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Anesthesia & Analgesia:
doi: 10.1213/ANE.0000000000000188
Anesthetic Pharmacology: Research Report

Inhibition of Voltage-Gated Na+ Channels by the Synthetic Cannabinoid Ajulemic Acid

Foadi, Nilufar MD*; Berger, Christian MD*; Pilawski, Igor VMD*; Stoetzer, Carsten MD*; Karst, Matthias MD*; Haeseler, Gertrud MD*; Wegner, Florian MD; Leffler, Andreas MD*; Ahrens, Jörg MD*

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Author Information

From the *Department of Anesthesia and Critical Care Medicine, and Department of Neurology and Clinical Neurophysiology, Medizinische Hochschule Hannover, Hannover, Germany.

Christian Berger, MD, is currently affiliated with Clinic for Cardiology, Herford Hospital, Herford, Germany.

Gertrud Haeseler, MD, is currently affiliated with Clinic for Anaesthesia and Critical Care Medicine, St. Elisabeth hospital Dorsten, Dorsten, Germany.

Accepted for publication December 18, 2013.

Published ahead of print April 22, 2014

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Jörg Ahrens, MD, Clinic for Anaesthesia and Critical Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany. Address e-mail to ahrens.j@mh-hannover.de.

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Abstract

BACKGROUND: The synthetic cannabinoid ajulemic acid has been demonstrated to alleviate pain in patients suffering from chronic neuropathic pain. Cannabinoids interact with several molecules within the pain circuit, including a potent inhibition of voltage-gated sodium channels. In this study, we closely characterized this property on neuronal and nonneuronal sodium channels.

METHODS: The inhibition of sodium inward currents by ajulemic acid was studied in vitro. Human embryonic kidney 293t cells were used as the expression system for Nav1.2, 1.3, 1.4, 1.5, 1.5N406K, 1.5F1760A, and 1.7; Nav1.8 was transiently expressed in ND7/23 cells. Nav1.2, Nav1.3, and Nav 1.8 were from rats, and Nav1.4, Nav1.5, and Nav1.7 were of human origin. Sodium currents were analyzed by means of the whole cell patch-clamp technique. The investigated concentrations of ajulemic acid were 0.1, 0.3, 1, 3, 10, and 30 μmol/L.

RESULTS: Ajulemic acid reversibly and concentration-dependently inhibited all voltage-gated sodium channel (Nav) isoforms investigated in this study, including Nav1.2, 1.3, 1.4, 1.5, 1.7, and 1.8. Tonic block of resting channels yielded half-maximal inhibitory concentration values between 2 and 9 μmol/L and was strongly enhanced on inactivated channels, suggesting state-dependent inhibition by ajulemic acid. Tonic block did not differ significantly when comparing Nav1.2 and Nav1.3, Nav1.4 and Nav1.5, and Nav1.7 and Nav1.8. Statistical analysis of other combinations of subunits (e.g., Nav1.2 and Nav1.4) by analysis of variance yielded a significant difference in block. Although we did not observe any relevant use-dependent block, ajulemic acid induced a strong hyperpolarizing shift of the voltage dependency of fast inactivation and modest shift of slow inactivation. The local anesthetic-insensitive Nav1.5 constructs N406K and F1760A displayed a preserved sensitivity to block by ajulemic acid. Finally, we found that low concentrations of ajulemic acid efficiently inhibited Navβ4 peptide-mediated resurgent currents in Nav1.5.

CONCLUSIONS: Our data suggest that block of sodium channels can be a relevant mechanism by which ajulemic acid alleviates neuropathic pain. The potent inhibition of resurgent currents and the preserved block on local anesthetic-insensitive channels indicates that ajulemic acid interacts with a conserved but yet unknown site of sodium channels.

