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Ma M, Xu H, Ye L, Li C, Zhu H, Jiang W, Wang W, Yang H, Yang Y, Wang Y, Tian J. Synthesis and evaluation of neuroactive steroids with novel pharmacophore at C-21 let identify a compound with advantageous PK profile and higher EC 50 and E max as PAM on GABAA receptor. Eur J Med Chem 2024; 276:116602. [PMID: 38971049 DOI: 10.1016/j.ejmech.2024.116602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/03/2024] [Accepted: 06/13/2024] [Indexed: 07/08/2024]
Abstract
Zuranolone (SAGE-217) is a neuroactive steroid (γ-aminobutyric acid)A (GABAA) receptor positive allosteric modulator (PAM) as the first oral drug approved by the FDA in 2023, which is used to treat patients with postpartum depression (PPD). SAGE-217 has a "black box" warning with impairing ability to drive or engage in other potentially hazardous activities. In addition, SAGE-217 can cause CNS depressant effects such as somnolence and confusion, suicidal thoughts and behavior and embryo-fetal toxicity. Based on the structure-activity relationship (SAR) of SAGE-217, a total of 28 neuroactive steroids with novel pharmacophore at C-21 modulated SAGE-217 derivatives were designed and synthesized. The biological activities were evaluated by both synaptic α1β2γ2 GABAA receptor and extrasynaptic α4β3δ GABAA receptor cell assays. The optimal compound S28 exhibited much more potent potency and similar efficacy at extrasynaptic GABAA receptor than SAGE-217. Different from above, compound S28 exhibited similar potency and lower efficacy at synaptic GABAA receptor than SAGE-217, which were consistent with the analysis of molecular docking and dynamics simulation results. The appropriate lower efficacy at synaptic GABAA receptor of compound S28 might contribute to reduce the side effects of excessive sedation. Furthermore, compound S28 was demonstrated to have excellent in vivo pharmacokinetic (PK) parameters, robust in vivo pharmacodynamic (PD) effects and good safety profiles. Therefore, compound S28 represents a potentially promising treatment of PPD candidate that warrants further investigation.
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Affiliation(s)
- Mingxu Ma
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, China; State Key Laboratory of Advanced Drug Delivery and Release Systems, Shandong Luye Pharmaceutical Co., Ltd., Yantai, Shandong, 264003, China
| | - Hengwei Xu
- State Key Laboratory of Advanced Drug Delivery and Release Systems, Shandong Luye Pharmaceutical Co., Ltd., Yantai, Shandong, 264003, China
| | - Liang Ye
- State Key Laboratory of Advanced Drug Delivery and Release Systems, Shandong Luye Pharmaceutical Co., Ltd., Yantai, Shandong, 264003, China; School of Public Health and Management, Binzhou Medical University, Yantai, 256603, China
| | - Chunmei Li
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, China; State Key Laboratory of Advanced Drug Delivery and Release Systems, Shandong Luye Pharmaceutical Co., Ltd., Yantai, Shandong, 264003, China
| | - Haibo Zhu
- State Key Laboratory of Advanced Drug Delivery and Release Systems, Shandong Luye Pharmaceutical Co., Ltd., Yantai, Shandong, 264003, China; School of Public Health and Management, Binzhou Medical University, Yantai, 256603, China
| | - Wanglin Jiang
- State Key Laboratory of Advanced Drug Delivery and Release Systems, Shandong Luye Pharmaceutical Co., Ltd., Yantai, Shandong, 264003, China; School of Pharmacy, Binzhou Medical University, Yantai, 256603, China
| | - Wenyan Wang
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, China; State Key Laboratory of Advanced Drug Delivery and Release Systems, Shandong Luye Pharmaceutical Co., Ltd., Yantai, Shandong, 264003, China
| | - Huijie Yang
- State Key Laboratory of Advanced Drug Delivery and Release Systems, Shandong Luye Pharmaceutical Co., Ltd., Yantai, Shandong, 264003, China
| | - Yingjie Yang
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, China; State Key Laboratory of Advanced Drug Delivery and Release Systems, Shandong Luye Pharmaceutical Co., Ltd., Yantai, Shandong, 264003, China
| | - Yao Wang
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, China; State Key Laboratory of Advanced Drug Delivery and Release Systems, Shandong Luye Pharmaceutical Co., Ltd., Yantai, Shandong, 264003, China
| | - Jingwei Tian
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, China; State Key Laboratory of Advanced Drug Delivery and Release Systems, Shandong Luye Pharmaceutical Co., Ltd., Yantai, Shandong, 264003, China.
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Scheggi S, Concas L, Corsi S, Carta M, Melis M, Frau R. Expanding the therapeutic potential of neuro(active)steroids: a promising strategy for hyperdopaminergic behavioral phenotypes. Neurosci Biobehav Rev 2024; 164:105842. [PMID: 39103066 DOI: 10.1016/j.neubiorev.2024.105842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/10/2024] [Accepted: 08/01/2024] [Indexed: 08/07/2024]
Abstract
Imbalances in dopamine activity significantly contribute to the pathophysiology of several neuropsychiatric disorders, including addiction, ADHD, schizophrenia, impulse control disorders, and Parkinson's Disease. Neuro(active)steroids, comprising endogenous steroids that finely modulate neuronal activity, are considered crucial regulators of brain function and behavior, with implications in various physiological processes and pathological conditions. Specifically, subclasses of Neuro(active)steroids belonging to the 5α reductase pathway are prominently involved in brain disorders characterized by dopaminergic signaling imbalances. This review highlights the neuromodulatory effects of Neuro(active)steroids on the dopamine system and related aberrant behavioral phenotypes. We critically appraise the role of pregnenolone, progesterone, and allopregnanolone on dopamine signaling. Additionally, we discuss the impact of pharmacological interventions targeting 5α reductase activity in neuropsychiatric conditions characterized by excessive activation of the dopaminergic system, ranging from psychotic (endo)phenotypes and motor complications to decision-making problems and addiction.
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Affiliation(s)
- Simona Scheggi
- Dept. of Molecular and Developmental Medicine, University of Siena, Italy
| | - Luca Concas
- Dept. Of Biomedical Sciences, University of Cagliari, Italy
| | - Sara Corsi
- Dept. of Developmental and Regenerative Neurobiology, Lund University, Sweden
| | - Manolo Carta
- Dept. Of Biomedical Sciences, University of Cagliari, Italy
| | - Miriam Melis
- Dept. Of Biomedical Sciences, University of Cagliari, Italy
| | - Roberto Frau
- Dept. Of Biomedical Sciences, University of Cagliari, Italy; Guy Everett Laboratory, University of Cagliari, Cagliari, Italy.
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Sánchez-Lafuente CL, Johnston JN, Reive BS, Scheil KKA, Halvorson CS, Jimenez M, Colpitts D, Kalynchuk LE, Caruncho HJ. A single intravenous reelin injection restores corticosterone-induced neurochemical and behavioral alterations in dams during the post-partum period. Front Mol Neurosci 2024; 17:1442332. [PMID: 39228796 PMCID: PMC11369980 DOI: 10.3389/fnmol.2024.1442332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Accepted: 08/06/2024] [Indexed: 09/05/2024] Open
Abstract
Introduction Treatment with the synaptic plasticity protein reelin has rapid antidepressant-like effects in adult corticosterone (CORT)-induced depressed rats, whether administered repeatedly or acutely. However, these effects remain unexplored in the context of post-partum depression (PPD). Methods This study investigated the antidepressant-like effect of a single injection of reelin in a CORT-induced model of PPD. Long-Evans female dams received either daily subcutaneous CORT (40 mg/kg) or saline injections (controls) from the post-partum day (PD) 2 to 22, and on PD22 were treated with a single intravenous reelin (3 μg) or vehicle injection. Results Reelin treatment fully normalized to control levels the CORT-induced increase in Forced Swim Test (FST) immobility and the decrease in reelin-positive cells in the subgranular zone of the intermediate hippocampus. It also increased the number of oxytocin-positive cells in the paraventricular nucleus (PVN), the number of reelin-positive cells in the dorsal and ventral hippocampus, and the dendritic complexity of newborn neurons in the intermediate hippocampus, causing a partial recovery compared to controls. None of these changes were associated with fluctuations in estrogen levels measured peripherally. Discussion This study brings new insights into the putative antidepressant-like effect of peripherally administered reelin in an animal model of PPD. Future studies should be conducted to investigate these effects on a dose-response paradigm and to further elucidate the mechanisms underlying the antidepressant-like effects of reelin.
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Jin L, Yang K, Wu X, Zhang J. Safety assessment of brexanolone in the FAERS database: real adverse event analysis and discussion of side effects. Expert Opin Drug Saf 2024:1-7. [PMID: 39093352 DOI: 10.1080/14740338.2024.2387316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 06/27/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Postpartum depression (PPD) is linked to hormonal changes. Brexanolone, the first FDA-approved drug for PPD, is a potential treatment. This study analyzes Brexanolone's safety using the FAERS database, highlighting its adverse effects and potential risk factors. METHODS We analyzed FAERS data from Q3 2019 to Q3 2023, evaluating adverse reactions to Brexanolone. The analysis includes demographics, reporting regions, reporter identities, and types of adverse reactions. RESULTS Most reports are from the United States, with consumers and physicians as primary reporters. Adverse reactions mainly involve severe systemic diseases, administration site reactions, injuries, intoxication, operational complications, and mental disorders. Specific adverse reactions include incorrect drug monitoring, PPD, intrusive thoughts, delayed treatment efficacy, sedation complications, product discontinuation, misuse, infusion site leakage and pain, and medication errors. CONCLUSION The study confirms known safety information about Brexanolone and provides comprehensive data for medical practices and public health decisions. However, relying on spontaneous reports may introduce biases and incomplete information. Continued monitoring and reporting of adverse reactions to newer drugs like Brexanolone remain crucial.
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Affiliation(s)
- Liuyin Jin
- Department of Science and Education, Lishui Second People's Hospital, Lishui, China
| | - Kaixia Yang
- Department of Neurology, The Affiliated Lihuili Hospital of Ningbo University, Ningbo University, Ningbo, China
| | - Xiping Wu
- Department of Neurology, The Affiliated Lihuili Hospital of Ningbo University, Ningbo University, Ningbo, China
| | - Jing Zhang
- Second Department of Infectious Disease, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
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Fogaça MV, Daher F, Picciotto MR. Effects of ketamine on GABAergic and glutamatergic activity in the mPFC: biphasic recruitment of GABA function in antidepressant-like responses. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.07.29.605610. [PMID: 39131322 PMCID: PMC11312475 DOI: 10.1101/2024.07.29.605610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Major depressive disorder (MDD) is associated with disruptions in glutamatergic and GABAergic activity in the medial prefrontal cortex (mPFC), leading to altered synaptic formation and function. Low doses of ketamine rapidly rescue these deficits, inducing fast and sustained antidepressant effects. While it is suggested that ketamine produces a rapid glutamatergic enhancement in the mPFC, the temporal dynamics and the involvement of GABA interneurons in its sustained effects remain unclear. Using simultaneous photometry recordings of calcium activity in mPFC pyramidal and GABA neurons, as well as chemogenetic approaches in Gad1-Cre mice, we explored the hypothesis that initial effects of ketamine on glutamate signaling trigger subsequent enhancement of GABAergic responses, contributing to its sustained antidepressant responses. Calcium recordings revealed a biphasic effect of ketamine on activity of mPFC GABA neurons, characterized by an initial transient decrease (phase 1, <30 min) followed by an increase (phase 2, >60 min), in parallel with a transient increase in excitation/inhibition levels (10 min) and lasting enhancement of glutamatergic activity (30-120 min). Previous administration of ketamine enhanced GABA neuron activity during the sucrose splash test (SUST) and novelty suppressed feeding test (NSFT), 24 h and 72 h post-treatment, respectively. Chemogenetic inhibition of GABA interneurons during the surge of GABAergic activity (phase 2), or immediately before the SUST or NSFT, occluded ketamine's behavioral actions. These results indicate that time-dependent modulation of GABAergic activity is required for the sustained antidepressant-like responses induced by ketamine, suggesting that approaches to enhance GABAergic plasticity and function are promising therapeutic targets for antidepressant development.
