Science in medicine

Mutations in sodium-channel gene SCN9A cause a spectrum of human genetic pain disorders
Joost P.H. Drenth1 and Stephen G. Waxman2,3
2Department 1Department

of Medicine, Division of Gastroenterology and Hepatology, University Medical Center St. Radboud, Nijmegen, The Netherlands. of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA. 3Center for Neuroscience and Regeneration Research, West Haven VA Medical Center, West Haven, Connecticut, USA.

The voltage-gated sodium-channel type IX subunit, known as Nav1.7 and encoded by the gene SCN9A, is located in peripheral neurons and plays an important role in action potential production in these cells. Recent genetic studies have identified Nav1.7 dysfunction in three different human pain disorders. Gain-of-function missense mutations in Nav1.7 have been shown to cause primary erythermalgia and paroxysmal extreme pain disorder, while nonsense mutations in Nav1.7 result in loss of Nav1.7 function and a condition known as channelopathy-associated insensitivity to pain, a rare disorder in which affected individuals are unable to feel physical pain. This review highlights these recent developments and discusses the critical role of Nav1.7 in pain sensation in humans.
Painisoneofthemostpervasivesymptomsinclinicalmedicine; itoccursinamultitudeofclinicalconditionsandisencountered bycliniciansineverysubspecialty.Yettreatmentofchronicor recurrentpainremainschallenging,inpartbecausethetherapeuticarmamentariumisincomplete.Hopefully,thiswillchange asaresultofincreasedunderstandingofthemolecularbasisof pain.Overthepastseveralyears,elucidationofthegeneticdefects underlyingthreemonogenicpaindisordershasprovidedimportantinsightsabouthumanpainanditsmolecularsubstrates. Here,webrieflyreviewtheserecentadvances. A genetic basis for pain Theunravelingofthehumangenomemayallowustocompare variationsatthegeneticlevelwithinterindividualdifferencesin painthresholdsandpainperception.Moststudiesinthepasthave focusedongeneticpolymorphismsthatmightberesponsiblefor interindividualdifferencesinpainperception.Forexample,a commonfunctionalSNP(V58M)inthecatechol-O-methyltransferase(COMT)genemodifiespainsensitivity(1).COMThasbroad biologicalfunctions,includingthemetabolismofcatecholamines, suchasneurotransmitters,thatmodulateneuronalcellsignaling. IndividualshomozygousfortheValgenotypearelesssensitiveto paincomparedwiththosewithMethomozygosity(1);however, thedifferencesinpainsensitivitybetweengroupsarerelatively subtle.Amoredramaticsetofobservationshasbeenreportedin studiesofrareMendeliandisorders.Overadecadeago,mutations inthevoltage-dependentcalciumchannel,P/Qtype1Asubunit (CACNL1A4)wereidentifiedinfamilieswithfamilialhemiplegic migraine,asubtypeofmigrainewithauraandparalysis(2).This findingindicatedthatchanneldysfunctioncouldleadtohuman disordersinwhichpainisaprominentsymptom.Morerecent geneticstudieshaveidentifiedthevoltage-gatedsodium-channel
Nonstandard abbreviations used:CIP,channelopathy-associatedinsensitivityto pain;DRG,dorsalrootganglion;Nav1.7,sodiumchannelencodedbySCN9A;PE,primaryerythermalgia;PEPD,paroxysmalextremepaindisorder;SCN9A,voltage-gated sodium-channeltypeIXsubunit. Conflict of interest:Theauthorshavedeclaredthatnoconflictofinterestexists. Citation for this article:J. Clin. Invest.117:36033609(2007).doi:10.1172/JCI33297.