The therapeutic use of Δ9-tetrahydrocannabinol (Δ9-THC) and various synthetic cannabinoids for pain treatment has attracted considerable interest.1–3 However, psychoactive effects mediated via central CB1 receptors and insufficient analgesic effects have reduced the enthusiasm about the therapeutic utility of cannabinoids as analgesics.4 Ajulemic acid (AJA, chemical structure in Fig. 1) is a synthetic derivative of Δ9-THC-11-oic acid, a main metabolite of Δ9-THC. AJA induces both anti-inflammatory and analgesic effects in rodent models of acute and neuropathic pain.5–7 Phase 2 clinical studies with AJA showed strong analgesic effects in patients with neuropathic pain but only minor cannabinoid-like psychoactive side effects.8,9 Regarding the anti-inflammatory effects of AJA, the nuclear receptor PPAR-γ was identified as a possible mediating molecule.10,11 While the affinity of AJA to the cannabinoid receptors CB1 and CB2 is supposed to be rather weak,11 we have previously demonstrated that AJA acts as a positive allosteric modulator on the strychnine-sensitive α1 and α1β glycine receptors.12 This modulation of glycine receptors, and in particular, the α3 glycine receptor, has recently been reported to be essential for the analgesic efficacy of several cannabinoids in mice.13,14

Figure 1
Figure 1
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Another observed effect of cannabinoids with a potential relevance for analgesia is the inhibition or modulation of voltage-gated sodium channels. Δ9-THC, but also several other endogenous and synthetic cannabinoids, have been demonstrated to directly inhibit sodium channels.15–18 However, studies with a detailed analysis of different sodium channel isoforms are lacking. Furthermore, the molecular mechanisms responsible for cannabinoid-induced inhibition of sodium channels are largely lacking. Theile and Cummins19 reported that the endogenous cannabinoid anandamide very potently inhibits Navβ4 peptide-mediated resurgent currents in Nav1.7 and suggested a molecular mechanism distinct from the local anesthetic binding site. Resurgent currents seem to be enhanced in several inherited sodium channel mutations, causing muscle and neuronal channelopathies,20 and recent reports indicate that resurgent currents can drive pain in humans.21,22

In this study, we investigated the effects of AJA on 6 different α-subunits of sodium channels. To determine whether the effects of AJA are mediated via the local anesthetic binding site, we also tested the local anesthetic-insensitive Nav1.5-mutants N406K and F1760A.23,24 In addition, we questioned whether Navβ4-peptide-mediated resurgent current is inhibited by AJA. We hypothesized that AJA might be an effective modulator of sodium channels with a beneficial pharmacological profile in vivo.

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METHODS

Cell Culture and Transfection Procedures

Stably transfected human embryonic kidney 293 (HEK293) cells expressing the α-subunits Nav1.2, Nav1.3, Nav1.4, Nav1.5, and Nav1.7 were grown under standard conditions as described in previous studies 25. Nav1.2 and Nav1.3 were from rats, and Nav1.4, Nav1.5, and Nav1.7 were of human origin. Briefly, cells were cultured in Dulbecco`s modified Eagle medium (GIBCO-Invitrogen, Karlsruhe, Germany), supplemented with 10% heat-inactivated fetal bovine serum (Biochrom, Berlin, Germany), 1% penicillin/streptomycin (GIBCO-Invitrogen), and 0.4% Zeocin (Nav1.5) or 200 to 400 μg/mL G418 (Nav1.2, 1.3, 1.4 and Nav1.7) (Invitrogen) at 37°C in 5% CO2. As Nav1.8 (from rats) expresses very poorly in HEK 293 cells, we expressed Nav1.8 in the neuroblastoma cell line ND7/23 as previously described.25 The mutant constructs Nav1.5-N406K, and Nav1.5-F1760A were constructed with a mutagenesis kit (Quickchange XL kit, Qiagen GmbH, Hilden) according to the instructions of the manufacturer. Potential mutants were confirmed by DNA sequencing. Transient expression of the mutant constructs (2–3 μg) in HEK-293t cells, and rat Nav1.8 (5 μg) in ND7/23 cells was achieved by means of the calcium phosphate precipitation technique 26. EGFP (1 μg) was cotransfected to allow identification of transfected cells. After incubation for 12 to 15 hours, cells were replated in culture dishes and used for experiments within 2 days.