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Affiliation(s)
- Manoela V. Fogaça
- Department of Pharmacology and Physiology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA
- Department of Psychiatry, Yale University School of Medicine, 34 Park Street, New Haven, CT 06519, USA
| | - Fernanda Daher
- Department of Pharmacology and Physiology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - Marina R. Picciotto
- Department of Psychiatry, Yale University School of Medicine, 34 Park Street, New Haven, CT 06519, USA
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Singhal M, Modi N, Bansal L, Abraham J, Mehta I, Ravi A. The Emerging Role of Neurosteroids: Novel Drugs Brexanalone, Sepranolone, Zuranolone, and Ganaxolone in Mood and Neurological Disorders. Cureus 2024; 16:e65866. [PMID: 39219949 PMCID: PMC11364262 DOI: 10.7759/cureus.65866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2024] [Indexed: 09/04/2024] Open
Abstract
This review investigates the potential of neurosteroids, including brexanolone, zuranolone, sepranolone, and ganaxalone, as therapeutic agents for a range of mood and neurological disorders. Notably, these disorders encompass postpartum depression, post-traumatic stress disorder (PTSD), major depressive disorder (MDD), epilepsy, and Alzheimer's disease. Brexanolone and zuranolone have emerged as frontrunners in the treatment of postpartum depression, offering rapid relief from debilitating symptoms. Their mechanism of action involves modulation of the gamma-aminobutyric acid (GABA) system, which plays a pivotal role in mood regulation. Clinical trials have demonstrated their efficacy, heralding a potential breakthrough in addressing this often-overlooked condition. In the context of PTSD and MDD, neurosteroids have demonstrated significant promise. Their positive allosteric modulation of GABA-A receptors translates into improved mood stabilization and reduced symptoms. This novel approach represents a departure from conventional treatments and could offer newfound hope for individuals grappling with these disorders. Beyond mood disorders, neurosteroids, especially ganaxalone, exhibit potential in the realm of epilepsy management. Ganaxalone's capacity to control seizures is attributed to its GABAergic activity, which helps restore the delicate balance of neurotransmission in epileptic brains. Moreover, neurosteroids have revealed neuroprotective properties in Alzheimer's disease models. By influencing the GABAergic system, they mitigate excitotoxicity, a hallmark of Alzheimer's pathology. This neuroprotection opens a novel avenue for slowing neurodegeneration, although further research and clinical validation are essential. In conclusion, this review underscores the substantial therapeutic promise of neurosteroids in mood and neurological disorders. Their modulation of the GABA system emerges as a central mechanism of action, emphasizing the importance of GABAergic signaling in these conditions. The path forward entails continued investigation and clinical trials to fully unlock the potential of neurosteroids, offering hope for enhanced treatments in these challenging clinical domains.
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Affiliation(s)
- Malay Singhal
- Neurology, Mahatma Gandhi Memorial Medical College, Indore, IND
| | - Nishi Modi
- Psychiatry and Behavioral Sciences, Government Medical College Surat, Surat, IND
| | - Lajpat Bansal
- Psychiatry and Behavioral Sciences, Maharaja Agrasen Institute of Medical Research and Education, Hissar, IND
| | - Jeby Abraham
- General Medicine, Yenepoya Medical College, Mangalore, IND
| | - Ishani Mehta
- Neurology, Maharaja Agrasen Institute of Medical Research and Education, Hissar, IND
| | - Arun Ravi
- Psychiatry and Behavioral Sciences, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
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Cardaci V, Carminati M, Tondello M, Pecorino B, Serretti A, Zanardi R. Understanding and treating postpartum depression: a narrative review. Int Clin Psychopharmacol 2024:00004850-990000000-00143. [PMID: 38941162 DOI: 10.1097/yic.0000000000000560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Postpartum depression (PPD) is an increasingly prevalent but still poorly characterized disorder. Causal and modulating factors include hormones fluctuations, such as estrogen, progesterone, and allopregnolone, pathways imbalances, such as oxytocin and kynurenine, chronobiological factors, and brain imaging alterations. Treatment may differ from the traditional major depression management, while selective serotonin reuptake inhibitors such as sertraline are commonly used and suggested by guidelines, neurosteroids such as brexanolone and the more convenient zuranolone have been recently approved. Newer neurosteroids such as ganaxolone, valaxanolone, and lysaxanolone are currently under development, but also esketamine and psychedelics are promising potential treatments. Other somatic treatments including brain stimulation techniques and light therapy also showed benefit. PPD is therefore increasingly understood as, at least partially, independent from major depressive disorder. Specific and individualized treatments including pharmacological and non-pharmacological therapies are progressively being introduced in the routine clinical practice.
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Affiliation(s)
- Vincenzo Cardaci
- Department of Clinical Neurosciences, Vita-Salute San Raffaele University, Milan
| | - Matteo Carminati
- Department of Clinical Neurosciences, Vita-Salute San Raffaele University, Milan
| | - Mattia Tondello
- Department of Clinical Neurosciences, Vita-Salute San Raffaele University, Milan
| | - Basilio Pecorino
- Department of Medicine and Surgery, Kore University of Enna, Enna
| | | | - Raffaella Zanardi
- Department of Clinical Neurosciences, Vita-Salute San Raffaele University, Milan
- Department of Psychiatry, Mood Disorder Unit, IRCCS San Raffaele Hospital, Milan, Italy
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Zhang W, Liu T, Li J, Singh J, Chan A, Islam A, Petrache A, Peng Y, Harvey K, Ali AB. Decreased extrasynaptic δ-GABA A receptors in PNN-associated parvalbumin interneurons correlates with anxiety in APP and tau mouse models of Alzheimer's disease. Br J Pharmacol 2024. [PMID: 38886118 DOI: 10.1111/bph.16441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Alzheimer's disease (AD) is associated with gradual memory loss and anxiety which affects ~75% of AD patients. This study investigated whether AD-associated anxiety correlated with modulation of extrasynaptic δ-subunit-containing GABAA receptors (δ-GABAARs) in experimental mouse models of AD. EXPERIMENTAL APPROACH We combined behavioural experimental paradigms to measure cognition performance, and anxiety with neuroanatomy and molecular biology, using familial knock-in (KI) mouse models of AD that harbour β-amyloid (Aβ) precursor protein App (AppNL-F) with or without humanized microtubule-associated protein tau (MAPT), age-matched to wild-type control mice at three different age windows. RESULTS AppNL-F KI and AppNL-F/MAPT AD models showed a similar magnitude of cognitive decline and elevated magnitude of anxiety correlated with neuroinflammatory hallmarks, including triggering receptor expressed on myeloid cells 2 (TREM2), reactive astrocytes and activated microglia consistent with accumulation of Aβ, tau and down-regulation of Wnt/β-catenin signalling compared to aged-matched WT controls. In both the CA1 region of the hippocampus and dentate gyrus, there was an age-dependent decline in the expression of δ-GABAARs selectively expressed in parvalbumin (PV)-expressing interneurons, encapsulated by perineuronal nets (PNNs) in the AD mouse models compared to WT mice. In vivo positive allosteric modulation of the δ-GABAARs, using a δ-selective-compound DS2, decreased the level of anxiety in the AD mouse models, which was correlated with reduced hallmarks of neuroinflammation, and 'normalisation' of the expression of δ-GABAARs. CONCLUSIONS Our data show that the δ-GABAARs could potentially be targeted for alleviating symptoms of anxiety, which would greatly improve the quality of life of AD individuals.
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Dennis CL, Singla DR, Brown HK, Savel K, Clark CT, Grigoriadis S, Vigod SN. Postpartum Depression: A Clinical Review of Impact and Current Treatment Solutions. Drugs 2024; 84:645-659. [PMID: 38811474 DOI: 10.1007/s40265-024-02038-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/31/2024]
Abstract
Depression during the first year postpartum (postpartum depression) impacts millions of women and their families worldwide. In this narrative review, we provide a summary of postpartum depression, examining the etiology and consequences, pharmacological and psychological treatments, and potential mechanisms of change and current barriers to care. Psychological treatments are effective and preferred by many perinatal patients over medications, but they often remain inaccessible. Key potential mechanisms underlying their effectiveness include treatment variables (e.g., dosage and therapeutic alliance) and patient behaviors (e.g., activation and avoidance and emotional regulation). Among pharmacological treatments, the selective serotonin reuptake inhibitor (SSRI) sertraline is generally the first-line antidepressant medication recommended to women in the postpartum period due to its minimal passage into breastmilk and the corresponding decades of safety data. Importantly, most antidepressant drugs are considered compatible with breastfeeding. Neurosteroids are emerging as an effective treatment for postpartum depression, although currently this treatment is not widely available. Barriers to widespread access to treatment include those that are systematic (e.g., lack of specialist providers), provider-driven (e.g., lack of flexibility in treatment delivery), and patient-driven (e.g., stigma and lack of time for treatment engagement). We propose virtual care, task-sharing to non-specialist treatment providers, and collaborative care models as potential solutions to enhance the reach and scalability of effective treatments to address the growing burden of postpartum depression worldwide and its negative impact on families and society.
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Affiliation(s)
- Cindy-Lee Dennis
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Canada.
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Rm 280, Toronto, ON, M6J 1H4, Canada.
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
| | - Daisy R Singla
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
| | - Hilary K Brown
- Department of Health and Society, University of Toronto, Toronto, Canada
- Women's College Hospital, Toronto, Canada
- Women's College Research Institute, Toronto, Canada
| | - Katarina Savel
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Canada
| | - Crystal T Clark
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Women's College Hospital, Toronto, Canada
- Women's College Research Institute, Toronto, Canada
| | - Sophie Grigoriadis
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Simone N Vigod
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Women's College Hospital, Toronto, Canada
- Women's College Research Institute, Toronto, Canada
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Balan I, Boero G, Chéry SL, McFarland MH, Lopez AG, Morrow AL. Neuroactive Steroids, Toll-like Receptors, and Neuroimmune Regulation: Insights into Their Impact on Neuropsychiatric Disorders. Life (Basel) 2024; 14:582. [PMID: 38792602 PMCID: PMC11122352 DOI: 10.3390/life14050582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/18/2024] [Accepted: 04/28/2024] [Indexed: 05/26/2024] Open
Abstract
Pregnane neuroactive steroids, notably allopregnanolone and pregnenolone, exhibit efficacy in mitigating inflammatory signals triggered by toll-like receptor (TLR) activation, thus attenuating the production of inflammatory factors. Clinical studies highlight their therapeutic potential, particularly in conditions like postpartum depression (PPD), where the FDA-approved compound brexanolone, an intravenous formulation of allopregnanolone, effectively suppresses TLR-mediated inflammatory pathways, predicting symptom improvement. Additionally, pregnane neurosteroids exhibit trophic and anti-inflammatory properties, stimulating the production of vital trophic proteins and anti-inflammatory factors. Androstane neuroactive steroids, including estrogens and androgens, along with dehydroepiandrosterone (DHEA), display diverse effects on TLR expression and activation. Notably, androstenediol (ADIOL), an androstane neurosteroid, emerges as a potent anti-inflammatory agent, promising for therapeutic interventions. The dysregulation of immune responses via TLR signaling alongside reduced levels of endogenous neurosteroids significantly contributes to symptom severity across various neuropsychiatric disorders. Neuroactive steroids, such as allopregnanolone, demonstrate efficacy in alleviating symptoms of various neuropsychiatric disorders and modulating neuroimmune responses, offering potential intervention avenues. This review emphasizes the significant therapeutic potential of neuroactive steroids in modulating TLR signaling pathways, particularly in addressing inflammatory processes associated with neuropsychiatric disorders. It advances our understanding of the complex interplay between neuroactive steroids and immune responses, paving the way for personalized treatment strategies tailored to individual needs and providing insights for future research aimed at unraveling the intricacies of neuropsychiatric disorders.
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Affiliation(s)
- Irina Balan
- Bowles Center for Alcohol Studies, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (I.B.); (S.L.C.); (M.H.M.); (A.G.L.)
- Department of Psychiatry, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Giorgia Boero
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA;
| | - Samantha Lucenell Chéry
- Bowles Center for Alcohol Studies, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (I.B.); (S.L.C.); (M.H.M.); (A.G.L.)
- Neuroscience Curriculum, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Minna H. McFarland
- Bowles Center for Alcohol Studies, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (I.B.); (S.L.C.); (M.H.M.); (A.G.L.)
- Neuroscience Curriculum, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Alejandro G. Lopez
- Bowles Center for Alcohol Studies, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (I.B.); (S.L.C.); (M.H.M.); (A.G.L.)
- Department of Biochemistry and Biophysics, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - A. Leslie Morrow
- Bowles Center for Alcohol Studies, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (I.B.); (S.L.C.); (M.H.M.); (A.G.L.)
- Department of Psychiatry, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Pharmacology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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Ali DN, Ali HM, Lopez MR, Kang S, Choi DS. Astrocytic GABAergic Regulation in Alcohol Use and Major Depressive Disorders. Cells 2024; 13:318. [PMID: 38391931 PMCID: PMC10887002 DOI: 10.3390/cells13040318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/26/2024] [Accepted: 02/06/2024] [Indexed: 02/24/2024] Open
Abstract
Gamma-aminobutyric acid (GABA) is the major inhibitory neurotransmitter in the central nervous system (CNS). Most GABAergic neurons synthesize GABA from glutamate and release it in the synaptic cleft in the CNS. However, astrocytes can also synthesize and release GABA, activating GABA receptors in the neighboring neurons in physiological and pathological conditions. As the primary homeostatic glial cells in the brain, astrocytes play a crucial role in regulating GABA homeostasis and synaptic neurotransmission. Accumulating evidence demonstrates that astrocytic GABA dysregulation is implicated in psychiatric disorders, including alcohol use disorder (AUD) and major depressive disorder (MDD), the most prevalent co-occurring psychiatric disorders. Several current medications and emerging pharmacological agents targeting GABA levels are in clinical trials for treating AUD and MDD. This review offers a concise summary of the role of astrocytic GABA regulation in AUD and MDD. We also provide an overview of the current understanding and areas of debate regarding the mechanisms by which astrocytes regulate GABA in the CNS and their potential significance in the molecular basis of AUD and MDD, paving the way toward future research directions and potential therapeutic target areas within this field.