typeIXsubunit(SCN9A,referredtohereinasNav1.7)asakey playerinthreeconditionsinwhichrecurrentpainortheinabilitytosensepainisaprominentsymptom(38).Thesedisorders primaryerythermalgia(PE),paroxysmalextremepaindisorder (PEPD),andchannelopathy-associatedinsensitivitytopain(CIP) aretypifiedbyverydifferentpainphenotypes.Remarkably, recentworkhasshownthatdifferenttypesofchannelopathies (diseasescausedbydisturbedfunctionofionchannelsubunits ortheproteinsthatregulatethem),allinvolvingthesameNav1.7 sodiumchannel,underlieallthreeofthesedisorders(38).These discoveriesallowbetterunderstandingnotonlyofthemolecular pathogenesisoftheseparticulardisordersbutalsoofthemolecularpathophysiologyofpain(9). Sodium channels Voltage-gatedsodiumchannelsplayacriticalroleinthegeneration andconductionofactionpotentialsandarethusimportantfor electricalsignalingbymostexcitablecells(10,11).Sodiumchannelsareintegralmembraneproteinsandarecomprisedofalarge subunit,whichformsthevoltage-sensitiveandion-selectivepore, andsmallerauxiliarysubunit(s)thatcanmodulatethekinetics andvoltagedependenceofchannelgating(12).Todate,weknow of9isoformsofthesodium-channelsubunit(Nav1.1Nav1.9), eachwithauniquecentralandperipheralnervoussystemdistribution(10).Fourcloselyrelatedsodiumchannels(Nav1.1,-1.2,-1.3, and-1.7)areencodedbyasetof4genes(SCN1A, SCN2A, SCN3A, and SCN9A,respectively)locatedwithinaclusteronchromosome 2q24.3.MutationsinthegenesencodingNav1.1,-1.2,and-1.3are responsibleforagroupofepilepsysyndromeswithoverlapping clinicalcharacteristicsbutdivergentclinicalseverity(13,14).Here, wefocusononeofthesubunits,Nav1.7,becauseofitscritical roleinpainsensation. Nav1.7isencodedbySCN9A,a113.5-kbgenecomprising26exons (OMIM603415)(Figure1A).Theencodedsodiumchanneliscomposedof1977aminoacidsorganizedinto4domains,eachwith6 transmembranesegments(15),andispredominantlyexpressedin thedorsalrootganglion(DRG)neuronsandsympatheticganglionneurons(16)(Figure1B).Immunohistochemicalstudiesshow thatNav1.7ispresentatthedistalendsofthewire-likeprojections
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Figure 1
Mutations in the sodium-channel subunit Nav1.7 that are associated with the genetic pain disorders PE, PEPD, and CIP. (A) Nav1.7 is encoded by the 113.5-kb gene SCN9A, comprising 26 coding exons. The identity and location of known patient mutations in Nav1.7 that have been linked to PE (*), PEPD (^), and CIP (#) are shown. Note that the mutations are spread over the entire gene sequence; however, mutations linked to PEPD tend to be located closer to the 3 end of the gene. (B) A schematic of the Nav1.7 sodium-channel subunit showing the 4 domains (D1D4), each with 6 transmembrane segments. Locations of known mutations associated with genetic pain disorders PE, PEPD, and CIP are shown. COOH indicates the C-terminus of the peptide chain. HN indicates the N-terminus of the peptide chain.

ofneuronsknownasneurites,closetotheimpulsetriggerzone whereneuronalfiringisinitiated(16)(Figure2).Interestingly,the largemajorityofDRGneuronsthatexpressNav1.7arepainsensing(nociceptive),suggestingaroleforthissodiumchannelinthe pathogenesisofpain(17).InadditiontoNav1.7,Nav1.8andNav1.9 arealsopredominantlypresentinsmallnociceptivesensoryneuronsandthenervefibersemanatingfromthem(18,19). Physiology of Nav1.7 Insensoryneurons,multiplevoltage-dependentsodiumcurrents canbedifferentiatedbytheirgatingkineticsandvoltagedependenceandcanalsobedefinedbytheirsensitivitytothevoltagegatedsodium-channelblockertetrodotoxin(12).TheNav1.7chan3604

nelproducesarapidlyactivatingandinactivatingcurrentthatis sensitivetosubmicromolarlevelsoftetrodotoxin.ThisisincontrastwithNav1.8,whichisalsopresentwithinDRGneuronsbut isfairlyresistanttotetrodotoxin.Nav1.7appearstobeimportant inearlyphasesofneuronalelectrogenesis.Nav1.7ischaracterized byslowtransitionofthechannelintoaninactivestatewhenitis depolarized,eventoaminordegree,apropertythatallowsthese channelstoremainavailableforactivationwithsmallorslowly developingdepolarizations,usuallymimickedbyelectrophysiologistsasramp-likestimuli(20).Thus,Nav1.7actsasathreshold channelthatamplifiessmall,subtledepolarizationssuchasgeneratorpotentials,therebybringingneuronstovoltagesthatstimulateNav1.8,whichhasamoredepolarizedactivationthresholdand

