathological score was 6.5 in the L-DF group and 15.5 in the control group (p = 0.005). In the memantine group 5/10 animals survived seven days, as compared with 9/10 in the placebo group, and the median behavioural score on day 7 was 3.5 compared with 7.5 in the placebo group (p = 0.39). The median of the total histopathological score was 16 in the memantine group and 14 in the placebo group (p = 0.25). In the LD-F + lamotrigine group 7/8 animals survived for seven days, as compared with 4/8 in the lamotrigine only group and 3/8 among the controls. EEG burst recovery 7 hours after the start of rewarming was highest in the LDF + lamotrigine group, the median being 94% (p = 0.024 vs. controls), compared with 81% in the lamotrigine group and 64% in the control group. The median behavioural score on day 7 was 9 in the LD-F + lamotrigine group (p = 0.004 vs. controls), 4 in the lamotrigine group and 0 in the control group, while the median of total histopathological score was 14 (p = 0.046 vs controls), 14.5 (p = 0.062 vs. controls) and 21, respectively. The control group had the highest intracerebral lactate, glutamate and glycerol levels after HCA. In conclusion, the results indicate that the NA+ channel blocker lamotrigine improves the neurological outcome after a prolonged period of HCA but that the NMDA receptor antagonist memantine does not have this property in the present setting. The leukocyte-depleting filter mitigates brain injury after a prolonged period of HCA, and lamotrigine can potentiate this effect.

Rezente Studien zur Versorgung von Patienten mit Antidementiva deuten auf deutliche Defizite hin. Ziel der vorliegenden Untersuchung war die Erfassung der leitliniengerechten bzw. zulassungsübergreifenden Versorgung mit Acetylcholinesterase-Hemmern (AChEI) und Memantine bei hausärztlich betreuten Alzheimer- bzw. Demenzpatienten. Des Weiteren sollten Determinanten auf ihre Assoziation mit einer Einnahme/Verschreibung von Antidementiva identifiziert werden. Die vorliegende Untersuchung basiert auf Daten, welche im Rahmen der prospektiven longitudinalen AgeCoDe-Studie (German Study on Aging, Cognition and Dementia in Primary Care Patients) erfasst wurden. Die Datenerhebung erfolgte an 6 Studienzentren über 5 Follow-up Perioden (FUP). Insgesamt wurde der Verlauf von 3.327 initial demenzfreien Patienten über 5 Follow-up Perioden zwischen Januar 2003 (Basisdokumentation) bis November 2012 (FUP-5) untersucht. Patienten die innerhalb dieser Zeit eine Alzheimer- bzw. Demenzdiagnose erhielten wurden im Hinblick auf ihre medikamentöse Versorgungssituation analysiert. Eine leitliniengerechte medikamentöse Therapie erfolgte bei 12,4% (AChEI) und 4,8% (Memantine) der inzidenten AD-Patienten bzw. bei 12,1% (AChEI) und 3,9% (Memantine) der inzidenten Demenzpatienten. Innerhalb der einzelnen FUP erfolgte eine leitliniengerechte medikamentöse Therapie bei 8,8 - 22,6% (AChEI) und 7,7 - 14.8% (Memantine) der prävalenten AD-Patienten bzw. bei 7,4 - 21,2% (AChEI) und 8,8 - 13,4% (Memantine) der prävalenten Demenzpatienten. Die Off-Label Therapie mit AChEI bei prävalenten Patienten mit schwerer Krankheitsausprägung konnte bei 8 - 29,2% der AD-Patienten und 6,9 - 25% der Demenzpatienten festgestellt werden. Fehlbehandlungen mit Memantine bei inzidenten Patienten mit leichtem Schweregrad ließen sich bei 4,4% der AD-Patienten und 3,8% der Demenzpatienten feststellen. Bei prävalenten Patienten lag eine Fehlbehandlung mit Memantine innerhalb des Untersuchungszeitraums bei 3,3 - 9,3% der AD-Patienten und 2,6 - 7,4% der Demenzpatienten vor. Anhand der Daten kann festgestellt werden, dass die Einnahme von AChEI mit einem höheren Alter sowie schlechteren MMSE-Werten assoziiert ist. Eine Einnahme von Memantine ist mit einem höheren Bildungsstand, schlechteren MMSE bzw. IADL-Werten assoziiert. Es konnte gezeigt werden, dass eine leitliniengerechte medikamentöse Therapie mit AChEI und Memantine bei hausärztlichen Alzheimer- und Demenzpatienten nur im geringen Umfang erfolgt. Fehlbehandlungen