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Affiliation(s)
- Dina N. Ali
- Department of Molecular Pharmacology and Experimental Therapeutics, Rochester, MN 55905, USA; (D.N.A.); (H.M.A.); (M.R.L.); (S.K.)
| | - Hossam M. Ali
- Department of Molecular Pharmacology and Experimental Therapeutics, Rochester, MN 55905, USA; (D.N.A.); (H.M.A.); (M.R.L.); (S.K.)
| | - Matthew R. Lopez
- Department of Molecular Pharmacology and Experimental Therapeutics, Rochester, MN 55905, USA; (D.N.A.); (H.M.A.); (M.R.L.); (S.K.)
| | - Shinwoo Kang
- Department of Molecular Pharmacology and Experimental Therapeutics, Rochester, MN 55905, USA; (D.N.A.); (H.M.A.); (M.R.L.); (S.K.)
| | - Doo-Sup Choi
- Department of Molecular Pharmacology and Experimental Therapeutics, Rochester, MN 55905, USA; (D.N.A.); (H.M.A.); (M.R.L.); (S.K.)
- Neuroscience Program, Rochester, MN 55905, USA
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
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12
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Zhang M, Xie W, Li J, Zheng J, Zhou Y. Postmarketing safety profile of brexanolone: a pharmacovigilance analysis based on FDA Adverse Event Reporting System (FAERS). Arch Womens Ment Health 2024; 27:35-44. [PMID: 37831172 DOI: 10.1007/s00737-023-01378-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 10/03/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE Brexanolone (Zulresso®) that was approved for the USA in March 2019 is indicated for the treatment of postpartum depression (PPD), but information on adverse drug reactions (ADRs) associated with its use is limited. The main aim of this study was to explore the postmarketing safety profile of brexanolone. METHODS In our case/non-case pharmacovigilance study based on the FDA Adverse Event Reporting System (FAERS), the reporting odds ratio and information component with 95% confidence intervals were estimated as measures of disproportionate reporting. Primary disproportionality analyses were performed by comparing brexanolone with all other drugs or selective serotonin reuptake inhibitors (SSRIs). Sensitivity analyses were performed on a subset of perinatal depression. RESULTS We identified 267 cases using brexanolone. Brexanolone was reported as a primary or secondary suspect drug in most cases (n = 260, 97.38%). Of the total brexanolone cases, positive dechallenge and discontinuation accounted for 12.36% (n = 33) and 26.22% (n = 70), respectively. Serious outcomes were reported in 11.61% (n = 31) patients. Compared to all the other drugs or SSRIs within the same time window, the reporting risks of brexanolone were mainly from psychiatric and nervous systems. Sensitivity analyses indicated that these significant disproportionalities were mostly retained. CONCLUSION Our pharmacovigilance analysis showed a high reporting frequency of psychiatric and nervous system ADRs associated with the use of brexanolone. In additional prospective research, these signals urgently need to be clarified.
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Affiliation(s)
- Meilian Zhang
- Department of Ultrasound, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Wenhuo Xie
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Jianbin Li
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Jiaping Zheng
- Department of Rehabilitation Medicine, School of Health, Fujian Medical University, Fuzhou, China.
| | - Yu Zhou
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fujian Medical University, Fuzhou, China.
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13
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Gorman-Sandler E, Wood G, Cloude N, Frambes N, Brennen H, Robertson B, Hollis F. Mitochondrial might: powering the peripartum for risk and resilience. Front Behav Neurosci 2023; 17:1286811. [PMID: 38187925 PMCID: PMC10767224 DOI: 10.3389/fnbeh.2023.1286811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/01/2023] [Indexed: 01/09/2024] Open
Abstract
The peripartum period, characterized by dynamic hormonal shifts and physiological adaptations, has been recognized as a potentially vulnerable period for the development of mood disorders such as postpartum depression (PPD). Stress is a well-established risk factor for developing PPD and is known to modulate mitochondrial function. While primarily known for their role in energy production, mitochondria also influence processes such as stress regulation, steroid hormone synthesis, glucocorticoid response, GABA metabolism, and immune modulation - all of which are crucial for healthy pregnancy and relevant to PPD pathology. While mitochondrial function has been implicated in other psychiatric illnesses, its role in peripartum stress and mental health remains largely unexplored, especially in relation to the brain. In this review, we first provide an overview of mitochondrial involvement in processes implicated in peripartum mood disorders, underscoring their potential role in mediating pathology. We then discuss clinical and preclinical studies of mitochondria in the context of peripartum stress and mental health, emphasizing the need for better understanding of this relationship. Finally, we propose mitochondria as biological mediators of resilience to peripartum mood disorders.
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Affiliation(s)
- Erin Gorman-Sandler
- Department of Pharmacology, Physiology, and Neuroscience, University of South Carolina School of Medicine, Columbia, SC, United States
- Columbia VA Healthcare System, Columbia, SC, United States
| | - Gabrielle Wood
- Department of Pharmacology, Physiology, and Neuroscience, University of South Carolina School of Medicine, Columbia, SC, United States
| | - Nazharee Cloude
- Department of Pharmacology, Physiology, and Neuroscience, University of South Carolina School of Medicine, Columbia, SC, United States
| | - Noelle Frambes
- Department of Pharmacology, Physiology, and Neuroscience, University of South Carolina School of Medicine, Columbia, SC, United States
| | - Hannah Brennen
- Department of Pharmacology, Physiology, and Neuroscience, University of South Carolina School of Medicine, Columbia, SC, United States
| | - Breanna Robertson
- Department of Pharmacology, Physiology, and Neuroscience, University of South Carolina School of Medicine, Columbia, SC, United States
| | - Fiona Hollis
- Department of Pharmacology, Physiology, and Neuroscience, University of South Carolina School of Medicine, Columbia, SC, United States
- Columbia VA Healthcare System, Columbia, SC, United States
- USC Institute for Cardiovascular Disease Research, Columbia, SC, United States
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14
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Reddy DS. Neuroendocrine insights into neurosteroid therapy for postpartum depression. Trends Mol Med 2023; 29:979-982. [PMID: 37541828 PMCID: PMC10834837 DOI: 10.1016/j.molmed.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/09/2023] [Accepted: 07/13/2023] [Indexed: 08/06/2023]
Abstract
Postpartum depression (PPD) is associated with a decline in progesterone-derived anxiolytic-antidepressant neurosteroids after delivery. Neurosteroid replacement therapy (NRT) with GABA-A receptor-modulating allopregnanolone (brexanolone) shows promise as the first drug treatment for PPD. Here we describe the molecular insights of the neurosteroid approach for rapid relief of PPD symptoms compared with traditional antidepressants.
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Affiliation(s)
- Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX 77807, USA; Texas A&M Health Institute of Pharmacology and Neurotherapeutics, Texas A&M University Health Science Center, Bryan, TX 77807, USA.
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15
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Vecera CM, C. Courtes A, Jones G, Soares JC, Machado-Vieira R. Pharmacotherapies Targeting GABA-Glutamate Neurotransmission for Treatment-Resistant Depression. Pharmaceuticals (Basel) 2023; 16:1572. [PMID: 38004437 PMCID: PMC10675154 DOI: 10.3390/ph16111572] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 10/22/2023] [Accepted: 10/25/2023] [Indexed: 11/26/2023] Open
Abstract
Treatment-resistant depression (TRD) is a term used to describe a particular type of major depressive disorder (MDD). There is no consensus about what defines TRD, with various studies describing between 1 and 4 failures of antidepressant therapies, with or without electroconvulsive therapy (ECT). That is why TRD is such a growing concern among clinicians and researchers, and it explains the necessity for investigating novel therapeutic targets beyond conventional monoamine pathways. An imbalance between two primary central nervous system (CNS) neurotransmitters, L-glutamate and γ-aminobutyric acid (GABA), has emerged as having a key role in the pathophysiology of TRD. In this review, we provide an evaluation and comprehensive review of investigational antidepressants targeting these two systems, accessing their levels of available evidence, mechanisms of action, and safety profiles. N-methyl-D-aspartate (NMDA) receptor antagonism has shown the most promise amongst the glutamatergic targets, with ketamine and esketamine (Spravato) robustly generating responses across trials. Two specific NMDA-glycine site modulators, D-cycloserine (DCS) and apimostinel, have also generated promising initial safety and efficacy profiles, warranting further investigation. Combination dextromethorphan-bupropion (AXS-05/Auvelity) displays a unique mechanism of action and demonstrated positive results in particular applicability in subpopulations with cognitive dysfunction. Currently, the most promising GABA modulators appear to be synthetic neurosteroid analogs with positive GABAA receptor modulation (such as brexanolone). Overall, advances in the last decade provide exciting perspectives for those who do not improve with conventional therapies. Of the compounds reviewed here, three are approved by the Food and Drug Administration (FDA): esketamine (Spravato) for TRD, Auvelity (dextromethorphan-bupropion) for major depressive disorder (MDD), and brexanolone (Zulresso) for post-partum depression (PPD). Notably, some concerns have arisen with esketamine and brexanolone, which will be detailed in this study.
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Affiliation(s)
- Courtney M. Vecera
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center, Houston, TX 77054, USA
| | - Alan C. Courtes
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center, Houston, TX 77054, USA
| | - Gregory Jones
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center, Houston, TX 77054, USA
| | - Jair C. Soares
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center, Houston, TX 77054, USA
| | - Rodrigo Machado-Vieira
- John S. Dunn Behavioral Sciences Center at UTHealth Houston, 5615 H.Mark Crosswell Jr St, Houston, TX 77021, USA
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16
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Luscher B, Maguire JL, Rudolph U, Sibille E. GABA A receptors as targets for treating affective and cognitive symptoms of depression. Trends Pharmacol Sci 2023; 44:586-600. [PMID: 37543478 PMCID: PMC10511219 DOI: 10.1016/j.tips.2023.06.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 06/23/2023] [Accepted: 06/23/2023] [Indexed: 08/07/2023]
Abstract
In the past 20 years, our understanding of the pathophysiology of depression has evolved from a focus on an imbalance of monoaminergic neurotransmitters to a multifactorial picture including an improved understanding of the role of glutamatergic excitatory and GABAergic inhibitory neurotransmission. FDA-approved treatments targeting the glutamatergic [esketamine for major depressive disorder (MDD)] and GABAergic (brexanolone for peripartum depression) systems have become available. This review focuses on the GABAA receptor (GABAAR) system as a target for novel antidepressants and discusses the mechanisms by which modulation of δ-containing GABAARs with neuroactive steroids (NASs) or of α5-containing GABAARs results in antidepressant or antidepressant-like actions and discusses clinical data on NASs. Moreover, a potential mechanism by which α5-GABAAR-positive allosteric modulators (PAMs) may improve cognitive deficits in depression is presented.
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Affiliation(s)
- Bernhard Luscher
- Department of Biology, Pennsylvania State University, University Park, PA 16802, USA; Department of Biochemistry and Molecular Biology, Pennsylvania State University, University Park, PA 16802, USA; Department of Psychiatry, Pennsylvania State University, University Park, PA 16802, USA; Penn State Neuroscience Institute, Pennsylvania State University, University Park, PA 16802, USA
| | - Jamie L Maguire
- Department of Neuroscience, Tufts University School of Medicine, Boston, MA 02111, USA
| | - Uwe Rudolph
- Department of Comparative Biosciences, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, IL 61802, USA; Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, IL 61802, USA.
| | - Etienne Sibille
- Campbell Family Mental Health Research Institute of the Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
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17
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Reddy DS, Mbilinyi RH, Estes E. Preclinical and clinical pharmacology of brexanolone (allopregnanolone) for postpartum depression: a landmark journey from concept to clinic in neurosteroid replacement therapy. Psychopharmacology (Berl) 2023; 240:1841-1863. [PMID: 37566239 PMCID: PMC10471722 DOI: 10.1007/s00213-023-06427-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 07/17/2023] [Indexed: 08/12/2023]
Abstract
This article describes the critical role of neurosteroids in postpartum depression (PPD) and outlines the landmark pharmacological journey of brexanolone as a first-in-class neurosteroid antidepressant with significant advantages over traditional antidepressants. PPD is a neuroendocrine disorder that affects about 20% of mothers after childbirth and is characterized by symptoms including persistent sadness, fatigue, dysphoria, as well as disturbances in cognition, emotion, appetite, and sleep. The main pathology behind PPD is the postpartum reduction of neurosteroids, referred to as neurosteroid withdrawal, a concept pioneered by our preclinical studies. We developed neurosteroid replacement therapy (NRT) as a rational approach for treating PPD and other conditions related to neurosteroid deficiency, unveiling the power of neurosteroids as novel anxiolytic-antidepressants. The neurosteroid, brexanolone (BX), is a progesterone-derived allopregnanolone that rapidly relieves anxiety and mood deficits by activating GABA-A receptors, making it a transformational treatment for PPD. In 2019, the FDA approved BX, an intravenous formulation of allopregnanolone, as an NRT to treat PPD. In clinical studies, BX significantly improved PPD symptoms within hours of administration, with tolerable side effects including headache, dizziness, and somnolence. We identified the molecular mechanism of BX in a neuronal PPD-like milieu. The mechanism of BX involves activation of both synaptic and extrasynaptic GABA-A receptors, which promote tonic inhibition and serve as a key target for PPD and related conditions. Neurosteroids offer several advantages over traditional antidepressants, including rapid onset, unique mechanism, and lack of tolerance upon repeated use. Some limitations of BX therapy include lack of aqueous solubility, limited accessibility, hospitalization for treatment, lack of oral product, and serious adverse events at high doses. However, the unmet need for synthetic neurosteroids to address this critical condition supersedes these limitations. Recently, we developed novel hydrophilic neurosteroids with a superior profile and improved drug delivery. Overall, approval of BX is a major milestone in the field of neurotherapeutics, paving the way for the development of novel synthetic neurosteroids to treat depression, epilepsy, and status epilepticus.