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sameresearcherscreatedmicedeficientinbothNav1.7andNav1.8 (27).MicedeficientinNav1.8haddeficitsinsensinginflammatorypain(initiatedbytissuedamage/inflammation)andvisceral pain(initiatedbydamageorinjurytointernalorgans)butnot neuropathicpain(28).ThethermalpainthresholdinmicedeficientinbothNav1.7andNav1.8micewastwicethatofmicelackingonlyNav1.7.Therewasnoeffectoninducedneuropathicpain inthedoubleknockouts,andtheeffectofthelossofNav1.7in raisingthethresholdforinflammatorypainwassooverwhelmingthatnoadditionaleffectofNav1.8deletionwasseen.Collectively,theseresultsclearlyimplicateNav1.7asamajorsodium channelinperipheralnociceptionandsuggestafunctionallink toNav1.8.Althoughinsightful,thesedatashouldbeinterpreted withcaution,asdirectevaluationofpaininmiceisnotpossible. Instead,researchersrelyonbehavioralchangesofanimalssuch assignsofpawguarding,lifting,andlimping.Asaconsequence, therelevanceoftheobservedchangestohumanpainremains tobedetermined. Figure 2
Neuronal Nav1.7 channels. Nav1.7 (shown here in red after immunocytostaining with anti-Nav1.7 antibody; Alomone Reagents) within the tip of a growing neurite from rat DRG neuron in culture. Image kindly provided by Joel A. Black, Department of Neurology, Yale University, New Haven, Connecticut, USA.

whichproducesmostofthetransmembranecurrentresponsible forthedepolarizingphaseofactionpotentials(21).Inthisregard, Nav1.7ispoisedasamoleculargatekeeperofpaindetectionat peripheralnociceptors. Inflammatory mediators and pain Anumberof(inflammatory)mediators,suchasprostaglandin (22),adenosine(23),andserotonin(24),affecttheelectrophysiologicalpropertiesofvoltage-gatedsodiumchannels.Thesemediatorsincreasethemagnitudeofthecurrent,leadtoactivationofthe channelatmorehyperpolarizedpotentials,andenhancetherates ofchannelactivationandinactivation.Asaconsequence,inflammationcansensitizenociceptiveneurons.Inanexperimental modelofinflammatorypaininwhichanirritantwasinjectedinto thehindpawinrats,Nav1.7proteinexpressionwasupregulated withinDRGneuronsthatprojecttheiraxonstotheinflamedarea (25),achangethatshouldincreaseexcitabilityofthesecells.Collectively,thesedatasuggestthatNav1.7contributes,atleastin part,topainassociatedwithinflammation. Animal studies of Nav1.7 ToobtaininsightintothephysiologicalroleofNav1.7,Nassaretal. generatedtargetedknockoutmicethatlackNav1.7withinnociceptiveDRGneurons(26).SelectivedeletionofNav1.7innociceptorsfrommiceproducesaphenotypeinwhichheat-inducedpain thresholdsareminimallyaltered,thereisnochangeinpunctate mechanicalpainthreshold,andcold-evokedchannelactivityis unchanged.Incontrast,thereisageneralfailuretodeveloppainor hypersensitivityinresponsetoinflammatorystimuli,whileneuropathicpain(chronicpainresultingfrominjurytothenervous system)remainsintact.TheseresultsareconsistentwithanimportantroleofNav1.7insettingtheinflammatorypainthreshold. ToassesstheroleofNav1.7further,especiallyinrelationtoother sodiumchannelsexpressedinperipheralsensoryneurons,the

Primary erythermalgia Primaryoridiopathicerythermalgia(OMIM133020)isanautosomaldominant,inheriteddisorder.Clinically,PEischaracterizedby attacksorepisodesofsymmetricalburningpainofthefeet,lower legs,andsometimeshands,elevatedskintemperatureofaffected areas,andreddenedextremities(Figure3)(2932).PEissometimes termederythromelalgia,althoughsomeauthoritiesreservethelatter termforaconditionthatiscausedbyarteriolarinflammationasa resultofplatelet-richthrombiintheend-arterialmicrovasculature, inwhichtheplateletcountisinvariablyelevated(>400109cells/l) andashortcourseofaspirinbringsswiftrelief(33).Plateletcounts inPEareinvariablynormal,andaspirinisineffective.Patients withPEusuallydevelopsymptomswithinthefirstdecadeoflife. Asthediseaseprogresses,theerythemacanextendtotheupper legs,nosetip,earlobes,andchin.Intheearlyyearsofthedisease, theerythemaisintermittent,butatlaterages,thefeetandhands maybeconstantlyredandedematous.Complaintsareprovokedby

Figure 3
Red feet and lower legs in a patient with primary erythermalgia. Image courtesy of The Erythromelalgia Association.