mit Memantine konnten nur bei einem gleichbleibend geringen Anteil der Patienten mit leichtem Demenzschweregrad nachgewiesen werden.:Inhaltsverzeichnis Abkürzungsverzeichnis III Abbildungsverzeichnis V Tabellenverzeichnis IX 1 Einleitung 1 2 Stand der Forschung 3 2.1 Formen der Demenzerkrankung und aktuelle Klassifikationssysteme 3 2.2 Demenzspezifische Medikation 9 2.3 Versorgungssituation mit demenzspezifischer Medikation 15 3 Fragestellung 20 4 Material und Methoden 21 4.1 Stichprobenbeschreibung und Studiendesign 21 4.2 Befragung der Studienteilnehmer, Befragung der Angehörigen und Hausärzte 23 4.2.1 Instrumente zur Erfassung der kognitiven Leistung und der Alltagskompetenz 23 4.2.2 Definition der milden kognitiven Beeinträchtigungen 25 4.2.3 Definition der Demenz und der Demenz-Schweregrade 25 4.2.4 Erfassung der Medikation 26 4.2.5 Soziodemographische Merkmale 27 4.3 Datenanalyse 28 5 Ergebnisse 30 5.1 Schweregradspezifische medikamentöse Therapie bei inzidenten Alzheimer- und Demenzpatienten 33 5.2 Schweregradspezifische medikamentöse Therapie bei prävalenten Alzheimer- und Demenzpatienten 41 5.3 Medikamentöse Therapie bei nicht-dementen Patienten 47 5.4 Determinanten einer medikamentösen Therapie. 51 6 Diskussion 63 6.1 Studienpopulation 63 6.2 Antidementive Therapie bei inzidenten und prävalenten Alzheimer- und Demenzpatienten 65 6.3 Antidementive Therapie bei nicht-dementen Patienten 69 6.4 Determinanten einer antidementiven Behandlung 70 6.5 Stärken und Limitationen der Studie 72 7 Schlussfolgerung 75 Zusammenfassung der Arbeit 76 Literaturverzeichnis 78 Anlagen 86 Cox-Regressionsanalyse für Acetylcholinesterase-Hemmer 86 Cox-Regressionsanalyse für Memantine 87 Ethikvotum 88 Erklärung über die eigenständige Abfassung der Arbeit 89 Lebenslauf 90 Danksagung 91

Posttraumatic stress disorder (PTSD) is a severe anxiety disorder characterised by hypothalamic-pituitary-adrenal (HPA)-axis abnormalities, hyperarousal, anxiety, flashbacks of trauma memories and avoidance. Increasing evidence is now accumulating that the disorder is also associated with shrinkage of the hippocampus and cognitive dysfunction that may have its origin in stress-induced excitotoxicity. Animal studies have indeed highlighted a potential role of the excitotoxic glutamatenitric oxide (NO) pathway in the stress response. Since PTSD appears to be an illness that progresses and worsens over time after an initial severe traumatic event, this study has used an animal model that emphasises repeated trauma to investigate the effect of stress on hippocampal NO synthase (NOS) activity, the release of the nitrogen oxide metabolites of NO (NOx), and also the evoked release of cGMP. Furthermore, the modulation and dependency of these responses on glutamate, NO and cGMP activity using drugs selective for these targets, will also be investigated. Rats (n=10/group) were exposed to repeated stress together with saline or drug administration immediately after the stress procedure and continuing for one week post-stress. The animals were then sacrificed for assay of hippocampal NOS activity, NO, and cGMP accumulation. Animals received either the glutamate-NMDA receptor antagonist, memantine (MEM;5mg/kg ip/d), the neuronal NOS selective inhibitor, 7- nitroindazole monosodium salt (7-NINA;20mg/kg ip/d), the cGMP-specific PDE inhibitor, sildenafil (SIL;10mg/kg ip/d) or the NFkb antagonist, pyrollidine dithiocarbamate (PDTC;70mg/kg ip/d). The latter inhibits the nuclear transcription factor, NFkb, responsible for inducing the expression of iNOS, while it also appears to mediate the glutamatergic actions on NOS expression, Stress significantly increased hippocampal NOS activity, as well as significantly increased hippocampal cGMP and NO, levels. These increases were blocked by pretreatment with either PDTC or 7-NINA, while memantine was without effect. Sildenafil significantly augmented stress induced NO, accumulation, as well as cGMP. although the latter failed to reach significance. 