Mittal, A.; Martin, M. F.; Provins, L.; Hall, A.; Ledecq, M.; Wolff, C.; Gillard, M.; Horanyi, P. S.; Coleman, J. A.

Brivaracetam (BRV) and levetiracetam (LEV) are antiseizure medications (ASMs) that target synaptic vesicle protein 2A (SV2A), while UCB1244283 acts as a positive allosteric modulator of these medications. The SV2A-BRV-UCB1244283 complex reveals how UCB1244283 allosterically enhances BRV binding by occupying an allosteric site near the primary binding site, preventing BRV dissociation. This allosteric site, formed by hydrophobic and uncharged residues, is a novel small-molecule binding site in SV2A. Structural analysis and mutagenesis suggest that an allosteric network between the primary and allosteric sites governs high-affinity ASM binding. UCB1244283 selectively binds SV2A over SV2B and SV2C, with specific mutations disrupting binding. The structure explains why UCB1244283 binding to SV2A selectively allows interaction with specific ASMs but not others due to steric hinderance. Structural comparison reveals that distinct conformational differences between the SV2A-BRV-UCB1244283 and other SV2A-ligand complexes, particularly in the transmembrane domain, influence binding at both sites. Future research will explore potential therapeutics targeting the allosteric site and their impact on SV2A regulation.