Piracetam and piracetam-like drugs: the view of a clinical pharmacologist

What it is

These are drugs that improve performance, memory and learning ability. Piracetam was created first - it appeared in the sixties of the last century. In the seventies, scientist Corneliu Giurgia discovered that this medicine stabilizes the membranes of cells in the central nervous system, improving the functioning of brain cells. They didn’t know the exact mechanism of how piracetam works—they were just guessing. Giurja proposed using it to restore mental abilities after injuries, oxygen starvation of the brain, with senile dementia and congenital dementia in children.

Most nootropics are of animal origin. They are extracted from the brains of pigs and cattle, rich in low molecular weight proteins. The drugs are inexpensive and rarely cause side effects, which is why doctors love them.

Application diagram

Nootropic drugs are prescribed in the following situations:

1. Symptomatic treatment of psychoneurological diseases accompanied by decreased memory and attention, impaired mental activity, mood changes and behavioral disorders. Typically, nootropics are prescribed in the complex therapy of Alzheimer's disease and senile dementia.
2. Rehabilitation after ischemic stroke.
3. Comatose states of various origins.
4. Treatment of cortical myoclonus - in combination with other drugs.
5. Treatment of dizziness and related conditions.
6. Comprehensive treatment of dyslexia in children. This condition makes it difficult to learn reading and writing skills while maintaining overall learning ability.
7. Treatment of abstinence and psychoorganic syndrome against the background of chronic alcoholism.
8. Complex therapy of sickle cell anemia.
9. The dosage of the drug is calculated taking into account age. Typically, nootropics are prescribed 2-4 times a day for a course of 6-8 weeks.

When to use them

Most often, nootropics appear in the prescriptions of neurologists. They are prescribed for everything - from neurosis and OCD, from VSD, which does not exist, and dementia. In hospitals, nootropic drugs are administered intravenously to speed up tissue recovery after a stroke or transient ischemic attack - as prescribed by clinical recommendations. But they do not recommend using some nootropics during the acute period of ischemic stroke due to possible neuronal depletion and steal syndrome. Therefore, focusing only on them is not enough.

“First, the doctor makes a generally accepted diagnosis,” says GMS Clinic neurologist Sergei Makarov. — If we are talking about vascular cognitive impairment, then first of all the risk factors are corrected: diabetes mellitus, atherosclerosis and arterial hypertension. Not all diseases require medication."

But many neurologists and psychiatrists, who are not interested in new research, prescribe nootropics to people with impaired memory, attention and learning ability, focusing only on clinical recommendations. For example, Cerebrolysin is recommended for the prevention of dementia at the initial signs of Alzheimer's disease. Also, many doctors believe that nootropics will help you stay sane and memory longer in case of chronic vascular disorders of the brain.

“When a child has a disorder of psychoneurological development, the doctor is tempted to give something to “improve brain function,” says Varvara Khaletskaya, MD, neurologist at the Fantasy children’s clinic. “After all, sometimes there is no effective method leading to a complete recovery. Therefore, the doctor and the parent are trying to invest bit by bit: pedagogical correction, physiotherapy and medications.

It’s another matter when there is an effective treatment protocol, but the doctor continues to treat in his own way. It turns out ugly: instead of pedagogical correction, a child with psycho-speech disorders is given nootropic drugs, and they are advised to “wait” with classes. Or in the case of sensorineural hearing impairment, for which hearing aids are possible, they are referred to a neurologist to “feed” the auditory nerve. In this case, time is simply wasted. Before prescribing a treatment with insufficient evidence base, the doctor should make sure that there is a more effective solution.”