7-NINA and memantine significantly blocked the increase in cGMP evoked by time-dependent sensitisation (TDS)-stress, with PDTC attenuating this response, but not significantly. Additionally, administration of each drug separately for seven days without exposure to stress, did not evoke significant changes in NOx levels, compared to the control group. However, significant increases in cGMP levels, compared to the control group, were found with all four drugs. Repeated trauma therefore activates the NO-cGMP pathway, possibly involving actions on both nNOS and iNOS. The NMDA receptor appears less involved after chronic repeated stress, and may have limited therapeutic implications. Sub-cellular NO-modulation, however, may represent an important therapeutic strategy in preventing the effects of severe stress and in treating PTSD. / Thesis (M.Sc. (Pharmacology))--North-West University, Potchefstroom Campus, 2005.

Posttraumatic stress disorder (PTSD) is a severe anxiety disorder characterised by hypothalamic-pituitary-adrenal (HPA)-axis abnormalities, hyperarousal, anxiety, flashbacks of trauma memories and avoidance. Increasing evidence is now accumulating that the disorder is also associated with shrinkage of the hippocampus and cognitive dysfunction that may have its origin in stress-induced excitotoxicity. Animal studies have indeed highlighted a potential role of the excitotoxic glutamatenitric oxide (NO) pathway in the stress response. Since PTSD appears to be an illness that progresses and worsens over time after an initial severe traumatic event, this study has used an animal model that emphasises repeated trauma to investigate the effect of stress on hippocampal NO synthase (NOS) activity, the release of the nitrogen oxide metabolites of NO (NOx), and also the evoked release of cGMP. Furthermore, the modulation and dependency of these responses on glutamate, NO and cGMP activity using drugs selective for these targets, will also be investigated. Rats (n=10/group) were exposed to repeated stress together with saline or drug administration immediately after the stress procedure and continuing for one week post-stress. The animals were then sacrificed for assay of hippocampal NOS activity, NO, and cGMP accumulation. Animals received either the glutamate-NMDA receptor antagonist, memantine (MEM;5mg/kg ip/d), the neuronal NOS selective inhibitor, 7- nitroindazole monosodium salt (7-NINA;20mg/kg ip/d), the cGMP-specific PDE inhibitor, sildenafil (SIL;10mg/kg ip/d) or the NFkb antagonist, pyrollidine dithiocarbamate (PDTC;70mg/kg ip/d). The latter inhibits the nuclear transcription factor, NFkb, responsible for inducing the expression of iNOS, while it also appears to mediate the glutamatergic actions on NOS expression, Stress significantly increased hippocampal NOS activity, as well as significantly increased hippocampal cGMP and NO, levels. These increases were blocked by pretreatment with either PDTC or 7-NINA, while memantine was without effect. Sildenafil significantly augmented stress induced NO, accumulation, as well as cGMP. although the latter failed to reach significance. 7-NINA and memantine significantly blocked the increase in cGMP evoked by time-dependent sensitisation (TDS)-stress, with PDTC attenuating this response, but not significantly. Additionally, administration of each drug separately for seven days without exposure to stress, did not evoke significant changes in NOx levels, compared to the control group. However, significant increases in cGMP levels, compared to the control group, were found with all four drugs. Repeated trauma therefore activates the NO-cGMP pathway, possibly involving actions on both nNOS and iNOS. The NMDA receptor appears less involved after chronic repeated stress, and may have limited therapeutic implications. Sub-cellular NO-modulation, however, may represent an important therapeutic strategy in preventing the effects of severe stress and in treating PTSD. / Thesis (M.Sc. (Pharmacology))--North-West University, Potchefstroom Campus, 2005.

