GABAA Receptors and Drug-Resistant Epilepsy: Why It's Time to Think Outside the Pore.

Drug-resistant epilepsy (DRE) represents a major clinical hazard, characterised by persistent uncontrolled seizures that elevate risks of trauma, cognitive deterioration, psychiatric comorbidity, and sudden unexpected death in epilepsy, while cumulative medication exposure, healthcare burden, and functional impairment substantially worsen long-term morbidity and quality of life. In DRE, disruptions in GABAA receptors (GABAAR) function through altered subunit composition, receptor mislocalisation, or impaired trafficking, undermine inhibitory control and contribute to persistent seizures. The regulation of intracellular chloride by NKCC1 and KCC2 further shapes GABAAR-mediated inhibition, where imbalances in these transporters exacerbate network hyperexcitability. Structural studies, including high-resolution cryo-EM, reveal how ligand binding, receptor conformation, and interactions with auxiliary proteins modulate GABAAR activity, offering insights into why some subtypes respond differently to benzodiazepines or neurosteroids. Emerging evidence suggests that targeting receptor-associated proteins, trafficking pathways, or specific subunit combinations may offer novel ways to restore inhibitory tone and overcome pharmacoresistance. Understanding how these molecular, structural, and cellular factors converge to alter GABAAR function provides a roadmap for designing therapies that are both effective and precise, especially for DRE. By unravelling the mechanisms behind GABAAR dysfunction in DRE, new avenues open for restoring network stability and improving outcomes for patients living with DRE.