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Figure 4
Four clinical situations in which Nav1.7 channel activity is altered. PE and PEPD are autosomal dominant (AD) conditions, while CIP is inherited via an autosomal recessive (AR) trait. The mutations of the Nav1.7 channel grossly dictate that there is a gain of function (increased channel activity) in PE and PEPD, while Nav1.7 channel function is lost (absent) in CIP. The resultant phenotype is reflected in the lower row. In humans, the Nav1.7 mutations result in pain in the feet and hands (in PE) or ocular, mandibular, and/or rectal pain (in PEPD). In CIP, there is a loss of Nav1.7 channel function, resulting in an inability to register pain.

exercise,prolongedstanding,orexposuretowarmth,whichusually compelspatientsnottowearsocksorclosedshoes,evenduringthe winter.Patientstypicallysleepwithuncoveredfeet,oftencooledby afan.Coldalleviatesthesecomplaints,andsomepatientssearch forreliefbyimmersionoffeetinice-coldwater.Thegreatestthreat isthattheseactionscanleadtotrenchfootwithsubsequentskin infectionsandeventolimbamputations(34). Agenome-widelinkagestudyinalargekindredofindividuals withPEdetectedstrongevidenceforlinkagewithpolymorphic markers on chromosome 2q (35). Haplotype analysis in four additionalfamiliesconfirmedthelocus,andrecombinantevents definedthecriticalintervalto7.94cM.Subsequentanalysisof anotherfamilyallowednarrowingoftheregionto5.98cM(3). Thisintervalcontainsfivegenesencodingsodium-channel subunits.Afterconfirmingthepresenceofthisgeneticintervalin twoaffectedfamilies,twocandidategenes,includingSCN9A,were tested(3).Amissensemutation(L858H)inSCN9Awasidentified thatsegregatedwiththediseaseinathree-generationChinesefamilywhileanI848Tmutationwaspresentinasinglesporadiccase. Bothmutationsaffectedconservedresiduesinthepore-forming subunitoftheNav1.7channel,andmultiplealignmentindicated thattheaffectedaminoacidsareconservedinsodiumchannels. Subsequentindependentstudiesconfirmedthesefindingsand identifiedmissensemutations(mutationsinwhichoneamino acidisreplacedbyanother)inindividualsfromallofthefamilies thathadbeenexaminedintheoriginallinkagestudy(4).Todate, nearlyadozenSCN9Amutationsinmultiplefamilieshavebeen identifiedascausingPE(5,6,3641).Mostofthesemutations havebeenfoundinfamiliesfromTheNetherlands,theUnited States,Belgium,France,Canada,andChina,withaclearautosomaldominantinheritancepattern,althoughafewrepresentde novofoundermutations(amutationthataroseintheDNAofan individualseveralgenerationsearlierandwhomisconsideredto beafounderofadistinctpopulation)(5,6). AllofthePEmutationsdetectedtodatearemissensemutations thatchangeimportantandhighlyconservedaminoacidresidues oftheNav1.7protein.ThemajorityofmutationsthatcausePE arelocatedincytoplasmiclinkersoftheNav1.7channel,butsome mutations(e.g.,F216SandN395K)arelocatedintransmembrane domainsofthechannel(Figure1B).ThePEmutationscausea