Piracetam and piracetam-like drugs: the view of a clinical pharmacologist

Currently, there are more than 10 “piracetam-like” drugs, including piracetam itself, which are used in various countries around the world or are at one or another stage of clinical trials. These include: • piracetam, levetiracetam, seletracetam and brivaracetam (developed by UCB Pharma, Belgium); • oxiracetam (developed by ISF, Italy); • aniracetam (developed by Roche Pharmaceuticals, Switzerland); • pramiracetam (developed by Warner-Lambert, USA) [6]; • phenylpiracetam (developed at the Institute of Medical and Biological Problems of the Russian Academy of Medical Sciences, produced by Valenta Pharmaceuticals, Russia). All of these drugs have a chemical structure similar to piracetam, the main component of which is the pyrrolidone ring, and therefore this group is called “racetams” (Fig. 1). Despite the structural similarity, the clinical effects observed with the use of racetams are quite diverse and allow us to divide them into 3 subgroups: 1. Drugs primarily used to treat cognitive impairment. This subgroup includes piracetam, pramiracetam, phenylpiracetam, oxiracetam and aniracetam (the latter two drugs are no longer used in clinical practice). It should be noted that drugs in this group can also be used for balance disorders, cortical myoclonus and dyslexia. 2. Drugs for the treatment of epilepsy. This subgroup includes levetiracetam, brivaracetam and seletracetam. The effect of these drugs on cognitive function is unclear. 3. The third subgroup includes drugs whose clinical effectiveness is unknown. These drugs include nefiracetam (which has not been shown to improve cognitive function in stroke patients) and rolipram (currently being studied as an antidepressant). This subgroup also includes a number of other drugs that are at the stage of clinical trials. Thus, we can say that piracetam and piracetam-like drugs (drugs) (let’s call them piracetam analogues) have found their use in a fairly wide range of neurological diseases [1], which is based on the results of clinical studies with different designs (both open uncontrolled and double-blind, placebo-controlled). These drugs have been actively studied over the past three decades, resulting in a significant number of publications. Of more than 10 new piracetam-like drugs, 8 have undergone clinical trials for various CNS indications in recent years. When searching the Internet using the US National Library of Medicine PubMed database [2] using the keywords “clinical trial” and “international nonproprietary name of the drug” (piracetam or the international nonproprietary name of the “piracetam-like” drug), more than 300 publications were found. Table 1 shows the dynamics of publications on clinical trials of piracetam and piracetam-like drugs over four time periods: 2007–2010, 2004–2006, 1999–2003. and until 1999. Two articles are meta-analyses: one is the clinical effectiveness of piracetam in cognitive disorders [3], the other is a meta-analysis of the effectiveness of piracetam and piracetam-like drugs in experimental strokes in animals [4]. This review analyzes the results of experimental and clinical studies of piracetam and piracetam-like drugs belonging to the first subgroup of drugs that studied the effectiveness of piracetam in the treatment of cognitive impairment. Mechanisms of action of piracetam It should be noted that the pharmacology of piracetam-like drugs is much less studied than their clinical use [5]. These compounds modulate the processes of excitation and/or inhibition of neurotransmitters, neurohormones and/or postsynaptic signals. These effects of piracetam and piracetam-like drugs can manifest themselves in the form of an effect on cognitive and mnestic functions [5]. Based on the results of several experimental studies, it has been suggested that piracetam plays an important role in energy metabolism, including increasing brain oxygenation and the permeability of cellular and mitochondrial membranes to Krebs cycle mediators [7,8], increasing the synthesis of cytochrome b5 [9 ]. The similarity of the chemical structure of piracetam to GABA suggests that piracetam is likely to have GABAergic effects [10]. Other researchers suggest that piracetam “works” as an antioxidant/neurotonic [11,12] and increases acetylcholine receptor density [13]. The number of such hypotheses, each of which quite convincingly describes one or another aspect of the mechanism of action of piracetam, is quite large; however, in order to form a unified concept, additional research on the drug is required. Due to the differences between piracetam and piracetam-like drugs, it is unlikely that all of these drugs will act in the same way, affecting the same target molecules. A number of hypotheses focus on the modulation by piracetam of the function of ion channels (sodium, potassium, calcium) in the neuronal membranes of neurons or neuromuscular synapses. Thus, it has been established that piracetam, oxiracetam and aniracetam activate the AMPA type of glutamate receptors (the endogenous ligand is amino-3-hydroxy-5-methylisoxazole-4-propionate), but do not affect the NMDA receptors of neurons. This leads to an increase in the release of calcium from the cell [14], resulting in a decrease in the concentration of intracellular calcium. Pramiracetam increases the rate of sodium-dependent choline uptake in the hippocampus in rats. Its effect on cognitive function may occur through acceleration of the flow of impulses from cholinergic neurons in the hippocampal septum [15]. The experiment established that phenylpiracetam has an affinity for H-cholinergic receptors, but not for NMDA-type glutamate receptors. However, injections of this drug (100 mg/kg, intraperitoneal) increase the number of both H-cholinergic and NMDA receptors in rats, but reduce the number of serotonin and dopamine receptors in brain tissue [16]. Unlike other piracetam-like drugs, levetiracetam has pronounced anticonvulsant activity, and therefore is used to treat patients suffering from epilepsy. Its mechanism of