Der TRPC5-Ionenkanal gehört zur Familie der transienten Rezeptorpotenzial-Kanäle und wird vorwiegend im Zentralnervensystem exprimiert. Um die Funktionsweise des Kanals besser zu verstehen, wurden in dieser Arbeit im Rahmen eines Wirkstoffscreenings die folgenden Verbindungen als neue Ionenkanalmodulatoren identifiziert und charakterisiert: Mit einer EC50 um 9 μM aktiviert das Glucocorticoid Methylprednisolon den TRPC5-Kanal. Seine, für den Konzentrationsbereich gute TRPC5-Selektivität und die Erfahrung aus jahrzehntelanger Anwendung in der Medizin machen es zu einer vielversprechenden Verbindung. Das Benzothiadiazin-Derivat BTD ist mit einer EC50 von 1,3 μM nach Englerin A derzeit die Verbindung mit der zweithöchsten Potenz. BTD kennzeichnet eine hohe Selektivität und eine ausgeprägte Subtypspezifizität, denn der nächstverwandte TRPC4-Kanal reagiert nicht auf BTD-Stimulation. Gleichzeitig aktiviert BTD sämtliche heteromere Kanalkomplexe mit TRPC5-Beteiligung. In elektrophysiologischen Versuchen an Zellen mit endogener TRPC5-Expression löste eine BTD-Stimulation TRPC5-ähnliche Ströme aus. Durch Struktur-Wirkungsbeziehungen in Verbindung mit den Hits des Primär-screenings wurden Verbindungen mit Adamantan Grundstruktur als weitere TRPC5-Modulatoren identifiziert. Diese zeigen ein bimodales Verhalten, da sie TRPC5-Kanäle in nanomolarer Konzentration aktivieren, in mikromolarer Konzentration jedoch inhibieren können. Dem strukturverwandten Anti-Parkinsonmedikament Amantadin und dem Antidementivum Memantin konnten ebenfalls TRPC5-aktivierende Wirkungen nachgewiesen werden. / TRPC5 belongs to the family of transient receptor potential channels and is predominantly expressed in the central nervous system. A compound screening assay was performed to identify and characterise novel TRPC5 channel modulators. Here, we present methylprednisolon as a TRPC5 channel activator with an EC50 of 9 µM. The compound shows a satisfying selectivity for TRPC5 channels. Due to years of experience in medicinal application, methylprednisolone is an interesting substance. The benzothiadiazine derivative BTD is even more potent, showing an EC50 of 1.3 µM. Thus BTD belongs to the most potent TRPC5 channel activators available. Furthermore, BTD is highly selective for TRPC5 channels. In addition, BTD activates all heteromeric channel complexes containing TRPC5 subunits. Several compounds with adamantine substituents were identified as TRPC5 channel modulators. Among them are channel activators, inhibitors and bimodal modulators, covering a potency range from nanomolar to micromolar concentrations. Interestingly, the neuroactive substances amantadine and memantine were identified as novel TRPC5 channel activators with nanomolar potency.

