"It only takes one bad apple to spoil the bunch, and the same may be true of certain proteins in the brain. Studies have suggested that just one rogue protein (in this case, a protein that is misfolded or shaped the wrong way) can act as a seed"...
Mechanism of Action
The etiology and pathogenesis of amyotrophic lateral sclerosis (ALS) are not known, although a number of hypotheses have been advanced. One hypothesis is that motor neurons, made vulnerable through either genetic predisposition or environmental factors, are injured by glutamate. In some cases of familial ALS the enzyme superoxide dismutase has been found to be defective.
The mode of action of RILUTEK (riluzole) is unknown. Its pharmacological properties include the following, some of which may be related to its effect: 1) an inhibitory effect on glutamate release, 2) inactivation of voltage-dependent sodium channels, and 3) ability to interfere with intracellular events that follow transmitter binding at excitatory amino acid receptors.
Riluzole has also been shown, in a single study, to delay median time to death in a transgenic mouse model of ALS. These mice express human superoxide dismutase bearing one of the mutations found in one of the familial forms of human ALS.
It is also neuroprotective in various in vivo experimental models of neuronal injury involving excitotoxic mechanisms. In in vitro tests, riluzole protected cultured rat motor neurons from the excitotoxic effects of glutamic acid and prevented the death of cortical neurons induced by anoxia.
Due to its blockade of glutamatergic neurotransmission, riluzole also exhibits myorelaxant and sedative properties in animal models at doses of 30 mg/kg (about 20 times the recommended human daily dose) and anticonvulsant properties at a dose of 2.5 mg/kg (about 2 times the recommended human daily dose).
Riluzole is well-absorbed (approximately 90%), with average absolute oral bioavailability of about 60% (CV=30%). Pharmacokinetics are linear over a dose range of 25 to 100 mg given every 12 hours. A high fat meal decreases absorption, reducing AUC by about 20% and peak blood levels by about 45%. The mean elimination half-life of riluzole is 12 hours (CV=35%) after repeated doses. With multiple-dose administration, riluzole accumulates in plasma by about twofold and steady-state is reached in less than 5 days. Riluzole is 96% bound to plasma proteins, mainly to albumin and lipoproteins over the clinical concentration range.
The 50 mg market tablet was equivalent, with respect to AUC, to the tablet used in the dose ranging clinical trials, while the Cmax was approximately 30% higher. Both tablets have been used in clinical trials. However, if doses greater than those recommended are given, it is likely that higher plasma levels will be achieved, the safety of which has not been established (see DOSAGE AND ADMINISTRATION).
Metabolism and Elimination
Riluzole is extensively metabolized to six major and a number of minor metabolites, not all of which have been identified. Some metabolites appear pharmacologically active in in vitro assays. The metabolism of riluzole is mostly hepatic and consists of cytochrome P450-dependent hydroxylation and glucuronidation.
There is marked interindividual variability in the clearance of riluzole, probably attributable to variability of CYP 1A2 activity, the principal isozyme involved in N-hydroxylation. In vitro studies using liver microsomes show that hydroxylation of the primary amine group producing N-hydroxyriluzole is the main metabolic pathway in human, monkey, dog and rabbit. In humans, cytochrome P450 1A2 is the principal isozyme involved in N-hydroxylation. In vitro studies predict that CYP 2D6, CYP 2C19, CYP 3A4 and CYP 2E1 are unlikely to contribute significantly to riluzole metabolism in humans. Whereas direct glucuroconjugation of riluzole (involving the glucurotransferase isoform UGT-HP4) is very slow in human liver microsomes, N-hydroxyriluzole is readily conjugated at the hydroxylamine group resulting in the formation of O- ( > 90%) and N-glucuronides.
Following a single 150 mg dose of 14C-riluzole to 6 healthy males, 90% and 5% of the radioactivity was recovered in the urine and feces respectively over a period of 7 days. Glucuronides accounted for more than 85% of the metabolites in urine. Only 2% of a riluzole dose was recovered in the urine as unchanged drug.