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Affiliation(s)
- Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, 77807, USA.
- Institute of Pharmacology and Neurotherapeutics, Texas A&M University Health Science Center, 8447 Riverside Pkwy, Bryan, TX, 77807, USA.
| | - Robert H Mbilinyi
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, 77807, USA
| | - Emily Estes
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, 77807, USA
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18
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Abstract
Perinatal depression is a common psychiatric condition that has negative effects on pregnancy and infant outcomes. Screening for the condition is relatively easy and should be done routinely in all medical care of the pregnant and postpartum woman and her infant. The risk-benefit analysis favors the use of antidepressant medications during pregnancy and lactation compared with the risk of untreated maternal depression. Other, nonpharmacological treatments will be discussed as well as new treatments, including a new class of medications that act on the inhibitory GABAergic neurotransmitter system.
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Affiliation(s)
- Anne Louise Stewart
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, PO Box 800548, Charlottesville, VA 22908, USA
| | - Jennifer L Payne
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, PO Box 800548, Charlottesville, VA 22908, USA.
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19
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Deligiannidis KM, Meltzer-Brody S, Maximos B, Peeper EQ, Freeman M, Lasser R, Bullock A, Kotecha M, Li S, Forrestal F, Rana N, Garcia M, Leclair B, Doherty J. Zuranolone for the Treatment of Postpartum Depression. Am J Psychiatry 2023; 180:668-675. [PMID: 37491938 DOI: 10.1176/appi.ajp.20220785] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
OBJECTIVE Postpartum depression (PPD) is a common perinatal complication with adverse maternal and infant outcomes. This study investigated the efficacy and safety of zuranolone, a positive allosteric modulator of synaptic and extrasynaptic GABAA receptors and neuroactive steroid, as an oral, once-daily, 14-day treatment course for patients with severe PPD. METHODS In this double-blind phase 3 trial, women with severe PPD were randomized in a 1:1 ratio to receive zuranolone 50 mg/day or placebo for 14 days. The primary endpoint was change from baseline in total score on the 17-item Hamilton Depression Rating Scale (HAM-D) at day 15; key secondary endpoints were change from baseline in HAM-D score at days 3, 28, and 45 and change from baseline in Clinical Global Impressions severity (CGI-S) score at day 15. Adverse events were monitored. RESULTS Among 196 patients randomized (zuranolone, N=98; placebo, N=98), 170 (86.7%) completed the 45-day study. Treatment with zuranolone compared with placebo resulted in statistically significant improvement in depressive symptoms at day 15 (least squares mean [LSM] change from baseline in HAM-D score, -15.6 vs. -11.6; LSM difference, -4.0, 95% CI=-6.3, -1.7); significant improvement in depressive symptoms was also reported at days 3, 28, and 45. CGI-S score at day 15 significantly improved with zuranolone compared with placebo. The most common adverse events (≥10%) with zuranolone were somnolence, dizziness, and sedation. No loss of consciousness, withdrawal symptoms, or increased suicidal ideation or behavior were observed. CONCLUSIONS In this trial, zuranolone demonstrated significant improvements in depressive symptoms and was generally well tolerated, supporting the potential of zuranolone as a novel, rapid-acting oral treatment for PPD.
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Affiliation(s)
- Kristina M Deligiannidis
- Division of Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York (Deligiannidis); Feinstein Institutes for Medical Research, Northwell Health, Manhasset, N.Y. (Deligiannidis); Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. (Deligiannidis); Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Meltzer-Brody); Maximos Obstetrics and Gynecology, League City, Tex. (Maximos); Department of Obstetrics and Gynecology, LCMC Health, New Orleans (Peeper); Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, Boston (Freeman); Sage Therapeutics, Cambridge, Mass. (Lasser, Bullock, Li, Rana, Garcia, Doherty); Biogen, Cambridge, Mass. (Kotecha, Forrestal, Leclair)
| | - Samantha Meltzer-Brody
- Division of Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York (Deligiannidis); Feinstein Institutes for Medical Research, Northwell Health, Manhasset, N.Y. (Deligiannidis); Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. (Deligiannidis); Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Meltzer-Brody); Maximos Obstetrics and Gynecology, League City, Tex. (Maximos); Department of Obstetrics and Gynecology, LCMC Health, New Orleans (Peeper); Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, Boston (Freeman); Sage Therapeutics, Cambridge, Mass. (Lasser, Bullock, Li, Rana, Garcia, Doherty); Biogen, Cambridge, Mass. (Kotecha, Forrestal, Leclair)
| | - Bassem Maximos
- Division of Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York (Deligiannidis); Feinstein Institutes for Medical Research, Northwell Health, Manhasset, N.Y. (Deligiannidis); Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. (Deligiannidis); Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Meltzer-Brody); Maximos Obstetrics and Gynecology, League City, Tex. (Maximos); Department of Obstetrics and Gynecology, LCMC Health, New Orleans (Peeper); Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, Boston (Freeman); Sage Therapeutics, Cambridge, Mass. (Lasser, Bullock, Li, Rana, Garcia, Doherty); Biogen, Cambridge, Mass. (Kotecha, Forrestal, Leclair)
| | - E Quinn Peeper
- Division of Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York (Deligiannidis); Feinstein Institutes for Medical Research, Northwell Health, Manhasset, N.Y. (Deligiannidis); Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. (Deligiannidis); Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Meltzer-Brody); Maximos Obstetrics and Gynecology, League City, Tex. (Maximos); Department of Obstetrics and Gynecology, LCMC Health, New Orleans (Peeper); Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, Boston (Freeman); Sage Therapeutics, Cambridge, Mass. (Lasser, Bullock, Li, Rana, Garcia, Doherty); Biogen, Cambridge, Mass. (Kotecha, Forrestal, Leclair)
| | - Marlene Freeman
- Division of Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York (Deligiannidis); Feinstein Institutes for Medical Research, Northwell Health, Manhasset, N.Y. (Deligiannidis); Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. (Deligiannidis); Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Meltzer-Brody); Maximos Obstetrics and Gynecology, League City, Tex. (Maximos); Department of Obstetrics and Gynecology, LCMC Health, New Orleans (Peeper); Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, Boston (Freeman); Sage Therapeutics, Cambridge, Mass. (Lasser, Bullock, Li, Rana, Garcia, Doherty); Biogen, Cambridge, Mass. (Kotecha, Forrestal, Leclair)
| | - Robert Lasser
- Division of Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York (Deligiannidis); Feinstein Institutes for Medical Research, Northwell Health, Manhasset, N.Y. (Deligiannidis); Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. (Deligiannidis); Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Meltzer-Brody); Maximos Obstetrics and Gynecology, League City, Tex. (Maximos); Department of Obstetrics and Gynecology, LCMC Health, New Orleans (Peeper); Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, Boston (Freeman); Sage Therapeutics, Cambridge, Mass. (Lasser, Bullock, Li, Rana, Garcia, Doherty); Biogen, Cambridge, Mass. (Kotecha, Forrestal, Leclair)
| | - Amy Bullock
- Division of Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York (Deligiannidis); Feinstein Institutes for Medical Research, Northwell Health, Manhasset, N.Y. (Deligiannidis); Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. (Deligiannidis); Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Meltzer-Brody); Maximos Obstetrics and Gynecology, League City, Tex. (Maximos); Department of Obstetrics and Gynecology, LCMC Health, New Orleans (Peeper); Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, Boston (Freeman); Sage Therapeutics, Cambridge, Mass. (Lasser, Bullock, Li, Rana, Garcia, Doherty); Biogen, Cambridge, Mass. (Kotecha, Forrestal, Leclair)
| | - Mona Kotecha
- Division of Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York (Deligiannidis); Feinstein Institutes for Medical Research, Northwell Health, Manhasset, N.Y. (Deligiannidis); Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. (Deligiannidis); Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Meltzer-Brody); Maximos Obstetrics and Gynecology, League City, Tex. (Maximos); Department of Obstetrics and Gynecology, LCMC Health, New Orleans (Peeper); Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, Boston (Freeman); Sage Therapeutics, Cambridge, Mass. (Lasser, Bullock, Li, Rana, Garcia, Doherty); Biogen, Cambridge, Mass. (Kotecha, Forrestal, Leclair)
| | - Sigui Li
- Division of Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York (Deligiannidis); Feinstein Institutes for Medical Research, Northwell Health, Manhasset, N.Y. (Deligiannidis); Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. (Deligiannidis); Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Meltzer-Brody); Maximos Obstetrics and Gynecology, League City, Tex. (Maximos); Department of Obstetrics and Gynecology, LCMC Health, New Orleans (Peeper); Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, Boston (Freeman); Sage Therapeutics, Cambridge, Mass. (Lasser, Bullock, Li, Rana, Garcia, Doherty); Biogen, Cambridge, Mass. (Kotecha, Forrestal, Leclair)
| | - Fiona Forrestal
- Division of Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York (Deligiannidis); Feinstein Institutes for Medical Research, Northwell Health, Manhasset, N.Y. (Deligiannidis); Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. (Deligiannidis); Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Meltzer-Brody); Maximos Obstetrics and Gynecology, League City, Tex. (Maximos); Department of Obstetrics and Gynecology, LCMC Health, New Orleans (Peeper); Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, Boston (Freeman); Sage Therapeutics, Cambridge, Mass. (Lasser, Bullock, Li, Rana, Garcia, Doherty); Biogen, Cambridge, Mass. (Kotecha, Forrestal, Leclair)
| | - Nilanjana Rana
- Division of Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York (Deligiannidis); Feinstein Institutes for Medical Research, Northwell Health, Manhasset, N.Y. (Deligiannidis); Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. (Deligiannidis); Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Meltzer-Brody); Maximos Obstetrics and Gynecology, League City, Tex. (Maximos); Department of Obstetrics and Gynecology, LCMC Health, New Orleans (Peeper); Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, Boston (Freeman); Sage Therapeutics, Cambridge, Mass. (Lasser, Bullock, Li, Rana, Garcia, Doherty); Biogen, Cambridge, Mass. (Kotecha, Forrestal, Leclair)
| | - Manny Garcia
- Division of Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York (Deligiannidis); Feinstein Institutes for Medical Research, Northwell Health, Manhasset, N.Y. (Deligiannidis); Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. (Deligiannidis); Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Meltzer-Brody); Maximos Obstetrics and Gynecology, League City, Tex. (Maximos); Department of Obstetrics and Gynecology, LCMC Health, New Orleans (Peeper); Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, Boston (Freeman); Sage Therapeutics, Cambridge, Mass. (Lasser, Bullock, Li, Rana, Garcia, Doherty); Biogen, Cambridge, Mass. (Kotecha, Forrestal, Leclair)
| | - Bridgette Leclair
- Division of Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York (Deligiannidis); Feinstein Institutes for Medical Research, Northwell Health, Manhasset, N.Y. (Deligiannidis); Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. (Deligiannidis); Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Meltzer-Brody); Maximos Obstetrics and Gynecology, League City, Tex. (Maximos); Department of Obstetrics and Gynecology, LCMC Health, New Orleans (Peeper); Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, Boston (Freeman); Sage Therapeutics, Cambridge, Mass. (Lasser, Bullock, Li, Rana, Garcia, Doherty); Biogen, Cambridge, Mass. (Kotecha, Forrestal, Leclair)
| | - James Doherty
- Division of Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York (Deligiannidis); Feinstein Institutes for Medical Research, Northwell Health, Manhasset, N.Y. (Deligiannidis); Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y. (Deligiannidis); Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Meltzer-Brody); Maximos Obstetrics and Gynecology, League City, Tex. (Maximos); Department of Obstetrics and Gynecology, LCMC Health, New Orleans (Peeper); Department of Psychiatry, Massachusetts General Hospital, and Harvard Medical School, Boston (Freeman); Sage Therapeutics, Cambridge, Mass. (Lasser, Bullock, Li, Rana, Garcia, Doherty); Biogen, Cambridge, Mass. (Kotecha, Forrestal, Leclair)
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20
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Walton NL, Antonoudiou P, Maguire JL. Neurosteroid influence on affective tone. Neurosci Biobehav Rev 2023; 152:105327. [PMID: 37499891 PMCID: PMC10528596 DOI: 10.1016/j.neubiorev.2023.105327] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 07/07/2023] [Accepted: 07/23/2023] [Indexed: 07/29/2023]
Abstract
Affective disorders such as depression and anxiety are among the most prevalent psychiatric illnesses and causes of disability worldwide. The recent FDA-approval of a novel antidepressant treatment, ZULRESSO® (Brexanolone), a synthetic neurosteroid has fueled interest into the role of neurosteroids in the pathophysiology of depression as well as the mechanisms mediating the antidepressant effects of these compounds. The majority of studies examining the impact of neurosteroids on affective states have relied on the administration of exogenous neurosteroids; however, neurosteroids can also be synthesized endogenously from cholesterol or steroid hormone precursors. Despite the well-established influence of exogenous neurosteroids on affective states, we still lack an understanding of the role of endogenous neurosteroids in modulating affective tone. This review aims to summarize the current literature supporting the influence of neurosteroids on affective states in clinical and preclinical studies, as well as recent evidence suggesting that endogenous neurosteroids may set a baseline affective tone.