Indiana University-Purdue University Indianapolis (IUPUI) / Alzheimer’s disease (AD) is a neurological disorder defined by the presence of plaques comprised mostly of amyloid-β (Aβ), and neurofibrillary tangles consisting of hyperphosphorylated microtubule associated protein tau (MAPT). AD is also characterized by widespread synapse loss and degeneration followed by death of neurons in the brain. Inflammatory processes, such as glial activation, are also implicated. In order to study mechanisms of neurodegeneration and evaluate potential therapeutic agents that could slow or reverse this process, a tissue culture system was developed based on primary embryonic cerebrocortical neurons. This culture system was observed to exhibit time-dependent neurodegeneration, glial proliferation, and synaptic marker loss consistent with AD-affected brains. The regulatory promoter regions of several genes implicated in AD, including the Aβ precursor protein (APP), β-amyloid cleaving enzyme (BACE1), and MAPT, were studied in this culture model. The MAPT gene promoter activity followed the pattern of neuronal maturation and degeneration quite closely, increasing in the initial phase of the tissue culture, then reducing markedly during neurodegeneration while APP and BACE1 gene promoters remained active. Deletion series of these promoters were tested to give an initial indication of the active regions of the gene promoter regions. Furthermore, the effects of exogenous Aβ and overexpression of p25, which are two possible pathogenic mechanisms of gene regulation in AD, were studied. Response to Aβ varied between the promoters and by length of the Aβ fragment used. Overexpression of p25 increased MAPT, but not APP or BACE1, promoter activity. This neurodegeneration model was also used to study the putative neuroprotective action of the NMDA receptor antagonist memantine. Treatment with memantine prevented loss of synaptic markers and preserved neuronal morphology, while having no apparent effect on glial activation. The protective action on synaptic markers was also observed with two other structurally distinct NMDA receptor antagonists, suggesting that the effects of memantine are produced by its action on the NMDA receptor. It is concluded that this tissue culture model will be useful for the study of gene regulation and therapeutic agents for neurodegeneration, and that the efficacy of memantine may result from preservation of synaptic connections in the brain.

Les antagonistes du récepteur N-méthyl-D-aspartate (NMDA) comme la kétamine, le dextrométhorphane et la mémantine sont utilisés pour la prise en charge de la douleur neuropathique. La kétamine est très efficace contre les douleurs neuropathiques réfractaires aux traitements conventionnels. Cependant, son utilisation est limitée du fait de nombreux effets indésirables. Un relais antalgique est alors proposé. Ce travail de thèse s’insère dans un programme de recherche dédié aux antagonistes du récepteur NMDA dans la prise en charge de la douleur neuropathique. Le premier objectif était d’évaluer dans une étude clinique randomisée, en simple insu, en groupes parallèles, contrôlée versus placebo, les effets antalgiques du dextrométhorphane et de la mémantine, administrés en relais de la kétamine chez 60 patients souffrant de douleurs neuropathiques d’origine périphérique. L’impact de ces traitements sur le statut cognitivo-émotionnel des patients et leur qualité de vie a également été examiné, ainsi que la modulation des effets de ces médicaments par le polymorphisme génétique impliqué dans le métabolisme (CYP2D6, CYP3A4,5), la biodisponibilité et l’élimination (NR1I2) de ces deux molécules. En parallèle une étude mécanistique centrée sur le dextrométhorphane a été réalisée chez vingt volontaires sains (étude randomisée, en double aveugle, en groupes croisés). L’objectif était d’étudier dans un modèle d’hyperalgie induite par le froid « Freeze injury » les caractéristiques pharmacologiques et mécanistiques déterminant les effets anti-nociceptifs, centraux et cognitifs du dextrométhorphane ainsi que le polymorphisme génétique impliqué dans leur modulation. Chez les patients, les effets antalgiques immédiats de la kétamine ont été confirmés et s’accompagnaient de l’amélioration des scores d’anxiété et de dépression, des aspects cognitifs et affectifs et du sommeil. Toutefois, par rapport au placebo, la mémantine et le dextrométhorphane n’ont pas permis de renforcer significativement l’antalgie induite par la kétamine. Chez les volontaires sains, le dextrométhorphane a révélé des effets anti-hyperalgiques suite à une sensibilisation périphérique et centrale. Cependant, aucun effet analgésique sur la douleur thermique aiguë n’a été observé. Ces deux approches clinique et mécanistique concernant l’effet curatif des antagonistes du récepteur NMDA ont permis d’une part de montrer : 1 - chez le patient, l’effet curatif prolongé de la kétamine et l’intérêt du dextrométhorphane et de la mémantine dans la prise en charge du retentissement négatif de la douleur neuropathique sur le statut cognitivo-émotionnel et la qualité de vie des patients; 2 - chez le volontaire sain, l’efficacité anti-hyperalgique