action has not been fully studied, but we can say that the drug does not directly affect such “classical” processes/targets for antiepileptic drugs as GABAergic transmission and sodium channels. The most likely site of application of levetiracetam is the SV2A protein. It is assumed that this protein is involved in the processes of exocytosis and, due to its structural similarity to membrane transporters, may play a role in maintaining synaptic homeostasis, in particular, components such as ATP and calcium. The effect on calcium homeostasis is confirmed by the data that SV2A interacts with synaptotagmin, which is a kind of calcium sensor of the cell, as well as by the inhibition under the influence of levetiracetam of calcium release by PC-12 cells, which contain SV2A, and the absence of such an effect in 3T3 fibroblasts, where no SV2A [52]. There is also evidence that, in a therapeutic dose range, levetiracetam reduces ion fluxes into neurons induced by activation of AMPA receptors [19]. This may be due to inhibition of calcium channels [17–19]. Levetiracetam and nefiracetam activate NMDA receptors. In cultured rat cortical neurons, this effect was mediated through activation of protein kinase C and phosphorylation of one of the NMDA receptor subunits. This, in turn, increases the binding of glycine to the NMDA receptor [20]. Fasoracetam modulates glutamate receptors, which leads to activation of adenylate cyclase and increased formation of cyclic adenosine monophosphate (cAMP), which is involved in various “signaling” processes, incl. such as learning and memory. The mechanism of action of colurocetam has been described in different ways. Most authors indicate that colurocetam affects choline transport [21], which leads to increased choline uptake in hippocampal synaptosomes [22]. It should be noted that the relationships between these various complex processes are very difficult to analyze. Clinical use of piracetam Piracetam was first registered in Europe in the early 1970s. It does not belong to potent drugs and drugs with a narrow therapeutic index, therefore, in experiments it is characterized by low toxicity, and in clinical settings by low frequency and mild severity of adverse reactions, such as anxiety, insomnia or drowsiness and agitation [3,5, 23]. Treatment of Cognitive Impairment Although the first reported effect of piracetam on the central nervous system was the suppression of nystagmus in the rabbit, further findings over the past 25 years have shown that the main effect of piracetam is to improve cognitive function. The earliest studies focused on pharmacological modulation of cerebral shock-induced amnesia. Giurgea and Mouravieff Lesuisse demonstrated that piracetam reduced the effect of electric shock on disorientation in rats in a water maze. Similar effects of piracetam and drugs similar to it in chemical structure have been described by many other authors. Studies of piracetam and aniracetam by Cumin et al., studies of piracetam and oxiracetam by Mondadori et al., and studies of etiracetam by Sara et al. showed significant protective effects against electrical shock. Buler et al. also described the antiamnestic effects of a whole series of piracetam analogues, including pramiracetam. The direct positive effect of nootropics on learning and memory has been repeatedly described [29]. Over the past 10 years, more than 20 review articles have been published with the results of clinical studies of piracetam confirming its clinical effectiveness (Table 2). In a study involving 162 patients who were diagnosed with age-related memory impairment, three groups of patients were formed. Patients of the first group received piracetam at a dose of 2.4 g/day, the second - 4.8 g/day, patients of the third group received placebo. The duration of the study was three months. All patients included in the study participated in a memory training program. The best results in tests for immediate (p<0.0004), general (p<0.002) and delayed (p<0.04) recall were achieved in the group of patients who took piracetam at a dose of 4.8 g/day. In the group of patients taking piracetam at a dose of 2.4 mg/day, a significant improvement compared with placebo was observed in immediate recall tests (p < 0.03) [30]. The therapeutic effect of piracetam in dementia is limited by the pathology underlying the disease. However, a number of studies have shown that piracetam can slightly improve the cognitive status of such patients [32]. A study of 130 patients diagnosed with mild to moderate dementia compared the effect of piracetam at a dose of 4.8 g/day with placebo. At the end of the 12-week treatment period, the piracetam group showed a significant improvement compared with the placebo group (p<0.001). Long-term treatment with piracetam may also slow the development of cognitive impairment. Thus, according to the results of a one-year double-blind study on patients diagnosed with probable Alzheimer's disease, in the group of patients taking piracetam, deterioration in cognitive function was observed in only one of the 14 scales used. At the same time, in the group of patients taking placebo, deterioration of cognitive functions was observed on 9 scales [33]. Of course, the number of patients participating in the studies described above is too small to draw valid conclusions about the effectiveness of piracetam, so two meta-analyses were conducted that examined the effectiveness of piracetam in elderly patients with age-related cognitive decline. Both meta-analyses used clinical global impression (CGI) scores from different studies. PCS is an important measurement tool that helps determine the clinical significance of any reported improvement. In addition, this scale is recommended for use as part of any clinical trial in patients with Alzheimer's disease. This scale is not sensitive to small changes in the patient's condition, which may not be clinically significant. Any change recorded using this scale is, by definition, clinically significant [32]. A smaller meta-analysis examined data from 6 randomized placebo-controlled