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Affiliation(s)
- Najah L Walton
- Program of Neuroscience, Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA; Department of Neuroscience, Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
| | - Pantelis Antonoudiou
- Program of Neuroscience, Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA; Department of Neuroscience, Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
| | - Jamie L Maguire
- Program of Neuroscience, Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA; Department of Neuroscience, Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA.
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Xu L, Ma J, Shi L, Li F. Design, Synthesis and Characterizations of Prodrugs of Brexanolone. Bioorg Med Chem Lett 2023; 90:129344. [PMID: 37217022 DOI: 10.1016/j.bmcl.2023.129344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/06/2023] [Accepted: 05/19/2023] [Indexed: 05/24/2023]
Abstract
A series of prodrugs of brexanolone, the synthetic version of the endogenously produced γ-aminobutyric acid A receptors positive allosteric modulator allopregnanolone, were designed, synthesized, and evaluated in vitro and in vivo. The effect of different function groups connecting to brexanolone C3 hydroxyl as well as those at the chain terminals of prodrug moieties were explored. Through these efforts, prodrugs that can efficiently release brexanolone in vitro and in vivo, and possess a potential for sustained delivery of a long acting brexanolone were discovered.
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Affiliation(s)
- Lianhong Xu
- Department of Discovery, Brii Biosciences, 1825 Grant Street, San Mateo, CA 94402, USA.
| | - Ji Ma
- Department of Discovery, Brii Biosciences, 1825 Grant Street, San Mateo, CA 94402, USA
| | - Leifeng Shi
- IDSU, WuXi AppTec Co., Ltd, 288 Fute Zhong Road, Waigaoqiao Free Trade Zone, Shanghai 20013, China
| | - Fuying Li
- IDSU, WuXi AppTec Co., Ltd, 288 Fute Zhong Road, Waigaoqiao Free Trade Zone, Shanghai 20013, China
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22
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Stefaniak M, Dmoch-Gajzlerska E, Jankowska K, Rogowski A, Kajdy A, Maksym RB. Progesterone and Its Metabolites Play a Beneficial Role in Affect Regulation in the Female Brain. Pharmaceuticals (Basel) 2023; 16:ph16040520. [PMID: 37111278 PMCID: PMC10143192 DOI: 10.3390/ph16040520] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/25/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Premenstrual dysphoric disorder is a female affective disorder that is defined by mood symptoms. The condition is linked to unstable progesterone concentrations. Progestin supplementation is given in cases of threatened or recurrent miscarriage and for luteal phase support. Progesterone is essential for implantation, immune tolerance, and modulation of uterine contractility. For a long time, the administration of progestins was associated with an unfavorable impact on mood, leading to negative affect, and, therefore, was contraindicated in existing mood disorders. Establishing the role of the natural progesterone derivative allopregnanolone in advances in the treatment of postpartum depression has shed new light on the general pathophysiology of mood disorders. Allopregnanolone directly interacts with gamma-aminobutyric acid type A (GABA-A) receptors even at nanomolar concentrations and induces significant anti-depressant, anti-stress, sedative, and anxiolytic effects. Postpartum depression is caused by a rapid drop in hormones and can be instantly reversed by the administration of allopregnanolone. Premenstrual dysphoric disorder can also be considered to result from insufficient neuroactive steroid action due to low progesterone derivative concentration, unstable hormone levels, or decreased receptor sensitivity. The decrease in progesterone levels in perimenopause is also associated with affective symptoms and an exacerbation of some psychosomatic syndromes. Bioidentical progesterone supplementation encounters several obstacles, including limited absorption, first-pass effect, and rapid metabolism. Hence, non-bioidentical progestins with better bioavailability were widely applied. The paradoxical, unfavorable effect of progestins on mood can be explained by the fact that progestins suppress ovulation and disturb the endocrine function of the ovary in the luteal phase. Moreover, their distinct chemical structure prevents their metabolism to neuroactive, mood-improving derivatives. A new understanding of progesterone-related mood disorders can translate the study results from case series and observational studies to cohort studies, clinical trials, and novel, effective treatment protocols being developed.
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Affiliation(s)
- Małgorzata Stefaniak
- Department of Obstetrics and Gynecology Didactics, Medical University of Warsaw, ul. Litewska 14/16, 00-575 Warsaw, Poland
| | - Ewa Dmoch-Gajzlerska
- Department of Obstetrics and Gynecology Didactics, Medical University of Warsaw, ul. Litewska 14/16, 00-575 Warsaw, Poland
| | - Katarzyna Jankowska
- Department of Endocrinology, Centre of Postgraduate Medical Education, ul. Cegłowska 80, 01-809 Warsaw, Poland
| | - Artur Rogowski
- Department of Minimally Invasive and Endoscopic Gynecology, Military Institute of Medicine, ul. Zegrzyńska 8, 05-119 Legionowo, Poland
| | - Anna Kajdy
- 1st Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, ul. Żelazna 90, 02-004 Warszawa, Poland
| | - Radosław B. Maksym
- 1st Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, ul. Żelazna 90, 02-004 Warszawa, Poland
- Correspondence:
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23
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Zarate CA. Key considerations for clinical trials in psychopharmacology. World Psychiatry 2023; 22:76-77. [PMID: 36640382 PMCID: PMC9840493 DOI: 10.1002/wps.21061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 01/15/2023] Open
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Abstract
Treatment of major depressive disorder (MDD) including treatment-resistant depression (TRD) remains a major unmet need. Although there are several classes of dissimilar antidepressant drugs approved for MDD, the current drugs have either limited efficacy or are associated with undesirable side effects and withdrawal symptoms. The efficacy and side effects of antidepressant drugs are mainly attributed to their actions on different monoamine neurotransmitters (serotonin, norepinephrine, and dopamine). Development of new antidepressants with novel targets beyond the monoamine pathways may fill the unmet need in treatment of MDD and TRD. The recent approval of intranasal Esketamine (glutamatergic agent) in conjunction with an oral antidepressant for the treatment of adult TRD patients was the first step toward expanding beyond the monoamine targets. Several other glutamatergic (AXS-05, REL-1017, AV-101, SLS-002, AGN24175, and PCN-101) and GABAergic (brexanolone, zuranolone, and ganaxolone) drugs are currently in different stages of clinical development for MDD, TRD and other indications. The renaissance of psychedelic drugs and the emergence of preliminary positive clinical trial results with psilocybin, Ayahuasca, 5-methoxy-N,N-dimethyltryptamine (5-MeO-DMT), and lysergic acid diethylamide (LSD) may pave the way towards establishing this class of drugs as effective therapies for MDD, TRD and other neuropsychiatric disorders. Going beyond the monoamine targets appears to be an effective strategy to develop novel antidepressant drugs with superior efficacy, safety, and tolerability for the improved treatment of MDD and TRD.
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Salwan A, Maroney M, Tremayne L. Patient-reported perceptions of brexanolone in the treatment of postpartum depression: A qualitative analysis. Ment Health Clin 2023; 12:342-349. [PMID: 36644587 PMCID: PMC9819138 DOI: 10.9740/mhc.2022.12.342] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 09/27/2022] [Indexed: 01/05/2023] Open
Abstract
Introduction Brexanolone demonstrates short-term efficacy for the treatment of postpartum depression (PPD). Postpartum depression is linked to infanticide and maternal suicide, and current treatment often fails to adequately control depressive symptoms. The purpose of this analysis is to further understand the experience(s) of women who have received brexanolone for the treatment of PPD. Methods Semistructured interviews modeled after the theory of planned behavior (TPB) were conducted to assess women's perceptions of treatment for PPD with brexanolone. Women who received treatment with brexanolone at this inpatient facility were eligible to participate in this study. The TPB is often used to predict intention to perform health-related behaviors. Semistructured interviews were recorded and transcribed, and thematic analysis was conducted to identify common ideas across all interviews. Follow-up assessment of depressive and anxious symptoms was also conducted using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), respectively. Results Five of the 10 women who received treatment with brexanolone at this facility were interviewed, and common themes related to the TPB were analyzed. Attitudes toward brexanolone were favorable, and having a strong support system was a motivating factor in receiving treatment for PPD. Insurance approval, need for childcare, and poor understanding of symptoms of PPD were barriers to receiving treatment with brexanolone. Symptoms of depression and anxiety were rated as low at the time of the follow-up interview as measured by the PHQ-9 (mean 1.6, range 1 to 3) and GAD-7 (mean 2.8, range 2 to 4), respectively. Discussion Brexanolone rapidly and sustainably reduced symptoms of PPD and was well-received by patients. Despite significant barriers to use, women who received treatment with brexanolone advocated for its availability as well as increased awareness of PPD.
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Affiliation(s)
- Aaron Salwan
- Behavioral Health Clinical Pharmacy Specialist, Montefiore Nyack Hospital, Nyack, New York,
| | - Megan Maroney
- Associate Professor, Rutgers the State University of New Jersey, Piscataway, New Jersey
| | - Lisa Tremayne
- Director, Perinatal Mood and Anxiety Disorders Clinic, Monmouth Medical Center, Long Branch, New Jersey
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Epperson CN, Rubinow DR, Meltzer-Brody S, Deligiannidis KM, Riesenberg R, Krystal AD, Bankole K, Huang MY, Li H, Brown C, Kanes SJ, Lasser R. Effect of brexanolone on depressive symptoms, anxiety, and insomnia in women with postpartum depression: Pooled analyses from 3 double-blind, randomized, placebo-controlled clinical trials in the HUMMINGBIRD clinical program. J Affect Disord 2023; 320:353-359. [PMID: 36191643 DOI: 10.1016/j.jad.2022.09.143] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/26/2022] [Accepted: 09/27/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Brexanolone is currently the only treatment specifically approved for postpartum depression (PPD) in the United States, based on the results from one Phase 2 and two Phase 3 double-blind, randomized, controlled trials in the HUMMINGBIRD program. METHODS Adults with PPD randomized to a 60-h infusion of brexanolone 90 μg/kg/h (BRX90) or placebo from the 3 trials were included in these post hoc analyses. Data on change from baseline (CFB) in the 17-item Hamilton Rating Scale for Depression (HAMD-17) total score, HAMD-17 Anxiety/Somatization and Insomnia subscales, and Clinical Global Impression of Improvement (CGI-I) scale were pooled. Response rates for HAMD-17 (≥50 % reduction from baseline) and CGI-I (score of 1 or 2) scales and time to response were analyzed. RESULTS Patients receiving BRX90 (n = 102) versus placebo (n = 107) achieved a more rapid HAMD-17 response (median, 24 vs 36 h; p = 0.0265), with an Hour-60 cumulative response rate of 81.4 % versus 67.3 %; results were similar for time to CGI-I response (median, 24 vs 36 h; p = 0.0058), with an Hour-60 cumulative response rate of 81.4 % versus 61.7 %. CFB in HAMD-17 Anxiety/Somatization and Insomnia subscales also favored BRX90 versus placebo, starting at Hour 24 through Day 30 (all p < 0.05), and response rates for both subscales were higher with BRX90. LIMITATIONS The study was not powered to assess exploratory outcomes. CONCLUSIONS Brexanolone was associated with rapid improvement in depressive symptoms and symptoms of anxiety and insomnia compared with placebo in women with PPD. These data continue to support the use of brexanolone to treat adults with PPD.
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Affiliation(s)
- C Neill Epperson
- Department of Psychiatry, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, United States of America.
| | - David R Rubinow
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Samantha Meltzer-Brody
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Kristina M Deligiannidis
- Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, United States of America; Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States of America
| | - Robert Riesenberg
- Atlanta Center for Medical Research, Atlanta, GA, United States of America
| | - Andrew D Krystal
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, United States of America
| | - Kemi Bankole
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Ming-Yi Huang
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Haihong Li
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Colville Brown
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Stephen J Kanes
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Robert Lasser
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
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Moreira LKS, Moreira CVL, Custódio CHX, Dias MLP, Rosa DA, Ferreira-Neto ML, Colombari E, Costa EA, Fajemiroye JO, Pedrino GR. Post-partum depression: From clinical understanding to preclinical assessments. Front Psychiatry 2023; 14:1173635. [PMID: 37143780 PMCID: PMC10151489 DOI: 10.3389/fpsyt.2023.1173635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/29/2023] [Indexed: 05/06/2023] Open
Abstract
Post-partum depression (PPD) with varying clinical manifestations affecting new parents remains underdiagnosed and poorly treated. This minireview revisits the pharmacotherapy, and relevant etiological basis, capable of advancing preclinical research frameworks. Maternal tasks accompanied by numerous behavioral readouts demand modeling different paradigms that reflect the complex and heterogenous nature of PPD. Hence, effective PPD-like characterization in animals towards the discovery of pharmacological intervention demands research that deepens our understanding of the roles of hormonal and non-hormonal components and mediators of this psychiatric disorder.