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hyperpolarizingshiftinthevoltagedependenceofchannelactivation,whichallowsthechanneltobeactivatedbysmallerthan normaldepolarizations,therebylikelyenhancingtheactivityof Nav1.7.MostofthePEmutationsalsoslowdeactivation,thus keepingthechannelopenlongeronceitisactivated(Figure4). Inaddition,inresponsetoaslow,depolarizingstimulus,most mutantchannelswillgeneratealargerthannormalinwardsodiumcurrent.Repriming,whichistherecoveryfrominactivation, hasbeenshowntobefasterforchannelspossessingspecificPE mutations(5,6,36,38,39,42,43).Eachofthesealterationsin activationanddeactivationcancontributetothehyperexcitability ofpain-signalingDRGneuronsexpressingthesemutantchannels, thuscausingextremesensitivitytopain(hyperalgesia)(44).While theexpressionofPENav1.7mutationsproduceshyperexcitabilityinDRGneurons,studiesonculturedratsympatheticganglion neuronsindicatethatexpressionofthesesamePEmutationsin sympatheticganglionneurons,thatis,anothercelltypeinwhich Nav1.7isnormallyexpressed,leadstoareductionofexcitability inthesecells(43).ThisoccursbecauseNav1.8channels,which arerelativelyresistanttoinactivationbydepolarizationandare selectivelyexpressedinadditiontoNav1.7inDRGneurons,are notpresentwithinsympatheticganglionneurons(43).ThesePE mutationsproducemembranedepolarizationduetoanoverlap betweenactivationandsteady-stateinactivation,whichinactivates sodiumchannelsotherthanNav1.8.Thedepolarizationbrings DRGneuronsclosertothethresholdofactivationfortheNav1.8 channelsthatarepresentwithinDRGneurons,thusincreasing theexcitabilityofthesecells.Butinsympatheticganglionneurons, whichlackNav1.8,theinactivationofthesodiumchannelsresults inreducedexcitability.IntroductionofNav1.8allowsthesecellsto fireactionpotentials,despitedepolarizationofrestingmembrane potential(43).Thisillustratesanimportantprinciple,thatthe phenotypeassociatedwithamonogenicchannelopathyisnotpredictableonthebasisofthechangesinphysiologyofthemutant sodiumchannelperse.Theeffectdependsonthecellbackground inwhichthemutantchannelisexpressed,sothatphysiological interactionsthatarespecifictoparticulartypesofneurons(inthe caseofPE,thephysiologicalinteractionofNav1.7andNav1.8)may betterexplainthesymptomsexperiencedbypatients(45).These dataprovideanexplanationofwhyPEpresentswithpaindueto

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hyperexcitabilityofnociceptorstogetherwithsympatheticdysfunction(flushing/erythema)thatisatleastinlargepartdueto hypoexcitabilityofsympatheticganglionneurons(43). Paroxysmal extreme pain disorder Theconditionfirstdescribedin1959asrectal,ocular,andsubmaxillarypain(46)hasrecentlybeenrenamedPEPD(OMIM167400) (47).PEPDisanautosomaldominantdisordercharacterizedby paroxysmalepisodes(ofsuddenonsetandincreasedintensityupon recurrence)ofpainatdifferentbodysites,accompaniedbyskin flushing.Therearefourwell-definedtypesofpainfulepisodes.The firstoccursatbirthwithanarchetypicalredflushspreadoverthe buttocksanddownthebacksofthelegstothesolesofthefeet(48). Asecondpatterninvolvesrectalpainthatismostevidentinchildhoodandtypicallyoccursatdefecation,asasudden(short-lived) onsetofburningpainthatmovesdowntothelowerextremities (47).Thepainisfollowedbyreddiscolorationoftheskinofthe pubicarea,scrotum,perineum,buttocks,andthebacksofboth legsandsolesofthefeet,lastingforaboutanhour.Theocularpatternofpainisdescribedasanintenseburningsensation,lasting 3060seconds,followedbyconjunctivalinjection(nonuniform rednessoftheconjunctiva)anderythemaoftheeyelidsandofthe skininthetemporalregion,lastingafewminutes(49,50).Attacks maybeprecipitatedbyyawningandcryingbutalsooccurspontaneously.Last,thereisparoxysmalpaininthemandibularregion onbothsides,withassociatedtransienterythemaoftheoverlying skin,togetherwithautonomicmanifestationssuchassalivation, lacrimation(tearing),andrhinorrhoea(runningnose).Symptoms maybeinducedinthesesubjectsbytheingestionofcolddrinks