Prolonged exposure to levetiracetam reveals a presynaptic effect on neurotransmission

Purpose: The antiepileptic drug levetiracetam (LEV) is an enigma. Despite the fact that it specifically binds to the presynaptic vesicle protein, SV2A, no satisfactory mechanism of action has yet been identified. Using a combination of electrophysiological and cellular imaging techniques, we carefully tested the hypothesis that LEV directly interferes with neurotransmitter release. Methods: We measured extracellular evoked responses in the CA I region of rat hippocampal slices after paired pulse stimulation and after application of up to 10 pulses applied at 580 Hz. In parallel experiments, we used quantitative 2-photon microscopy and the fluorescent vesicular marker FM1-43 to measure the effect of repetitive stimulation on presynaptic vesicle release. Results: Acute exposure to LEV (100 mu M) had no effect on paired pulse synaptic responses. However, when slices were exposed to LEV for 3 h, there was a significant alteration in paired pulse responses and a more striking reduction in late synaptic potentials delivered in an 80 Hz train. LEV significantly reduced the rate of vesicle release assessed by FM1-43 destaining during 1 Hz stimulation. Conclusion: LEV is unique among currently available antiepileptics, because it directly inhibits presynaptic neurotransmitter release in a use-dependent fashion. While there are alternate explanations for this observation, it is plausible that LEV exerts its effect by binding to a protein selectively expressed in presynaptic nerve terminals.