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Affiliation(s)
| | | | | | - Matheus L. P. Dias
- Institute of Biological Sciences, Federal University of Goiás, Goiania, GO, Brazil
| | - Daniel A. Rosa
- Institute of Biological Sciences, Federal University of Goiás, Goiania, GO, Brazil
| | - Marcos L. Ferreira-Neto
- Department of Physiology, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, Brazil
| | - Eduardo Colombari
- Department of Physiology and Pathology, School of Dentistry, São Paulo State University (UNESP), Araraquara, Brazil
| | - Elson A. Costa
- Institute of Biological Sciences, Federal University of Goiás, Goiania, GO, Brazil
| | - James O. Fajemiroye
- Institute of Biological Sciences, Federal University of Goiás, Goiania, GO, Brazil
- Graduate Program in Pharmaceutical Sciences, Campus Arthur Wesley Archibald, Evangelical University of Goiás, Anápolis, Brazil
- *Correspondence: James O. Fajemiroye,
| | - Gustavo R. Pedrino
- Institute of Biological Sciences, Federal University of Goiás, Goiania, GO, Brazil
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PILLEROVÁ M, PASTOREK M, BORBÉLYOVÁ V, RILJAK V, FRICK KM, HODOSY J, TÓTHOVÁ Ľ. Sex steroid hormones in depressive disorders as a basis for new potential treatment strategies. Physiol Res 2022; 71:S187-S202. [PMID: 36647907 PMCID: PMC9906660 DOI: 10.33549/physiolres.935001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The sex steroid hormones (SSHs) such as testosterone, estradiol, progesterone, and their metabolites have important organizational and activational impacts on the brain during critical periods of brain development and in adulthood. A variety of slow and rapid mechanisms mediate both organizational and activational processes via intracellular or membrane receptors for SSHs. Physiological concentrations and distribution of SSHs in the brain result in normal brain development. Nevertheless, dysregulation of hormonal equilibrium may result in several mood disorders, including depressive disorders, later in adolescence or adulthood. Gender differences in cognitive abilities, emotions as well as the 2-3 times higher prevalence of depressive disorders in females, were already described. This implies that SSHs may play a role in the development of depressive disorders. In this review, we discuss preclinical and clinical studies linked to SSHs and development of depressive disorders. Our secondary aim includes a review of up-to-date knowledge about molecular mechanisms in the pathogenesis of depressive disorders. Understanding these molecular mechanisms might lead to significant treatment adjustments for patients with depressive disorders and to an amelioration of clinical outcomes for these patients. Nevertheless, the impact of SSHs on the brain in the context of the development of depressive disorders, progression, and treatment responsiveness is complex in nature, and depends upon several factors in concert such as gender, age, comorbidities, and general health conditions.
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Affiliation(s)
- Miriam PILLEROVÁ
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovak Republic
| | - Michal PASTOREK
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovak Republic
| | - Veronika BORBÉLYOVÁ
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovak Republic
| | - Vladimír RILJAK
- Institute of Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Karyn M. FRICK
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Július HODOSY
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovak Republic
| | - Ľubomíra TÓTHOVÁ
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovak Republic
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Levien TL, Baker DE. Formulary Drug Reviews: Brexanolone Injection. Hosp Pharm 2022; 57:615-621. [PMID: 36081541 PMCID: PMC9445546 DOI: 10.1177/0018578719867685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433.
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Ghuman A, McEwen A, Tran KH, Mitchell N, Hanstock C, Seres P, Jhangri G, Burgess D, Baker G, Le Melledo JM. Prospective Investigation of Glutamate Levels and Percentage Gray Matter in the Medial Prefrontal Cortex in Females at Risk for Postpartum Depression. Curr Neuropharmacol 2022; 20:1988-2000. [PMID: 35236264 PMCID: PMC9886796 DOI: 10.2174/1570159x20666220302101115] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/19/2022] [Accepted: 02/27/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The substantial female hormone fluctuations associated with pregnancy and postpartum have been linked to a greater risk of developing depressive symptoms, particularly in high-risk women (HRW), i.e. those with histories of mood sensitivity to female hormone fluctuations. We have shown that glutamate (Glu) levels in the medial prefrontal cortex (MPFC) decrease during perimenopause, a period of increased risk of developing a major depressive episode. Our team has also demonstrated that percentage gray matter (%GM), another neural correlate of maternal brain health, decreases in the MPFC during pregnancy. OBJECTIVE To investigate MPFC Glu levels and %GM from late pregnancy up to 7 weeks postpartum in HRW and healthy pregnant women (HPW). METHODS Single-voxel spectra were acquired from the MPFC of 41 HPW and 22 HRW using 3- Tesla in vivo proton magnetic resonance spectroscopy at five different time points. RESULTS We observed a statistically significant interaction between time and group for the metabolite Glu, with Glu levels being lower for HRW during pregnancy and early postpartum (p<0.05). MPFC %GM was initially lower during pregnancy and then significantly increased over time in both groups (p<0.01). CONCLUSION This investigation suggests that the vulnerability towards PPD is associated with unique fluctuations of MPFC Glu levels during pregnancy and early postpartum period. Our results also suggest that the decline in MPFC %GM associated with pregnancy seems to progressively recover over time. Further investigations are needed to determine the specific role that female hormones play on the physiological changes in %GM during pregnancy and postpartum.
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Affiliation(s)
- Arjun Ghuman
- Address correspondence to these authors at the Department of Psychiatry, Room 1E7.14, 8440 112 street Walter Mackenzie Center, Edmonton, Alberta, Canada, T6G 2B7; Tel: 780-407-6578; Fax: 780-407-6672; E-mail:
| | - Alyssa McEwen
- Address correspondence to these authors at the Department of Psychiatry, Room 1E7.14, 8440 112 street Walter Mackenzie Center, Edmonton, Alberta, Canada, T6G 2B7; Tel: 780-407-6578; Fax: 780-407-6672; E-mail:
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Wald J, Henningsson A, Hanze E, Hoffmann E, Li H, Colquhoun H, Deligiannidis KM. Allopregnanolone Concentrations in Breast Milk and Plasma from Healthy Volunteers Receiving Brexanolone Injection, With Population Pharmacokinetic Modeling of Potential Relative Infant Dose. Clin Pharmacokinet 2022; 61:1307-1319. [PMID: 35869362 PMCID: PMC9439988 DOI: 10.1007/s40262-022-01155-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 11/25/2022]
Abstract
Background and Objective Women with postpartum depression (PPD) may expose their infants to antidepressants via breast milk. Brexanolone is the only FDA-approved antidepressant specifically indicated for the treatment of PPD. This open-label, phase Ib study of healthy lactating volunteers assessed pharmacokinetic (PK) properties of brexanolone and a population PK (PopPK) model determined the relative infant dose (RID) in breastfeeding mothers. Methods Twelve participants received a 60-h infusion of brexanolone (titration up to 90 µg/kg/h). Allopregnanolone concentration was measured in breast milk and plasma. The RID was computed using a nonlinear mixed-effects PopPK model of patients with PPD and healthy women (N = 156). Model results were extended across an integrated dataset of participants through day 7. Results Allopregnanolone concentration–time profiles were similar between breast milk and plasma (partition coefficient for concentration gradient [milk : plasma] 1.36). Mean (95% CI) Cmax was 89.7 ng/mL (74.19–108.39), and median (95% CI) tmax was 47.8 h (47.8–55.8) in plasma. The overall PK profile was best described by a two-compartment model with linear elimination and distribution. Body weight was the only significant covariate identified. There were no apparent differences in PopPK AUC and Cmax between participants with or without concomitant antidepressant treatment. Maximum RID was 1.3%. Conclusion The PopPK model successfully described the variability and concentration–time profiles of allopregnanolone in breast milk and plasma in healthy participants and in the plasma of brexanolone-treated patients with PPD. The rapid elimination of allopregnanolone from plasma and breast milk, and low RID, suggests the appropriateness of brexanolone weight-based dosing and supports other PK-related labeling recommendations. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-022-01155-w.
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Affiliation(s)
- Jeffrey Wald
- Sage Therapeutics, Inc., 215 First Street, Cambridge, MA, 02142, USA.
| | | | | | - Ethan Hoffmann
- Sage Therapeutics, Inc., 215 First Street, Cambridge, MA, 02142, USA
| | - Haihong Li
- Sage Therapeutics, Inc., 215 First Street, Cambridge, MA, 02142, USA
| | - Helen Colquhoun
- Sage Therapeutics, Inc., 215 First Street, Cambridge, MA, 02142, USA
| | - Kristina M Deligiannidis
- Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
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Vasiliu O. Investigational Drugs for the Treatment of Depression (Part 1): Monoaminergic, Orexinergic, GABA-Ergic, and Anti-Inflammatory Agents. Front Pharmacol 2022; 13:884143. [PMID: 35774601 PMCID: PMC9237478 DOI: 10.3389/fphar.2022.884143] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/14/2022] [Indexed: 12/27/2022] Open
Abstract
Therapeutic management of depression has currently important limitations, and its low efficacy is reflected in high rates of non-response even after multiple trials of antidepressants. Almost two-thirds of the patients diagnosed with major depression who received a 4–6 weeks trial of antidepressant could not reach remission, and more than 30% of these patients are considered treatment-resistant. In bipolar depression, the situation is also discouraging if we analyze the high suicide rate, the risk for the treatment-emergent affective switch when antidepressants are added, the high rate of treatment resistance (up to 25%), and the severe functional impairments associated with these episodes. Therefore, new therapeutic agents are needed, as well as new pathogenetic models for depression. The vast majority of the currently approved antidepressants are based on the monoamine hypothesis, although new drugs exploiting different neurotransmitter pathways have been recently approved by FDA. Brexanolone, an allopregnanolone analog, is an example of such new antidepressants, and its approval for post-partum depression inspired the search for a new generation of neurosteroids and GABA-ergic modulators, with an easier way of administration and superior tolerability profile. Orexin receptors antagonists are also extensively studied for different psychiatric disorders, depression included, in phase II trials. Antiinflammatory drugs, both cyclo-oxygenase 2 inhibitors and biological therapy, are investigated in patients with depressive disorders based on the proven correlation between inflammation and mood disorders in preclinical and clinical studies. Also, a new generation of monoamine-based investigational drugs is explored, ranging from triple reuptake inhibitors to atypical antipsychotics, in patients with major depression. In conclusion, there is hope for new treatments in uni- and bipolar depression, as it became clear, after almost seven decades, that new pathogenetic pathways should be targeted to increase these patients’ response rate.
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Pinna G, Almeida FB, Davis JM. Allopregnanolone in Postpartum Depression. Front Glob Womens Health 2022; 3:823616. [PMID: 35558166 PMCID: PMC9088875 DOI: 10.3389/fgwh.2022.823616] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 02/01/2022] [Indexed: 12/27/2022] Open
Abstract
Postpartum depression (PPD) is a debilitating psychiatric disorder characterized by a high worldwide prevalence and serious long-term negative outcomes for both mothers and children. The lack of a specific treatment and overreliance on pharmacotherapy with limited efficacy and delayed treatment response has constituted a complication in the management of PPD. Recently, the Food and Drug Administration (FDA) in the USA approved a synthetic formulation of the GABAergic neurosteroid allopregnanolone, administered intravenously (brexanolone) for the rapid, long-lasting and effective treatment of PPD. Hereinafter, we review findings on allopregnanolone biosynthesis and GABAA receptor plasticity in the pathophysiology of PPD. We also discuss evidence supporting the efficacy of brexanolone for the treatment of PPD, which opens a promising new horizon for neurosteroid-based therapeutics for mood disorders.
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Affiliation(s)
- Graziano Pinna
- The Psychiatric Institute, Department of Psychiatry, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
- *Correspondence: Graziano Pinna ;
| | - Felipe B. Almeida
- The Psychiatric Institute, Department of Psychiatry, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
- Graduate Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - John M. Davis
- The Psychiatric Institute, Department of Psychiatry, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
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Griffin SC, Young JR, Naylor JC, Allen KD, Beckham JC, Calhoun PS. Reciprocal Effects Between Depressive Symptoms and Pain in Veterans over 50 Years of Age or Older. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:295-304. [PMID: 34643735 PMCID: PMC9123932 DOI: 10.1093/pm/pnab294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Depression and chronic pain are major problems in American veterans, yet there is limited long-term research examining how they relate to one another in this population. This study examined the relationship between depressive symptoms and pain in U.S. veterans 50 years of age or older. METHODS This study used data on veterans from the 2002-2016 waves of the Health and Retirement Study (n = 4,302), a large-scale observational study of Americans 50 years of age or older. Measures included a short form of the Center for Epidemiologic Studies Depression scale and two items assessing the presence and degree of pain. Analyses included random-intercept cross-lagged panel models (RI-CLPM). RESULTS In the RI-CLPM, there were roughly equivalent cross-lagged effects between depressive symptoms and pain. There was also evidence that depressive symptoms and pain have a trait-like component and that these trait-like characteristics are associated. CONCLUSIONS These findings indicate that depressive symptoms and pain in veterans are stable characteristics in American veterans 50 years of age or older. There appear to be reciprocal effects between the two, whereby deviations in one's typical depressive symptoms predict subsequent deviations in one's pain level and vice versa; however, the size of these effects is very small. These findings suggest that clinicians should treat both depressive symptoms and pain, rather than assume that treatment benefits in one domain will lead to major benefits in another.