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Chemicals and Solutions

AJA was provided by Prof. Burstein, University of Massachusetts Medical School. AJA was prepared as 100 mmol/L stock solution in dimethylsulfoxide (Fluka, Steinheim, Germany), light-protected and stored in glass vessels at 4°C. The AJA stock was directly dissolved in bath solution to reach the final drug concentration immediately before the experiments. A stock solution of tetrodotoxin (TTX, 1 mmol/L in water) was directly dissolved in the bath solution to a final concentration of 300 nmol/L. TTX was used in all experiments on Nav1.8 to inhibit endogenous TTX-sensitive Na+ channels in ND7/23 cells. Test solutions were applied via a gravity-driven application system with a common outlet positioned approximately 100 μm from the cell. The bath solution contained (mmol/L) 140 mmol/L NaCl, 3 mmol/L KCl, 1 mmol/L MgCl2, 1 mmol/L CaCl2, and 10 mmol/L HEPES (adjusted to pH 7.4 with tetramethylammonium hydroxide). The pipette solution contained (mmol/L) 140 mmol/L CsF, 10 mmol/L NaCl, 1 mmol/L EGTA, and 10 mmol/L HEPES (adjusted to pH 7.3 with CsOH). The osmolarity of all solutions was adjusted to 290 to 300 mosm/L. For measuring resurgent currents of Nav1.5, the Navβ-4 peptide (KKLITFILKKTREK, JPT Peptide Technologies, Berlin, Germany) was included into the pipette solution with a final concentration of 100 μmol/L as has been described in previous reports.19

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Electrophysiology

Standard whole-cell voltage-clamp experiments were performed at room temperature. For data acquisition and further analysis, we used the EPC9 digitally controlled amplifier in combination with Pulse and Pulse Fit software (HEKA Electronics, Lambrecht, Germany). The data were filtered at 5 kHz and sampled at 20 kHz. Patch pipettes fabricated from borosilicate glass tubes (GB150EFT-10; Science Products, Germany) were pulled to a resistance of 1.0 to 2.0 MΩ after heat polishing. The series resistance was compensated by 60% to 80% to minimize voltage errors, and the capacitance artefacts were cancelled using the automatic subtraction of the EPC9 amplifier. Linear leak subtraction, based on resistance estimates from 4 hyperpolarizing pulses applied before the test pulse, was performed for all experiments.

To obtain concentration–response relationships, at least 5 independent experiments were performed. The experiments started with a control recording in the presence of extracellular solution, followed by the test recording where increasing concentrations of AJA were applied sequentially and finally concluded with the washout by extracellular solution.

The residual sodium current (I/Imax) in the presence of AJA, with respect to the current elicited with the same protocol in the respective control recording, was plotted against the applied concentration of the drug (C).

All averaged data were fitted using the Hill equation, Eq. 1, yielding the concentration for half-maximum channel blockade (IC50).

Equation (Uncited)
Equation (Uncited)
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The voltage dependence of fast and slow inactivation was assessed by applying a double-pulse protocol. Currents elicited by test pulses (Itest), after prepulses at varying potentials, normalized to the current elicited at the most hyperpolarized prepotential, represent the relative fraction of channels that have not been inactivated during the inactivating prepulse. Boltzmann fits to the resulting current-voltage plots yield the membrane potential at half-maximum channel availability (V0.5).

Equation (Uncited)
Equation (Uncited)
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Pulse Protocols

Drug effects on the peak current amplitude were investigated at a holding potential close to the resting potential in physiological conditions (−70 mV) or at a hyperpolarized membrane potential (−150 mV). Due to its distinct inactivation properties, Nav1.8 channels were examined after a holding potential of −40 mV instead of −70 mV.26

Use-dependent block was assessed by 60 test pulses to 0 mV applied at 10 Hz. Steady-state fast inactivation was examined in cells held at −150 mV and induced by 100-millisecond long prepulses from −150 to −40 mV in intervals of 5 mV. Slow inactivation was induced by 10-second long prepulses from −120 to −10 mV in steps of 10 mV, followed by a 100-millisecond long pulse at −120 mV, allowing recovery from fast inactivation.