trials involving 477 patients with vascular dementia, unclassified dementia, Alzheimer's disease, or cognitive impairment not meeting criteria for dementia. The ratio of patients who improved to those who did not was 3.47 (95% confidence interval) or 3.55, depending on whether a fixed- or random-effects model was used [34]. The second meta-analysis examined the effectiveness of piracetam for PCS in a larger number of studies and in a larger number of patients. It included both published and unpublished studies on piracetam. The number of studies was 19, the number of patients included was 1500. All studies were double-blind, parallel groups, placebo-controlled. They were carried out from 1972 to 1993. The studies involved patients 50 years of age and older with diagnoses of age-related cognitive impairment and degenerative dementia. The duration of the studies ranged from 6 to 52 weeks, piracetam was prescribed in doses from 2.4 to 8 g/day. This meta-analysis showed that improvement in the PCS was observed in more than 60% of patients taking piracetam, and only 30% of those taking placebo. The consequence of this is that the ratio of patients who showed improvement to those who did not show a change was favorable for piracetam, which was 2.45 (95% confidence interval) or 3.35 (95% confidence interval) depending on the statistical method used [3]. The meta-analysis data is consistent with the data obtained by Flicker and Grimley Evans, but is more accurate because smaller confidence intervals are used). Use of piracetam-like drugs in the Oxiracetam clinic. Due to the hydroxyl groups in the oxypyrrolidone core, oxiracetam has a favorable pharmacokinetic profile - high oral bioavailability [37]. In a prospective, double-blind study in 12 healthy volunteers, oxypiracetam attenuated the decline in neuropsychological performance (eg, semantic memory, reading) induced by scopolamine [38]. There is evidence that the use of oxiracetam for 2–6 months in people over the age of 65 years improves some cognitive impairment of non-specific etiology [39]. However, oxiracetam failed to benefit patients with Alzheimer's disease (albeit, the duration of treatment was only 1 month) [40]. The recommendations of the International Anti-Aging Systems (UK) indicate that oxiracetam can be used for “memory disorders caused by cerebrovascular insufficiency, mental impairment in old age,” but there is no such information from the manufacturer yet [5]. Pramiracetam. Replacing the amide group in the structure of piracetam with dipropane-2-ulaminoethyl also allows pramiracetam to have high bioavailability [41,42]. However, it is more active than piracetam and is therefore used in lower doses compared to piracetam [43]. Italian researchers demonstrated a reduction in the scopolamine-induced amnesic effect in healthy volunteers when treated with pramiracetam, that is, two out of five cognitive measures (including immediate and delayed verbal tests) were approximately 50% better than those receiving placebo [44]. . Two small studies were conducted in Ukraine: one in patients with cerebrovascular disease [45] and the other in patients with concussion [46]. The first study showed that visual and verbal memory improved modestly with pramiracetam in younger patients with chronic cerebrovascular and post-stroke cognitive symptoms and to a lesser extent in older patients. Aniracetam. Due to changes in the N-side chain derivative, aniracetam has low bioavailability and is rapidly eliminated [47]. In another small study in elderly patients with cerebrovascular disease, aniracetam was effective [48]. However, animations are not effective in patients with memory impairment, cognitive functions associated with chronic toxic effects of organic solvents [49]. Phenylpiracetam. Like piracetams, this drug has high bioavailability, however, data on pharmacokinetics were obtained on laboratory animals [50.51], the pharmacokinetic parameters in humans are not published. Phenylpiracetams reduces the severity of headache and general fatigue after 14 days of therapy in patients with cognitive disorders and/or depression after the CMT, with encephalopathies of various etiology [53, 54]. It has a favorable effect in patients with CVB [55], reduces the manifestations of asthenia and depression in patients with RS [56], chronic fatigue syndrome [57], in adolescents with asthenic syndrome [58]. Adding to anticonvulsants reduces the amount and frequency of seizures, slightly improves cognitive functions [59, 60]. Perhaps the drug reduces the titer of antibodies to myelin in cerebral stroke [61], but this is not confirmed in all studies [62]. In 80% of patients with an open -angle form of glaucoma after normalizing eye pressure, the drug contributed to the stabilization of the disease [63]. It is also recommended to astronauts to increase physical and mental performance, stimulate cognitive functions [6]. Nevertheless, to draw conclusions about the effectiveness of phenylpiracetam prematurely, since there are no large prospective placebo -controlled studies. The conclusion of the results of experimental and clinical studies accumulated to date allow us to say that it is necessary to deeply study the effectiveness and safety of piracetam and piracetam -like drugs. It seems that the effectiveness of these drugs according to most indications seems promising. Therefore, there is a need for better, large controlled clinical studies. It should also be noted that the neuroprotective effects of piracetam and piracetam -like drugs are practically not studied. Unlike most GABA --ergic preparations (for example, barbiturates, carbamazepine), which can cause pronounced NPR, including amnesia, piracetam and piracetam -like drugs are relatively safe. However, we can say that delayed effects of these drugs and potential risks associated with their use have not yet been identified. The mechanisms of action of piracetam and piracetam -like drugs are also not studied and require further clarifications. But the prospects of the use of piracetam in clinical practice are not in doubt.