oracidicorspicyfoods.Moreover,theseindividualsareproneto astrangefeelingofpressureorevenacramp-likesensationinthe nose,followingexposureofthefacetobrightsunlightorstrong winds.Insomepatients,thepainfulcrisismaybeassociatedwith nonepileptictonicseizuresandcardiacasystole(50).Carbamazepine,anantiepilepticdrug,iseffectiveinsomepatients,buthigh dosagesmaybeneededtoachieveefficacy(51).Aprincipaltargetof anticonvulsantdrugsinPEPDismostlikelythesodiumchannels locatedintheperipheralsensoryneuron(52). Agenome-widelinkagesearchinonelargepedigreewithPEPD ledtolinkagetoaregionofchromosome2q24.3(7).Haplotype analysisidentifiedseveralrecombinants,whichnarrowedthecriticalregiondownto16cM.AsthisregioncontainedSCN9A,the investigatorssequencedthisgeneandidentifiedeightheterozygous missensemutationsineightfamilies.Allmutationswereprivate, i.e.,eachfamilypossessedauniquemutation.Interestingly,one individualwascompoundheterozygousforR996Candadenovo mutation(V1298D).Thisindividualwasmoreseverelyaffected thanhisfather.InanotherfamilyinwhomR996Cwastheonly mutationidentified,therewasalessseverephenotype.InfivefamilieswithtypicalPEPD,therewerenoSCN9A mutationsfound(7). ThesefindingsareconsistentwiththegeneticheterogeneityofPE andsuggestlocusheterogeneityinPEPD. Functionalanalysisofthreemutations(I1461T,T1464I,and M1627K)thatareattributedtoPEPDwascarriedoutintransfectionexperimentsusingacell-basedassayinwhichamutantsodiumchannelwasintroducedintocellsthatnormallydonotexpress sodiumchannels(7).Onthebasisoftheseexperiments,these mutationswerereportedtoimpairinactivationofthesubunit oftheNav1.7channel(Figure4).Steady-stateinactivationwasonly partialinmutantchannelsandhadshiftedtowardhighervolt

agesinthecontextofnear-normalactivation.Thesechangesare predictedtopromoteprolongedactionpotentialsandrepetitive neuronfiringinresponsetoprovokingstimuli,suchasstretching andexposuretocoldtemperatures(7).ThedifferenteffectsofPE mutations(whichenhancechannelactivation)andPEPDmutations(whichimpairchannelinactivation)mightcontributeinpart tothedifferentsymptomatologyinthesetwodisorders.Ineither case,theseresultsareinkeepingwiththenotionthatNav1.7plays acriticalroleinmodulationofthepainthreshold. Channelopathy-associated insensitivity to pain IncontrastwithPEandPEPD,CIP(OMIM243000)isanautosomalrecessivedisorder(8,53).Individualswithcongenitalindifferencetopainhavepainlessinjuriesbeginningininfancybutotherwisenormalsensoryresponsesuponexamination.Perceptionof passivemovement,jointposition,andvibrationisnormal,asare tactilethresholdsandlighttouchperception.Thereisintactability todistinguishbetweensharpanddullstimuliandtodetectdifferencesintemperature.Theinsensitivitytopaindoesnotappearto beduetoaxonaldegeneration,asthenervesappeartobenormal upongrossexamination(8).Thecomplicationsofthediseasefollowtheinabilitytofeelpain,andmostindividualswillhaveinjuriestoliportonguecausedbybitingthemselvesinthefirst4years oflife.Patientshavefrequentbruisesandcuts,usuallyhaveahistoryoffracturesthatgounnoticed,andareoftenonlydiagnosed becauseoflimpingorlackofuseofalimb.Theliteraturecontains verycolorfuldescriptionsofpatientswithcongenitalinabilityto perceiveanyformofpain.Individualshavebeenreportedtowalk overburningcoalsandtoplaceknivesthroughtheirarmsanddrive spikesthroughahandaspartofcrucifixionreenactment(8). Coxetal.described6patientsstemmingfromthreeconsanguineousfamiliesofnorthernPakistaniorigin(8).Thehighlyinbred