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Affiliation(s)
- Sarah C Griffin
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Jonathan R Young
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Division of Behavioral Medicine and Neurosciences, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Jennifer C Naylor
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Division of Behavioral Medicine and Neurosciences, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Kelli D Allen
- Division of Behavioral Medicine and Neurosciences, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
- Allergy and Immunology & Thurston Arthritis Research Center, Division of Rheumatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Department of Veterans Affairs Health Care Center, Durham, North Carolina, USA
| | - Jean C Beckham
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Division of Behavioral Medicine and Neurosciences, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Patrick S Calhoun
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Division of Behavioral Medicine and Neurosciences, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
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Reddy DS. Neurosteroid replacement therapy for catamenial epilepsy, postpartum depression and neuroendocrine disorders in women. J Neuroendocrinol 2022; 34:e13028. [PMID: 34506047 PMCID: PMC9247111 DOI: 10.1111/jne.13028] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/27/2021] [Accepted: 08/05/2021] [Indexed: 12/11/2022]
Abstract
Neurosteroids are involved in the pathophysiology of many neuroendocrine disorders in women. This review describes recent advancements in pharmacology of neurosteroids and emphasizes the benefits of neurosteroid replacement therapy for the management of neuroendocrine disorders such as catamenial epilepsy (CE), postpartum depression (PPD) and premenstrual brain conditions. Neurosteroids are endogenous modulators of neuronal excitability. A variety of neurosteroids are present in the brain including allopregnanolone (AP), allotetrahydro-deoxycorticosterone and androstanediol. Neurosteroids interact with synaptic and extrasynaptic GABAA receptors in the brain. AP and related neurosteroids, which are positive allosteric modulators of GABAA receptors, are powerful anticonvulsants, anxiolytic, antistress and neuroprotectant agents. In CE, seizures are most often clustered around a specific menstrual period in women. Neurosteroid withdrawal-linked plasticity in extrasynaptic receptors has been shown to play a key role in catamenial seizures, anxiety and other mood disorders. Based on our extensive research spanning two decades, we have proposed and championed neurosteroid replacement therapy as a rational strategy for treating disorders marked by neurosteroid-deficiency, such as CE and other related ovarian or menstrual disorders. In 2019, AP (renamed as brexanolone) was approved for treating PPD. A variety of synthetic neurosteroids are in clinical trials for epilepsy, depression and other brain disorders. Recent advancements in our understanding of neurosteroids have entered a new era of drug discovery and one that offers a high therapeutic potential for treating complex brain disorders.
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Affiliation(s)
- Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University College of Medicine, Bryan, TX, USA
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Kaufman Y, Carlini SV, Deligiannidis KM. Advances in pharmacotherapy for postpartum depression: a structured review of standard-of-care antidepressants and novel neuroactive steroid antidepressants. Ther Adv Psychopharmacol 2022; 12:20451253211065859. [PMID: 35111296 PMCID: PMC8801644 DOI: 10.1177/20451253211065859] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022] Open
Abstract
Postpartum depression is one of the most common morbidities of childbearing, yet it is underdiagnosed and undertreated with negative consequences for mother and offspring. Despite the widespread use of standard-of-care antidepressants as the mainstay of treatment for postpartum depression, there is limited evidence on their safety and efficacy due to their slow onset of action and suboptimal outcomes. The emergence of gamma-aminobutyric acidergic neuroactive steroids may offer faster response and remission times and improved patient outcomes. This article reviews the evidence base for the efficacy of standard-of-care antidepressants, hormonal therapeutics including progestins and estradiol, and gamma-aminobutyric acidergic neuroactive steroids in the treatment of postpartum depression, as well as the safety of infant exposure to these agents during lactation.
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Affiliation(s)
- Yardana Kaufman
- Perinatal Psychiatry Center, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
| | - Sara V Carlini
- Perinatal Psychiatry Center, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
| | - Kristina M Deligiannidis
- Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, 75-59 263rd Street, Glen Oaks, NY, USA
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Deligiannidis KM, Meltzer-Brody S, Gunduz-Bruce H, Doherty J, Jonas J, Li S, Sankoh AJ, Silber C, Campbell AD, Werneburg B, Kanes SJ, Lasser R. Effect of Zuranolone vs Placebo in Postpartum Depression: A Randomized Clinical Trial. JAMA Psychiatry 2021; 78:951-959. [PMID: 34190962 PMCID: PMC8246337 DOI: 10.1001/jamapsychiatry.2021.1559] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 05/05/2021] [Indexed: 12/28/2022]
Abstract
Importance Postpartum depression (PPD) is one of the most common medical complications during and after pregnancy, negatively affecting both mother and child. Objective To demonstrate the efficacy and safety of zuranolone, a neuroactive steroid γ-aminobutyric acid receptor-positive allosteric modulator, in PPD. Design, Setting, and Participants This phase 3, double-blind, randomized, outpatient, placebo-controlled clinical trial was conducted between January 2017 and December 2018 in 27 enrolling US sites. Participant were women aged 18 to 45 years, 6 months or fewer post partum, with PPD (major depressive episode beginning third trimester or ≤4 weeks postdelivery), and baseline 17-item Hamilton Rating Scale for Depression (HAMD-17) score of 26 or higher. Analysis was intention to treat and began December 2018 and ended March 2019. Interventions Randomization 1:1 to placebo:zuranolone, 30 mg, administered orally each evening for 2 weeks. Main Outcomes and Measures Primary end point was change from baseline in HAMD-17 score for zuranolone vs placebo at day 15. Secondary end points included changes from baseline in HAMD-17 total score at other time points, HAMD-17 response (≥50% score reduction) and remission (score ≤7) rates, Montgomery-Åsberg Depression Rating Scale score, and Hamilton Rating Scale for Anxiety score. Safety was assessed by adverse events and clinical assessments. Results Of 153 randomized patients, the efficacy set comprised 150 patients (mean [SD] age, 28.3 [5.4] years), and 148 (98.7%) completed treatment. A total of 76 patients were randomized to placebo, and 77 were randomized to zuranolone, 30 mg. Zuranolone demonstrated significant day 15 HAMD-17 score improvements from baseline vs placebo (-17.8 vs -13.6; difference, -4.2; 95% CI, -6.9 to -1.5; P = .003). Sustained differences in HAMD-17 scores favoring zuranolone were observed from day 3 (difference, -2.7; 95% CI, -5.1 to -0.3; P = .03) through day 45 (difference, -4.1; 95% CI, -6.7 to -1.4; P = .003). Sustained differences at day 15 favoring zuranolone were observed in HAMD-17 response (odds ratio, 2.63; 95% CI, 1.34-5.16; P = .005), HAMD-17 score remission (odds ratio, 2.53; 95% CI, 1.24-5.17; P = .01), change from baseline for Montgomery-Åsberg Depression Rating Scale score (difference, -4.6; 95% CI, -8.3 to -0.8; P = .02), and Hamilton Rating Scale for Anxiety score (difference, -3.9; 95% CI, -6.7 to -1.1; P = .006). One patient per group experienced a serious adverse event (confusional state in the zuranolone group and pancreatitis in the placebo group). One patient in the zuranolone group discontinued because of an adverse event vs none for placebo. Conclusions and Relevance In this randomized clinical trial, zuranolone improved the core symptoms of depression as measured by HAMD-17 scores in women with PPD and was generally well tolerated, supporting further development of zuranolone in the treatment of PPD. Trial Registration ClinicalTrials.gov Identifier: NCT02978326.
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Affiliation(s)
- Kristina M. Deligiannidis
- Department of Psychiatry, Zucker Hillside Hospital, Glen Oaks, New York
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | | | | | | | | | - Sigui Li
- Sage Therapeutics, Inc, Cambridge, Massachusetts
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Patterson R, Krohn H, Richardson E, Kimmel M, Meltzer-Brody S. A Brexanolone Treatment Program at an Academic Medical Center: Patient Selection, 90-Day Posttreatment Outcomes, and Lessons Learned. J Acad Consult Liaison Psychiatry 2021; 63:14-22. [PMID: 34438099 DOI: 10.1016/j.jaclp.2021.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 08/02/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Brexanolone (Zulresso) is the first Federal Drug Administration-approved drug for the treatment of postpartum depression. Brexanolone is a positive allosteric modulator of the GABAA receptor and is given over 60 hours by infusion in a medical setting. This drug has been shown to be effective at significantly reducing Hamilton Rating Scale for Depression scores at 60 hours and 30 days after infusion; however, data beyond 30 days have not yet been available. There have been limited clinical programs able to offer brexanolone owing to the complexity of setting up this treatment in a medical setting. PURPOSE This study sought to obtain follow-up data from 16 patients who received a brexanolone infusion at UNC Hospitals in Chapel Hill, NC, between October 2019 and December 2020 and were beyond the 30-day postinfusion time point. We describe the methods used to successfully implement this treatment program in an academic medical center and discuss associated challenges and lessons learned with patient selection and process improvements. METHODS Hamilton Rating Scale for Depression scores were collected before and after infusion from 16 patients who received a brexanolone infusion at UNC. Patients were subsequently contacted for a follow-up interview to obtain Hamilton Rating Scale for Depression scores and complete a semistructured interview at least 30 days past treatment end (between 3 and 16 months after infusion). RESULTS All 16 patients had a significant reduction in Hamilton Rating Scale for Depression scores at 60 hours, scores dropping on average from 23.9 (standard deviation = 2.6) to 7.6 (standard deviation = 2.9). Eleven of 16 patients consented to provide follow-up data. Follow-up Hamilton Rating Scale for Depression scores remained lower than postinfusion at an average of 6.7 points (standard deviation = 5.1). CONCLUSION With a strategic cross-disciplinary approach, a Clinical Brexanolone Treatment Program was established at UNC Hospitals in 2019. Sixteen patients have been treated in the program, and 11 participated in a follow-up interview. All 11 patients gave very positive feedback about their treatment. Our program has found brexanolone to be a useful clinical tool in treating women with significant symptoms of postpartum depression.
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Affiliation(s)
- Riah Patterson
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC.
| | - Holly Krohn
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC
| | - Erin Richardson
- Department of Psychiatry, Dell Medical School University of Texas at Austin, Austin, TX
| | - Mary Kimmel
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC
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Treating Postpartum Depression: What Do We Know about Brexanolone? Diseases 2021; 9:diseases9030052. [PMID: 34287271 PMCID: PMC8293057 DOI: 10.3390/diseases9030052] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 11/16/2022] Open
Abstract
Postpartum depression (PPD) is defined as the onset of major depressive disorder in mothers, occurring during pregnancy or within 4 weeks post-delivery. With 7% of pregnancy-related death in the United States owing to mental health conditions, including PPD, and a global prevalence of 12%, PPD is a growing public health concern. In 2019, the Food and Drug Administration (FDA) approved brexanolone, an exogenous analog of allopregnanolone, as the first ever drug to be specifically indicated for treating patients with PPD. This approval was preceded by an open-label study and three randomized placebo-controlled trials, each assessing the safety, tolerability, and efficacy of brexanolone, using mean Hamilton Rating Scale for Depression (HAM-D) score reduction as the primary outcome. In each randomized controlled trial, the drug was administered as an intravenous infusion given over 60 h. Enrolled participants were followed up on days 7 and 30 to evaluate the sustained effect. A statistically significant reduction in mean HAM-D score compared to placebo was observed in all three studies, supporting brexanolone's use in treating moderate-to-severe PPD. Therefore, this article attempts to briefly review the pharmacology of brexanolone, evaluate the latest available clinical data and outcomes concerning its use, reevaluate its position as a 'breakthrough' in managing PPD, and review the cost-related barriers to its worldwide standardized use.
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Perinatal depression. Int Anesthesiol Clin 2021; 59:45-51. [PMID: 34001697 DOI: 10.1097/aia.0000000000000325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chen S, Gao L, Li X, Ye Y. Allopregnanolone in mood disorders: Mechanism and therapeutic development. Pharmacol Res 2021; 169:105682. [PMID: 34019980 DOI: 10.1016/j.phrs.2021.105682] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/10/2021] [Accepted: 05/14/2021] [Indexed: 01/23/2023]
Abstract
The neuroactive steroid allopregnanolone (ALLO) is an endogenous positive allosteric modulator of GABA type A receptor (GABAAR), and the down-regulation of its biosynthesis have been attributed to the development of mood disorders, such as depression, anxiety and post-traumatic stress disorder (PTSD). ALLO mediated depression/anxiety involves GABAergic mechanisms and appears to be related to brain-derived neurotrophic factor (BDNF), dopamine receptor, glutamate neurotransmission, and Ca2+ channel. In the clinical, brexanolone, as a newly developed intravenous ALLO preparation, has been approved for the treatment of postpartum depression (PPD). In addition, traditional antidepressants such as selective serotonin reuptake inhibitor (SSRI) could reverse ALLO decline. Recently, the translocation protein (TSPO, 18 kDa), which involves in the speed-limiting step of ALLO synthesis, and ALLO derivatization have been identified as new directions for antidepressant therapy. This review provides an overview of ALLO researches in animal model and patients, discusses its role in the development and treatment of depression/anxiety, and directs its therapeutic potential in future.
