A pilot study of Golexanolone, a new GABA-A receptor modulating steroid antagonist, in patients with covert hepatic encephalopathy

Sara Montagnese, Mette Lauridsen, Hendrik Vilstrup, Lisa Zarantonello, Geza Lakner, Sergey Fitilev, Igor Zupanets, Irina Kozlova, Elena Bunkova, Krzysztof Tomasiewicz, Jan Erik Berglund, Fredrik Rorsman, Hannes Hagström, Stergios Kechagias, Carin Edmark Ocklind, Joe Mauney, Fredrik Thunarf, Masoud Mokhatarani, Torbjörn Bäckström, Magnus DoverskogLars-Erik Lins, Maria Månsson, Per Samuelson, Dag Nilsson, Martin Schalling, Maja Johansson, Eva Arlander, Bruce F Scharschmidt*

*Corresponding author for this work

Research output: Contribution to journalJournal articleResearchpeer-review

Abstract

Background & Aims: Golexanolone is a novel small molecule GABA-A receptor-modulating steroid antagonist under development for the treatment of cognitive and vigilance disorders caused by allosteric over-activation of GABA-A receptors by neurosteroids. It restored spatial learning and motor coordination in animal models of hepatic encephalopathy (HE) and mitigated the effects of intravenous allopregnanolone in healthy adults in a dose-dependent fashion. Herein, we report data on the safety, pharmacokinetics (PK) and efficacy of golexanolone in adult patients with cirrhosis. Methods: Following single/multiple ascending dose studies, adults with Child-Pugh A/B cirrhosis and abnormal continuous reaction time (CRT) on screening were randomized to 3 weeks’ dosing with golexanolone (10, 40 or 80 mg BID) or placebo. CRT, psychometric hepatic encephalopathy score (PHES), animal naming test (ANT), Epworth sleepiness scale (ESS) and electroencephalogram (mean dominant frequency [MDF]; delta+theta/alpha+beta ratio [DT/AB]) were obtained at baseline, 10, and 21 days. Results: Golexanolone exhibited satisfactory safety and PK. Baseline characteristics were similar between the 12 and 33 patients randomized to placebo or golexanolone, respectively. By prespecified analyses, golexanolone was associated with directionally favourable changes vs. placebo in ESS (p = 0.047), MDF (p = 0.142) and DT/AB (p = 0.021). All patients also showed directionally favourable changes in CRT, PHES and ANT, but with no statistical difference between golexanolone and placebo. Post hoc analyses taking into account the variability and improvement in CRT, PHES and ANT observed between screening and baseline suggested an efficacy signal by cognitive measures as well. Conclusion: Golexanolone was well tolerated and associated with improvement in cognitive performance. These results implicate GABA-A receptor-modulating neurosteroids in the pathogenesis of HE and support the therapeutic potential of golexanolone. Lay summary: Many patients with cirrhosis experience subtle but disabling cognitive problems, including sleepiness and poor attention span, that impair their ability to be gainfully employed or carry out activities of daily living. This pilot study tested the hypothesis that these problems with cognition, for which there is no approved treatment, might be improved by an experimental drug, golexanolone, designed to normalize the function of receptors which inhibit brain function. The results of this study suggest that golexanolone is well tolerated and may improve cognition, as reflected by measures of sleepiness, attention span and brain wave activity, paving the way for future larger studies of this promising experimental drug. Clinical trial registration number: EudraCT 2016-003651-30.

Original languageEnglish
Book seriesJournal of Hepatology
Volume75
Issue number1
Pages (from-to)98-107
ISSN0169-5185
DOIs
Publication statusPublished - Jul 2021

Bibliographical note

Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.

Keywords

  • Allopregnanolone
  • GR3027
  • cirrhosis
  • neurosteroids
  • vigilance

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