populationallowedforautozygositymapping(homozygosityin whichthetwoallelesareidenticalbydescent),andagenome-wide searchledtotheidentificationofa20-cMhomozygousregionon chromosome2q24.3withamaximum2-pointlodscoreof3.2(a lodscoreof3ormoreisgenerallytakentoindicatethat2geneloci areclosetoeachotheronthechromosome;alodscoreof3means theoddsareathousandtooneinfavorofgeneticlinkage).Further refinementoftheregionto11.7Mbwasfacilitatedbyadditionof athirdfamily.AbioinformaticsapproachsuggestedSCN9Aasthe bestcandidatediseasegene.Sequencingledtotheidentificationof differenthomozygousmutationsofSCN9A,andeachfamilypossessedauniquemutation.Themutationswereidentifiedinexon 10(S459X),exon13(I767X),andexon15(W897X)(8).Allmutationsarenonsensemutations,thatis,theychangeacodonthat codesforoneaminoacidintoacodonthatdoesnotspecifyany aminoacid.Theseresultswereconfirmedbytwostudies:onestudy in9westernEuropeanandNorthandSouthAmericanfamilies (54)andanotherinalargeCanadianfamily(55).Bothstudiesused linkageanalysis,searchedforhomozygoushaplotypes,identified thesamegene,anddetected10truncatingSCN9Amutations.The majorityofaffectedpatientswerehomozygousforSCN9Amutations,but2patientswerecompoundheterozygousfordifferent SCN9Amutations(54).FunctionalstudiesshowthatCIP-associatedmutationscauselossoffunctionofNav1.7(8,55)(Figure4). ThisisincontrastwiththegeneticbasisofPEandPEPD,inwhich thedisordersresultfromgain-of-functionmutations.InDRG neuronsexpressingmutantNav1.7,thefiringofactionpotentials wasgreatlyimpairedandcomparabletobackground(8).
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Implications and questions Collectively,thedatafromrecentstudiesindicatethatNav1.7 functionisanessentialandnonredundantrequirementfornociceptioninhumans.However,thegeneticfindingsdonotfully explaintheclinicalpresentationsdescribed.Giventhewidespread expressionofNav1.7throughoutthesensorynervoussystem,itis remarkablethatPEandPEPDhavesuchdifferenttissuedistributionsofpain.Moreover,thevariabilityinageofclinicalonset remainsunexplained.Also,althoughphysiologicalstudieshave revealedatemperature-dependentshiftthatbringstheactivation thresholdofPEmutantchannelsclosetothatofwild-typeNav1.7 channels,possiblycontributingtothealleviationofpainbycoolinginPE(56),theparoxysmalnatureofthepainfulattacksin PEandPEPDisnotfullyunderstood.Theseobservationsargue thattheremaybefactorsotherthanthemutatedNav1.7channel, suchasstilltobeidentifiedbindingpartners(otherproteinmoleculesthatthechannelinteractswith,suchasfibroblastgrowth factorhomologousfactors,whichareknowntomodulatethe physiologicalpropertiesofthesodium-channelisoforms)thatare importantindeterminingthetopographicandtemporalpattern ofthesesymptoms(57,58). Theimportantroleofmutationsthatchangethesequenceof SCN9AinvariouspaindisorderssuggeststhatSCN9Apolymorphismsmightcontributetointersubjectvariabilityinthesensation ofpaininhumans.Thisshouldencourageresearcherstolookfor SCN9ApolymorphismsthatareassociatedwithchronicpaindisordersotherthanPEandPEPD.Itmightalsobeexpectedthatsome SCN9Apolymorphismsmightconferprotectionagainstpain. Implications for new therapeutic approaches to pain NeuropathicpaininPEistherapeuticallychallenging(59).Indeed, Nav1.7representsatargetthatmightbeinhibitedbysmallmoleculesinasubtype-specificorstate-dependentmannerduringectopicdischarge,producingpainreliefwhilesparingotherneuronal functions.Thedevelopmentofsubtypeselectivityofpotentially therapeuticallyusefulmoleculeshasproventobeachallenge.Severalclassesofdrugs,includinglocalanesthetics(e.g.,lidocaine), systemicantiarrhythmics(e.g.,mexiletine),andantiepilepticdrugs suchasphenytoinorcarbamazepine,targetsodiumchannelsand actaschannelblockers,althoughtheydonotshowahighdegree