Resurgent currents were recorded by a protocol consisting of a 20-millisecond prepulse to +30 mV, followed by 50-millisecond long test pulses from −110 to 0 mV in steps of 10 mV.

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Statistical Analysis

All data are presented as mean ± SEM. or fitted value ± SE of the fit. Sample sizes were ≥5 as shown in Tables 1 and 2. When pairs of groups were compared, statistical analysis was performed by use of the Student t test. When there were >2 groups, analysis of variance (ANOVA) followed by Tukey Honestly Significant Difference (HSD) tests were used. P < 0.05 was considered statistically significant.

Table 1
Table 1
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Table 2
Table 2
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RESULTS

Throughout all investigated isoforms, the onset of drug effect developed rapidly. A steady state of sodium channel block at a given concentration of AJA was obtained during 40 to 60 seconds of drug application. During washout, currents reached 50% to 70 % of the control current value. The blocking effect remained stable and was left unchanged even when the respective concentration of AJA was applied longer than 10 minutes.

We first examined the effect of AJA on Nav1.7. Tonic block was investigated on resting (Fig. 2A) and inactivated channels (Fig. 2B). AJA induced a concentration-dependent tonic block of Nav1.7, yielding IC50 values of 5.0 ± 0.7 (n = 13) for resting channels and 2.7 ± 0.3 μmol/L (n = 9) for inactivated channels (Table 1). Tonic block was significantly different compared with the other channel isoforms except for Nav1.8 (P = 0.7); see section below (statistical results of ANOVA).

Figure 2
Figure 2
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We next investigated further effects of 3 μmol/L AJA on Nav1.7; this concentration induced a robust inhibition of resting channels. As demonstrated in Figure 2D, 3 μmol/L AJA induced a small and not significant use-dependent block at 10 Hz (the last 20 of the applied repetitive pulses were compared by ANOVA P = 0.065; n = 6). We did not observe any effect of 3 μmol/L AJA on the current-voltage curve of Nav1.7 (n = 6) (Fig. 2F). In contrast, 3 μmol/L AJA induced robust effects on both fast (Fig. 2G) and slow inactivation (Fig. 2H). AJA 3 μmol/L induced a prominent hyperpolarizing shift of the steady-state inactivation curve from V0.5 −71 ± 1 mV in control solution to V0.5 −90 ± 1 mV in 3 μmol/L AJA (fast inactivation) (n = 8) (Table 2). Regarding slow inactivation, 3 μmol/L AJA induced a shift of the midpoint (V0.5) from −63 ± 1 mV in control solution to −73 ± 1 mV (n = 9) (Fig. 2H).

As is illustrated in Figure 3, A–J, AJA exhibited a tonic block on all investigated subunits. The IC50 values obtained by the Hill fit are shown in Table 1. Except for Nav1.8, all subunits were investigated as described above for Nav1.7. Statistical analysis generally yielded significant differences in IC50 values for tonic block of the investigated channel isoforms Nav1.2, 1.3, 1.4, 1.5, 1.7, and 1.8 (ANOVA, F(5, 49) = 69.051, P < 0.0001; for post hoc analysis, the Tukey HSD test was used). According to the post hoc test, IC50 values for block of resting channels by AJA were significantly lower in Nav1.4, 1.5, 1.7, 1.8 compared with Nav1.2 and 1.3 (P was 0.0001 for Nav1.4, 1.5, 1.7, and 1.8, respectively, in comparison with both Nav1.2 and Nav1.3, while P was 0.07 for Nav1.2 and 1.3 when comparing these 2 isoforms). IC50 values for Nav1.4 and Nav1.5 did not significantly differ (P = 0.99), the same as for Nav1.7 and Nav1.8 (P = 0.7). In comparison to the rest of the investigated isoforms, the respective IC50 value of all these 4 channels were significantly different (P < 0.001).