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Do they have any effect?

Until the 2000s, the actual mechanism of action and effectiveness of nootropics was not particularly studied. Doctors prescribed them, and people drank them. There was a myth circulating among medical students that a month-long course of nootropics before exams improves memorization of the material, and to be sure, you need to inject it into a muscle or vein.

Now the proof of the drug’s effectiveness is not the doctor’s word, but research data. There must be at least three thousand participants, and they must be divided into at least two groups, one of which is a control group with a placebo. At the same time, neither the doctor nor the patient knows what each of the subjects is drinking - medicine or a “dummy”.

Nootropic drugs have been little studied, and studies of their effectiveness are inadequate. Either there are too few people, or the criteria are unclear. For example, they estimate the number of test points only after treatment - they apparently forgot before treatment. The American FDA, in principle, does not consider nootropics to be drugs - in the USA they are sold as dietary supplements.

“Everyone knows that nootropics are drugs without proven effectiveness. But they continue to be used, says Varvara Khaletskaya. — There are statistics, there are international protocols that help the doctor. But at the same time, each doctor’s personal experience remains with a wide range: from “they are useless” to “they are effective in many patients.”

The fact is that there is a rare exception: piracetam improves cognitive function in people with severe dementia, according to an assessment of 19 high-quality studies. But with a traumatic brain injury or mild dementia, piracetam will no longer help. Moreover, it is useless for healthy people who want to follow the path of Eddie Morra from the film “Dark Areas” and become a megabrain. Therefore, if biohacking experiments with Mexidol seem to be effective, it is only due to self-persuasion.

Contraindications and side effects

Since piracetam is used in the treatment of various pathologies, the instructions focus on this, only a doctor should prescribe its use, based on the patient’s condition and the presence of contraindications. Do not use the drug if you are hypersensitive to the active substance or other components included in its composition. The medicine is not used to treat children under one year of age, as well as during pregnancy and lactation.

Piracetam tablets, the instructions indicate this, are not used in the presence of the following pathologies:

• Huntington's chorea, which is a genetic disease and is characterized at the initial stage of development by impaired coordination of movements.
• Chronic renal failure in severe form.
• Hemorrhagic stroke.
• Psychomotor agitation.

The decision to take piracetam should be made with extreme caution in case of hemostasis disorders, severe bleeding, or after major surgical operations.

Various side effects were observed when taking the drug. Patients most often experienced the following body reactions:

• Nausea and vomiting.
• Headache.
• Hives.
• Diarrhea.

As a rule, such side effects disappear on their own during therapy. More dangerous symptoms while taking the drug are decreased blood pressure, abdominal pain, depression, hallucinations, dermatitis, and confusion. Sometimes during treatment with the drug, motor disinhibition, increased libido, drowsiness or insomnia, and a constant feeling of internal anxiety occur. Overdose may increase side effects.

conclusions

Let's summarize:

1. Nootropil and Piracetam are drugs from the group of nootropics. They are prescribed in neurology and psychiatry to improve brain function.
2. Nootropil and Piracetam contain the same active ingredient. Indications, contraindications and adverse reactions of the drugs are the same.
3. The effectiveness of nootropics has not been confirmed by clinical trials. There is no evidence that their effect differs from placebo.

It is likely that piracetam can affect the functioning of the nervous system, but you should not rely on it. If a pathology is identified, the doctor will select other drugs that improve the patient’s condition - and will not limit himself to nootropics. There is no point in taking Nootropil or Piracetam for a healthy person. Sound sleep, proper nutrition, and exercise stimulate brain function better than any medication.