du dextrométhorphane sur les phénomènes de sensibilisation périphérique et centrale ainsi que ses répercussions sédatives et cognitives. En complément de ces deux études et dans le but de confirmer en clinique les effets curatifs du dextrométhorphane sur le triptyque douleur-cognition-émotion, une étude clinique randomisée, en double aveugle, en groupes parallèles, contrôlée versus placebo est en cours de réalisation chez 40 patientes souffrant de douleur neuropathique chimio-induite subséquente au traitement du cancer du sein. En conclusion de ce travail de thèse, l’étude des effets du dextrométhorphane dans deux populations différentes souligne l’intérêt de la recherche translationnelle. Chez le sujet volontaire sain, le dextrométhorphane exerce un effet anti-hyperalgique marqué et provoque des effets centraux délétères. Chez le patient présentant une douleur neuropathique d’origine périphérique et étant répondeur à la kétamine, seule une tendance est observée en faveur de l’effet anti-nociceptif du dextrométhorphane donné en relais de la kétamine. En revanche l’administration de dextrométhorphane s’accompagne d’un certain bénéfice au niveau cognitif et sur la qualité de vie des patients. / N-methyl-D-aspartate (NMDA) receptor antagonists such as ketamine, dextromethorphan and memantine have gained an increasing interest in the management of neuropathic pain. In Pain Clinics, ketamine is widely used in the relief of neuropathic pain. However, its use in clinical practice is limited due to its numerous side effects. It is therefore necessary to propose to patients a drug relay with other NMDA receptor antagonists. This work is part of an academic program research dedicated to NMDA receptor antagonists in the management of neuropathic pain. Its first objective was to evaluate the antalgic effects of dextromethorphan and memantine. This randomized, single-blind, parallel-group, placebo-controlled study in 60 ketamine responder patients aimed also to assess the cognitive-emotional status of patients and their quality life. In parallel, a mechanistic study focusing on dextromethorphan was performed in 20 healthy volunteers in a randomized, double-blind, cross-over, placebo-controlled study. The objective was to investigate in a freeze-injury model the pharmacokinetic and mechanistic characteristics of the anti-nociceptive, central and cognitive effects of dextromethorphan as well as the genetic polymorphism involved in its response variability.In patients, the immediate analgesic effects of ketamine were confirmed with improved anxiety and depression scores, cognitive and affective aspects of pain, and different sleep parameters. However, memantine and dextromethorphan, compared to placebo, did not significantly increase the ketamine-induced analgesia. The analysis of the genetic polymorphism did not reveal any variability in the analgesic efficacy of these treatments. In healthy volunteers, dextromethorphan revealed anti-hyperalgesic effects following peripheral and central sensitization but no analgesic effect on acute heat pain. Moreover, the variability of the anti-nociceptive activity of dextromethorphan described in the literature seems to be more related to the genetic polymorphism of the CYP2D6 gene than to that of the CYP3A4,5 and ABCB1 genes. Finally, dextrorphan, the main active metabolite of dextromethorphan, appears to be responsible for the deleterious sedative and cognitive effects of the drug. These two clinical and mechanistic approaches concerning the curative effect of the NMDA receptor antagonists showed : 1 - in patients, the prolonged curative effect of ketamine and the interest of dextromethorphan and memantine in the management of the neuropathic pain-related cognitive-emotional and quality of life impairment; 2 - in healthy volunteers, the anti-hyperalgesic efficacy of dextromethorphan on peripheral and central sensitization and its sedative and cognitive side effects. In addition to these two studies, a randomized, double-blind, parallel-group, placebo-controlled clinical study is ongoing in 40 patients with chemotherapy-induced peripheral neuropathic pain subsequently to the treatment of breast cancer. In conclusion the assessment of the effects of dextromethorphan in two different populations led to discordant results. In the healthy volunteer, dextromethorphan exerts a marked anti-hyperalgesic effect and causes deleterious central effects. In the patient with peripheral neuropathic pain, only a trend is observed in favor of the anti-nociceptive effect of dextromethorphan given in ketamine responder patients. More studies with larger population are needed to determine the importance of the CYP2D6, CYP3A4,5 and ABCB1 genetic polymorphisms on the anti-nociceptive activity of dextromethorphan. The translational approach of this thesis does not allow a firm conclusion on the clinical use of dextromethorphan in the curative treatment of chronic peripheral neuropathic pain. The use of dextromethorphan as a preventive agent via other administration routes (i.e. local) or in combination with other drugs, all require further exploration in order to improve the benefit/risk ratio of this molecule.