Figure 3
Figure 3
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In the overall view, in all investigated channel isoforms, AJA exhibited half-maximal inhibition of sodium currents at low micromolar concentrations (approximately 2–9 μmol/L, as shown in Table 1). AJA 3 μmol/L induced a strong hyperpolarizing shift of the steady-state inactivation on Nav1.2, Nav1.4, Nav1.5, 1.5NN406K, 1.5F1760A, and 1.7 (Table 2).

Tonic block of resting channels by the local-anesthetic insensitive Nav1.5-mutants N406K and F1760A revealed IC50 values of 3 ± 0.1 μmol/L (n = 9) for N406K (Fig. 4, A and B) and 4 ± 0.3 μmol/L (n = 8) for F1760A (Fig. 4, C and D, Table 1). Thus, both mutants displayed a preserved sensitivity to block by AJA. Statistical analysis by ANOVA (F(2,21) = 5.8267, P < 0.01) followed by the Tukey HSD post hoc test yielded significant differences in IC50 when Nav1.5 (wild-type) was compared with the mutant F1760A (P = 0.009); however, no significant difference in IC50 values was determined comparing the wild-type channel Nav1.5 with the mutant N406K (P = 0.7).

Figure 4
Figure 4
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Moreover, we found that 3 μmol/L AJA induced a prominent shift of steady-state fast inactivation of N406K (−87 ± 1 mV in control to −120 ± 1 mV in 3 μmol/L AJA, n = 10) (Fig. 4F) and of F1760A (−76 ± 1 mV in control to −118 ± 1 mV in 3 μmol/L AJA, n = 9) (Fig. 4G, Table 2).

We observed robust resurgent currents by including 100 μmol/L of the Navβ4-peptide into the pipette solution (Fig. 5, A and B). As is demonstrated in Figure 4C, 1 μmol/L AJA induced a robust inhibition of the resurgent current at all potentials. The inhibition of the peak current amplitude was 24 ± 4 % (n = 7). Tonic block of resting Nav1.5 channels by 1 μmol/L AJA was significantly less pronounced (6.6% ± 1%, n = 9) (P = 0.002, unpaired Student t test), indicating that AJA is indeed a potent inhibitor of resurgent currents.

Figure 5
Figure 5
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DISCUSSION

This in vitro study identified the synthetic cannabinoid AJA as a potent blocker of voltage-gated sodium channels. Despite the fact that AJA does not induce cardiac or central nervous side effects in human volunteers, we found that AJA nonspecifically blocked all investigated α-subunits in a low micromolar concentration range.9 The molecular mechanism mediating this property is distinct from that used by classical local anesthetics. Thus, AJA might target a yet unknown binding site of α-subunits of sodium channels. Although speculative, it is possible that substances targeting this binding site can suppress pathological excitability in sensory neurons while leaving normal membrane excitability largely unaffected.

It is generally acknowledged that the redistribution and altered functional expression of voltage-gated sodium channels are implicated in chronic painful neuropathies that can arise from peripheral nerve injury.27,28 Among the α-subunits investigated in this study, primarily Nav1.3, Nav1.7, and Nav1.8 are expressed in sensory neurons. There is strong evidence that Nav1.3 and Nav1.8 have an impact on neuropathic pain-like behavior after nerve injury in rodents, and Nav1.7 has emerged as a key molecule for peripheral pain processing and for certain painful neuropathies in humans.27,29 Although the Nav1.9 channel is thought to play a prominent role in nociception and has the most divergent amino acid sequence among all Nav channel isoforms, it was not studied because it cannot be reliably expressed in heterologous expression systems.30