The area-under-the-curve (AUC) of riluzole, after a single 50 mg oral dose, increases by about 1.7-fold in patients with mild chronic liver insufficiency (n=6; Child-Pugh's score A) and by about 3-fold in patients with moderate chronic liver insufficiency (n=6; Child-Pugh's score B) compared to healthy volunteers (n=12) (see WARNINGS and PRECAUTIONS). The pharmacokinetics of riluzole have not been studied in patients with severe hepatic impairment.
There is no significant difference in pharmacokinetic parameters between patients with moderate (n=5; creatinine clearance 30-50 ml.min-1) and severe (n=7; creatinine clearance < 30 ml.min-1) renal insufficiency and healthy volunteers (n=12) after a single oral dose of 50 mg riluzole. The pharmacokinetics of riluzole have not been studied in patients undergoing hemodialysis.
The pharmacokinetic parameters of riluzole after multiple dose administration (4.5 days of treatment at 50 mg riluzole b.i.d.) are not affected in the elderly ( ≥ 70 years).
No gender effect on riluzole pharmacokinetics has been found in young or elderly healthy subjects. However, in one placebo-controlled clinical trial with population pharmacokinetics, riluzole mean clearance was found to be 30% lower in female patients (corresponding to an approximate increase in AUC of 45%) as compared to male patients. No favorable or adverse effects of riluzole in relation to gender were seen in controlled trials, however.
Patients who smoke cigarettes eliminate riluzole 20% faster than non-smoking patients, based on a population pharmacokinetic analysis on data from 128 ALS patients, of whom 19 were smokers. However, there is no need for dosage adjustment in these patients.
A clinical study conducted to evaluate the pharmacokinetics of riluzole and its metabolite following repeated oral administration twice daily in healthy Japanese and Caucasian adult males showed that there were no significant racial differences in pharmacokinetic parameters between the Japanese and Caucasian subjects.
The efficacy of RILUTEK (riluzole) as a treatment of ALS was established in two adequate and well-controlled trials in which the time to tracheostomy or death was longer for patients randomized to RILUTEK (riluzole) than for those randomized to placebo.
These studies admitted patients with either familial or sporadic ALS, a disease duration of less than 5 years, and a baseline forced vital capacity greater than or equal to 60%.
In one study, performed in France and Belgium, 155 ALS patients were followed for at least 13 months (maximum duration 18 months) after being randomized to either 100 mg/day (given 50 mg BID) of RILUTEK (riluzole) or placebo.
Figure 1, which follows, displays the survival curves for time to death or tracheostomy. The vertical axis represents the proportion of individuals alive without tracheostomy at various times following treatment initiation (horizontal axis). Although these survival curves were not statistically significantly different when evaluated by the analysis specified in the study protocol (Logrank test p=0.12), the difference was found to be significant by another appropriate analysis (Wilcoxon test p=0.05). As seen, the study showed an early increase in survival in patients given riluzole. Among the patients in whom treatment failed during the study (tracheostomy or death) there was a difference between the treatment groups in median survival of approximately 90 days. There was no statistically significant difference in mortality at the end of the study.
Figure 1: kaplan-Meier Survival Curves
In the second study, performed in both Europe and North America, 959 ALS patients were followed for at least 1 year (North American centers) and up to 18 months (European centers) after being randomized to either 50, 100, 200 mg/day of RILUTEK (riluzole) or placebo.
Figure 2, which follows, displays the survival curves for time to death or tracheostomy for patients randomized to either 100 mg/day of RILUTEK (riluzole) or placebo. Although these survival curves were not statistically significantly different when evaluated by the analysis specified in the study protocol (Logrank test p = 0.076), the difference was found to be significant by another appropriate analysis (Wilcoxon test p = 0.05). Not displayed in Figure 2 are the results of 50 mg/day of RILUTEK (riluzole) which could not be statistically distinguished from placebo and the results of 200 mg/day which are essentially identical to 100 mg/day. As seen, the study showed an early increase in survival in patients given riluzole. Among the patients in whom treatment failed during the study (tracheostomy or death) there was a difference between the treatment groups in median survival of approximately 60 days. There was no statistically significant difference in mortality at the end of the study.
Figure 2: kaplan-Meier Survival Curves
Although riluzole improved early survival in both studies, measures of muscle strength and neurological function did not show a benefit.
Last reviewed on RxList: 8/4/2009
This monograph has been modified to include the generic and brand name in many instances.
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