1.Zubieta,J.K.,etal.2003.COMTval158metgenotypeaffectsmu-opioidneurotransmitterresponses toapainstressor.Science.299:12401243. 2.Ophoff, R.A., et al. 1996. Familial hemiplegic migraineandepisodicataxiatype-2arecausedby mutationsintheCa2+channelgeneCACNL1A4. Cell.87:543552. 3.Yang,Y.,etal.2004.MutationsinSCN9A,encoding asodiumchannelalphasubunit,inpatientswith primaryerythermalgia.J. Med. Genet.41:171174. 4.Drenth,J.P.,etal.2005.SCN9Amutationsdefine primaryerythermalgiaasaneuropathicdisorderof voltagegatedsodiumchannels.J. Invest. Dermatol. 124:13331338. 5.Han,C.,etal.2006.Sporadiconsetoferythermalgia:again-of-functionmutationinNav1.7.Ann. Neurol.59:553558. 6.Harty,T.P.,etal.2006.Na(V)1.7mutantA863Pin erythromelalgia:effectsofalteredactivationand steady-stateinactivationonexcitabilityofnociceptivedorsalrootganglionneurons.J. Neurosci. 26:1256612575. 7.Fertleman,C.R.,etal.2006.SCN9Amutationsin paroxysmalextremepaindisorder:allelicvariants underliedistinctchanneldefectsandphenotypes.
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ofchannelsubtypespecificityandthusinhibitmanytypesof sodiumchannelsratherthanselectivelyblockingNav1.7(52,58). Theseagents,whichactprimarilythroughuse-dependentblocks ofsodiumchannelsindeedarepartofthearmamentariumforthe treatmentofmanytypesofchronicpain,includingsomeformsof neuropathicpain.Severalofthesedrugshaveshownadegreeof efficacyinpatientswithpainduetomutationsinNav1.7.Some PEpatientshaverespondedtooralmexiletine(600mgdaily)(60). Interestingly,somePEmutationsattenuatetheinhibitoryeffect onsodiumchannelsofthesodium-channelblockerlidocaine, whileotherPEmutationsdonot,suggestingthattheresponseto treatmentwithsodium-channelblockersinPEmaydependonthe specificgenotype(61).Carbamazepineiseffectiveinsomepatients withPEPD,asitstabilizestheinactivatedstateofsodiumchannels, meaningthatfewerofthesechannelsareavailabletoopen,makingbraincellslessexcitable(7).Incontrast,preliminaryresultsin PEindicateloworabsenteffectivityofthisdrug(62).Moreover,in thosecasesinwhichlidocaineormexiletinearehelpfulinPE,the efficacyoftheseagentsisonlypartialortransient(63). Inconclusion,theseobservations,whiledrawnfromasmall numberofpatients,suggestthatblockadeofvoltage-gatedsodiumchannelsisapromisingtherapeuticoptionforthetreatment ofpainbutemphasizetheneedforthedesignofmorehighly focused,Nav1.7-specificblockersorgeneticallytailoredpharmacologicaloptionsforfuturetesting.Therewillundoubtedlybe progressalongtheselinesinthefuture. Acknowledgments We thank the patients who participated in the studies that aredescribedinthisreview.J.P.H.DrenthisarecipientofThe NetherlandsOrganizationforHealthResearchandDevelopmentVIDIawardresearchgrant.S.G.WaxmanistherecipientofgrantsfromtheDepartmentofVeteransAffairsandthe ErythromelalgiaAssociation. Addresscorrespondenceto:JoostP.H.Drenth,Departmentof Medicine,DivisionofGastroenterologyandHepatology,UniversityMedicalCenterSt.Radboud,POBox9101,6500HBNijmegen,TheNetherlands.Phone:31-24-3614760;Fax:31-24-3540103; E-mail:JoostPHDrenth@CS.com.
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