We found that AJA is an unspecific blocker of investigated α-subunits, excluding the possibility that analgesia induced by this compound involves a selective interaction with 1 sodium channel isoform. Although we did not have any direct reasons to hypothesize this property for AJA, the reported lack of cardiac and central nervous side effects in humans receiving AJA did not indicate an unselective inhibition of cardiac and neuronal α-subunits.8 Batista et al.31 reported that the plasma-concentration of AJA in patients receiving AJA at analgesic effective doses can be up to 2 μmol/. A fact that hinders the direct comparison between the plasma concentration in patients and the effective concentrations in our in vitro experiments is the plasma protein binding of AJA. From animal studies and unpublished phase I studies it is known that AJA is highly bound to plasma proteins in dog (99.5%–99.9%), rat (98.5%–99.8%), and human (97.0%–99.9%) samples (unpublished results of pharmacokinetic studies). Considering our experiments on Nav1.5 (heart) and Nav1.2 (central nervous system), one would definitely expect side effects to occur at these concentrations if the drug were all present in the free state and not bound to plasma proteins.

The state-dependent inhibition of sodium channels found for AJA in this study closely resembles the properties of local anesthetics, that is, our data strongly suggested that AJA also interacts with the local anesthetic binding site. However, both analyzed local anesthetic-insensitive Nav1.5-mutants (N406K and F1760A) displayed a preserved AJA sensitivity. These data more or less exclude a relevant interaction of AJA with the local anesthetics binding site and indicate that AJA targets a yet unknown site to block sodium channels. A more critical analysis of our data indeed reveals further properties of AJA that support this notion: Use-dependent block by 3 μmol/L AJA was minimal and probably not relevant. Use-dependent block is likely to arise from a higher affinity of a blocker to the open and inactivated states, and is a prototypical effect for most sodium channel blockers interacting with the local anesthetic binding site.32 Blockers with a high cardiotoxic potential, such as bupivacaine and amitriptyline, generally induce a very strong use-dependent block.23,33 It is possible that this property is predisposed for a high cardiac toxicity, and that the obvious lack of cardiotoxicity of AJA is due to its failure to induce use-dependent block. However, use-dependent inhibition may also be an important mechanism when sodium channel blockers are applied for treatment of neuropathic pain.34 Another remarkable property of AJA observed in this study was an impressive shift of the voltage dependency of steady-state fast inactivation. Even though this shift is also induced by local anesthetics and the opiod methadone,35 we are not aware of any substance inducing such a strong shift at low micromolar concentrations (approximately 20 mV by 3 μmol/L). For local anesthetics, this effect is due to an interaction with the local anesthetic site since it is abbreviated in local anesthetic channel mutants.32 However, the shift induced by AJA is perfectly preserved on the mutants Nav1.5—N406K and F1760A, and thus, this effect appears independent of the local anesthetic binding site.

Considering the lipophilic structure and chemical properties of AJA, interactions in the lipid bilayer of the cell membrane could be one possible site of action as suggested for halothane.36 AJA shares some features with volatile anesthetics. Both AJA and volatile anesthetics such as sevoflurane, desflurane, or isoflurane show a hyperpolarizing shift of the voltage-dependency of fast inactivation as well as a voltage-dependent block of sodium currents among the different sodium channel subunits.37–39 Unlike AJA, volatile anesthetics induce significant use-dependent inhibition, whose extent varies due to substance-specific differences in block among different volatile anesthetics.37

AJA’s LogP value (octanol:water partition coefficient) is approximately 7.55. Its lipophilicity might facilitate effects on binding sites in the lipid bilayer to shift the channel gating. But also an interaction with a hydrophobic pocket within the channel protein itself is hypothetically conceivable. Thus, further studies are needed to explore the detailed molecular mechanism of this drug’s action.

A comparable effect on steady-state fast inactivation observed for AJA in this study was recently demonstrated for the endogenous cannabinoid anandamide on Nav1.7.19 The authors of this study found that this property correlates with the ability of the drug to inhibit resurgent currents, and postulated that substances inducing a preferential block of resurgent currents might be useful therapeutic tools. It is interesting to note that this inhibitory property was suggested to be independent from the local anesthetic binding site.19 In our study, AJA inhibited Navβ4-peptide-mediated resurgent Nav1.5-currents more potently than transient currents generated by wild-type Nav1.5. Wild-type Nav1.5 was chosen because it was previously demonstrated to generate large Navβ4 peptide-mediated resurgent currents.40 In contrast, wild-type Nav1.7 hardly generates any detectable resurgent currents.19 As resurgent currents of different α-subunits have been suggested to drive different pain syndromes in humans,21,22 it is possible that the analgesic efficacy of AJA is in part due to inhibition of resurgent currents.

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Limitations of Our Study

We have studied the effects of AJA in vitro in sodium channel α-subunits. Alpha-subunits of sodium channels show normal gating characteristics (with respect to experiments in native tissue) when expressed in a mammalian cell line in the absence of the β-subunit.41,42 In HEK293 cells mRNA encoding, the β1α splicing of the putative regulatory sodium channel subunit is abundantly expressed.43

Irrespective of the role that altered expression of β-subunits may have in the development of pain states in vivo,44 concerns have been raised that exogenous introduction of β1 in HEK cells in vitro may lead to an overexpression of β-subunits which in turn might have unpredictable effects on the pharmacologic interaction between the sodium channel α-subunit and channel blockers.43

The advantage of this experimental approach is that drug interaction with the sodium channel can be studied without confounding factors in this model since it is generally accepted that the receptor sites for pharmacological agents interfering with voltage-gated sodium channels are located on the α-subunits.45

In summary, our in vitro study identified AJA as an unselective inhibitor of voltage-dependent sodium channels. This inhibition is concentration- and state-dependent, properties that AJA shares with other cannabinoids. It is assumed that these inhibitory effects of AJA are mediated by mechanisms distinct from the local anesthetic binding site. This could be one of the mechanisms by which AJA exerts analgesic effects in patients with neuropathic pain. Thus, AJA is not only an interesting drug with implications for pain treatment but also as a tool to further explore a yet poorly defined route to inhibit voltage-dependent sodium channels.

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DISCLOSURES

Name: Nilufar Foadi, MD.

Contribution: Nilufar Foadi designed experiments, acquired, analyzed, interpreted data, and participated in writing the manuscript.

Attestation: Nilufar Foadi read and approved the final manuscript and is the archival author.

Name: Christian Berger, MD.

Contribution: Christian Berger performed experiments and acquired, analyzed, and interpreted data.

Attestation: Christian Berger read and approved the final manuscript.

Name: Igor Pilawski, VMD.

Contribution: Igor Pilawski performed experiments and acquired, analyzed, and interpreted data.

Attestation: Igor Pilawski read and approved the final manuscript.

Name: Carsten Stoetzer, MD.

Contribution: Carsten Stoetzer performed experiments and acquired, analyzed, and interpreted data.

Attestation: Carsten Stoetzer read and approved the final manuscript.

Name: Matthias Karst, MD.

Contribution: Matthias Karst participated in design of experiments, contributed to the methods and illustrations, and edited the manuscript.

Attestation: Matthias Karst read and approved the final manuscript.

Name: Gertrud Haeseler, MD.

Contribution: Gertrud Haeseler participated in design of experiments, contributed to the methods and illustrations, and edited the manuscript.

Attestation: Gertrud Haeseler read and approved the final manuscript.

Name: Florian Wegner, MD.

Contribution: Florian Wegner participated in design of experiments, contributed to the methods and illustrations, and edited the manuscript.

Attestation: Florian Wegner read and approved the final manuscript.

Name: Andreas Leffler, MD.

Contribution: Andreas Leffler mentored, conceived, designed, coordinated the study, and drafted the manuscript.

Attestation: Andreas Leffler read and approved the final manuscript.

Name: Jörg Ahrens, MD.

Contribution: Jörg Ahrens mentored, conceived, designed, coordinated the study, and drafted the manuscript.

Attestation: Jörg Ahrens read and approved the final manuscript.

This manuscript was handled by: Marcel E. Durieux, MD, PhD.

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ACKNOWLEDGMENTS

We are indebted to Prof. Frank Lehmann-Horn (Ulm, Germany) for providing us with transfected cells, Andreas Niesel (Hannover, Germany) for technical support and Prof. Sumner Burstein, (Boston) for his kind supply of AJA.

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