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Affiliation(s)
- Shiyi Chen
- School of Pharmacy, Hangzhou Medical College (Zhejiang Academy of Medical Sciences), Hangzhou, Zhejiang, People's Republic of China; Key Laboratory of Neuropsychiatric Drug Research of Zhejiang Province, Hangzhou Medical College, Hangzhou, Zhejiang, People's Republic of China.
| | - Lijuan Gao
- School of Pharmacy, Hangzhou Medical College (Zhejiang Academy of Medical Sciences), Hangzhou, Zhejiang, People's Republic of China; Key Laboratory of Neuropsychiatric Drug Research of Zhejiang Province, Hangzhou Medical College, Hangzhou, Zhejiang, People's Republic of China.
| | - Xiaoyu Li
- School of Pharmacy, Hangzhou Medical College (Zhejiang Academy of Medical Sciences), Hangzhou, Zhejiang, People's Republic of China; Key Laboratory of Neuropsychiatric Drug Research of Zhejiang Province, Hangzhou Medical College, Hangzhou, Zhejiang, People's Republic of China.
| | - Yiping Ye
- School of Pharmacy, Hangzhou Medical College (Zhejiang Academy of Medical Sciences), Hangzhou, Zhejiang, People's Republic of China; Key Laboratory of Neuropsychiatric Drug Research of Zhejiang Province, Hangzhou Medical College, Hangzhou, Zhejiang, People's Republic of China.
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SAGE-217, A Novel GABA A Receptor Positive Allosteric Modulator: Clinical Pharmacology and Tolerability in Randomized Phase I Dose-Finding Studies. Clin Pharmacokinet 2021; 59:111-120. [PMID: 31338688 PMCID: PMC6994455 DOI: 10.1007/s40262-019-00801-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background SAGE-217, a novel γ-aminobutyric acid A (GABAA) receptor positive allosteric modulator, was evaluated in phase I, double-blind, placebo-controlled, single ascending dose (SAD) and multiple ascending dose (MAD) studies to assess the safety and pharmacokinetics (PK) of SAGE-217 following administration as an oral solution. Methods In the SAD study, subjects were randomized 6:2 to a single dose of SAGE-217 or placebo. Doses ranged from 0.25 to 66 mg across nine cohorts. In the MAD study, subjects were randomized 9:3 and received SAGE-217 (15, 30, or 35 mg) or placebo once daily for 7 days. In both studies, PK, maximum tolerated dose (MTD; against predetermined criteria), safety, and tolerability were assessed. Results A total of 108 healthy volunteers enrolled in the studies—72 subjects in the SAD study and 36 subjects in the MAD study. SAGE-217 was orally bioavailable, with a terminal-phase half-life of 16–23 h and a tmax of approximately 1 h. The MTDs for the oral solution of SAGE-217 in the SAD and MAD studies were determined to be 55 and 30 mg daily, respectively. In both studies, SAGE-217 was generally well tolerated, and no serious adverse events (SAEs) were reported. Most AEs were mild, dose-dependent, transient, occurred around the tmax, and related to drug pharmacology. Conclusions SAGE-217 was generally well tolerated, and its PK profile was well characterized. Based on this profile, SAGE-217 has been advanced into multiple phase II clinical programs and pivotal studies of major depressive disorder and postpartum depression. Electronic supplementary material The online version of this article (10.1007/s40262-019-00801-0) contains supplementary material, which is available to authorized users.
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Cornett EM, Rando L, Labbé AM, Perkins W, Kaye AM, Kaye AD, Viswanath O, Urits I. Brexanolone to Treat Postpartum Depression in Adult Women. PSYCHOPHARMACOLOGY BULLETIN 2021; 51:115-130. [PMID: 34092826 PMCID: PMC8146562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
ZULRESSO (Brexanolone) is a novel FDA-approved treatment for moderate-to-severe postpartum depression. Postpartum depression may be diagnosed in women experiencing depressive symptoms which can manifest as cognitive, behavioral, or emotional disturbances as early as the third trimester to 4 weeks following delivery. The efficacy of brexanolone suggests that neurosteroids such as allopregnanolone are important to treat PPD. However, it is currently unclear if brexanolone provides lasting relief of depressive symptoms at or beyond 30 days following administration. Further studies are necessary to make this determination.
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Affiliation(s)
- Elyse M Cornett
- Cornett, PhD, Rando, BS, Labbé, Kaye, MD, PhD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA. Perkins, BS, LSU School of Medicine, LSUHSC New Orleans, New Orleans, LA. Kaye, Pharm.D., FASCP, FCPhA, Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, CA. Viswanath, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, University of Arizona College of Medicine - Phoenix, Department of Anesthesiology, Phoenix, AZ, University School of Medicine, Department of Anesthesiology, Omaha, NE. Urits, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Boston, MA
| | - Lauren Rando
- Cornett, PhD, Rando, BS, Labbé, Kaye, MD, PhD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA. Perkins, BS, LSU School of Medicine, LSUHSC New Orleans, New Orleans, LA. Kaye, Pharm.D., FASCP, FCPhA, Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, CA. Viswanath, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, University of Arizona College of Medicine - Phoenix, Department of Anesthesiology, Phoenix, AZ, University School of Medicine, Department of Anesthesiology, Omaha, NE. Urits, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Boston, MA
| | - Austin M Labbé
- Cornett, PhD, Rando, BS, Labbé, Kaye, MD, PhD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA. Perkins, BS, LSU School of Medicine, LSUHSC New Orleans, New Orleans, LA. Kaye, Pharm.D., FASCP, FCPhA, Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, CA. Viswanath, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, University of Arizona College of Medicine - Phoenix, Department of Anesthesiology, Phoenix, AZ, University School of Medicine, Department of Anesthesiology, Omaha, NE. Urits, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Boston, MA
| | - Wil Perkins
- Cornett, PhD, Rando, BS, Labbé, Kaye, MD, PhD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA. Perkins, BS, LSU School of Medicine, LSUHSC New Orleans, New Orleans, LA. Kaye, Pharm.D., FASCP, FCPhA, Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, CA. Viswanath, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, University of Arizona College of Medicine - Phoenix, Department of Anesthesiology, Phoenix, AZ, University School of Medicine, Department of Anesthesiology, Omaha, NE. Urits, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Boston, MA
| | - Adam M Kaye
- Cornett, PhD, Rando, BS, Labbé, Kaye, MD, PhD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA. Perkins, BS, LSU School of Medicine, LSUHSC New Orleans, New Orleans, LA. Kaye, Pharm.D., FASCP, FCPhA, Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, CA. Viswanath, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, University of Arizona College of Medicine - Phoenix, Department of Anesthesiology, Phoenix, AZ, University School of Medicine, Department of Anesthesiology, Omaha, NE. Urits, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Boston, MA
| | - Alan David Kaye
- Cornett, PhD, Rando, BS, Labbé, Kaye, MD, PhD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA. Perkins, BS, LSU School of Medicine, LSUHSC New Orleans, New Orleans, LA. Kaye, Pharm.D., FASCP, FCPhA, Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, CA. Viswanath, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, University of Arizona College of Medicine - Phoenix, Department of Anesthesiology, Phoenix, AZ, University School of Medicine, Department of Anesthesiology, Omaha, NE. Urits, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Boston, MA
| | - Omar Viswanath
- Cornett, PhD, Rando, BS, Labbé, Kaye, MD, PhD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA. Perkins, BS, LSU School of Medicine, LSUHSC New Orleans, New Orleans, LA. Kaye, Pharm.D., FASCP, FCPhA, Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, CA. Viswanath, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, University of Arizona College of Medicine - Phoenix, Department of Anesthesiology, Phoenix, AZ, University School of Medicine, Department of Anesthesiology, Omaha, NE. Urits, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Boston, MA
| | - Ivan Urits
- Cornett, PhD, Rando, BS, Labbé, Kaye, MD, PhD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA. Perkins, BS, LSU School of Medicine, LSUHSC New Orleans, New Orleans, LA. Kaye, Pharm.D., FASCP, FCPhA, Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, CA. Viswanath, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, University of Arizona College of Medicine - Phoenix, Department of Anesthesiology, Phoenix, AZ, University School of Medicine, Department of Anesthesiology, Omaha, NE. Urits, MD, Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Boston, MA
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Abstract
INTRODUCTION Postpartum depression (PPD) is a serious and common complication of childbirth that can have deleterious effects not only on the mother but on the cognitive and behavioral development of exposed children. Brexanolone is a novel, soluble synthetic formulation of the natural hormone allopregnanolone and acts as a positive allosteric modulator of the gamma-aminobutyric acid A receptor (GABAA). Allopregnanolone levels dramatically decrease during the postpartum time-period and some studies indicate lower serum levels of allopregnanolone during pregnancy in women that go on to develop PPD.Areas covered: The author provides an overview of brexanolone as a treatment option for PPD including coverage of its pharmacokinetics, efficacy, safety, and tolerability. Furthermore, the author gives her expert perspectives on its use and its standing in the treatment armamentarium moving forward.Expert opinion: Brexanolone represents a breakthrough for psychiatry due to its novel mechanism of action, its rapid onset of action, and its sustained effects without continued administration. It is appropriate for use in women with moderate to severe PPD. Experience with the medication and further research is needed to clarify whether the current recommended dosing regimen is required for efficacy.
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Affiliation(s)
- Jennifer L Payne
- Associate Professor of Psychiatry and Behavioral Sciences, Women's Mood Disorders Center, Johns Hopkins School of Medicine, Baltimore, United States
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El-Mallakh RS, Ali Z. Extra-synaptic modulation of GABA A and efficacy in bipolar disorder. Med Hypotheses 2021; 147:110501. [PMID: 33515862 DOI: 10.1016/j.mehy.2021.110501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/22/2020] [Accepted: 01/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Bipolar disorder type I is a severe psychiatric condition that leads to significant morbidity and mortality and whose treatment remains suboptimal. Its pathophysiology involves disturbance in the control of ionic fluxes so that when patients are either manic or depressed, the resting membrane potential of neurons is more depolarized than normal. Available mood stabilizers have a shared mechanism of normalizing ion flux by compensating for ionic abnormalities, and normalizing membrane potential. HYPOTHESIS Agents that significantly potentiate extrasynaptic GABAA receptors are expected to be particularly effective in hyperpolarizing resting membrane potential in bipolar patients, thereby normalizing their membrane potential. DISCUSSION New neuroactive steroid-like agents are being tested in humans for depression and insomnia. These agents include brexanolone, ganaxolone, and gaboxadol. Brexanolone has been approved for the treatment of postpartum depression, ganaxolone is being studied for treatment-resistant depression, and gaboxadol development for the treatment of insomnia has been abandoned due to narrow therapeutic index. In addition to the current studies, these agents are expected to have particular efficacy in acute and prophylactic management of bipolar I disorder by hyperpolarizing the resting potential of neurons and antagonizing one of the most reproducible demonstrated biologic abnormalities of this illness.
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Affiliation(s)
- Rif S El-Mallakh
- Mood Disorders Research Program, Depression Center Department of Psychiatry and Behavioral Sciences University of Louisville School of Medicine, 401 East Chestnut Street, Suite 610 Louisville, Kentucky 40202, USA.
| | - Ziad Ali
- Department of Psychiatry, University of Kentucky College of Medicine, The Medical Center of Bowling Green, Bowling Green, KY, USA
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Saripalli A, Amar P, Duffee LE, Clayton AH. GABA-A Receptor Positive Allosteric Modulators as a Novel Approach to Treating Depression: A Review of Available Data. Neurology 2021. [DOI: 10.17925/usn.2021.17.2.77] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Edinoff AN, Odisho AS, Lewis K, Kaskas A, Hunt G, Cornett EM, Kaye AD, Kaye A, Morgan J, Barrilleaux PS, Lewis D, Viswanath O, Urits I. Brexanolone, a GABA A Modulator, in the Treatment of Postpartum Depression in Adults: A Comprehensive Review. Front Psychiatry 2021; 12:699740. [PMID: 34594247 PMCID: PMC8477036 DOI: 10.3389/fpsyt.2021.699740] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Postpartum depression (PPD) is one of the three major categories on the spectrum of postpartum psychiatric syndromes. Postpartum psychiatric syndromes are classified as either postpartum blues, postpartum depression, or postpartum psychosis. Postpartum depression is important to recognize clinically because of the effect it can have on the mother-child bond. The neurosteroid allopregnanolone, a progesterone derivative, is important for its role in positively modulating GABAA receptors. GABA-mediated signaling has been previously implicated in major depressive disorder. Allopregnanolone-mediated signaling has been identified as an important therapeutic target. Treatment with an allopregnanolone-analog, brexanolone, has been shown to improve depression scores in trials for the treatment of PPD. Brexanolone is a positive allosteric modulator of GABAA and is the first drug approved by the FDA to treat postpartum depression. Brexanolone enhances the inhibitory effects of GABAA, restores dysfunctional GABAA transmembrane channels, and mimics a naturally produced progesterone metabolite that fluctuates during pregnancy and postpartum. One open-label study and two phase two studies have some significant reduction in HAM-D scores after treatment and that the effect was still there 30 days post-treatment. Per the data reported, intravenous infusion of brexanolone could be efficacious and safe for the treatment of women suffering from postpartum depression.
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Affiliation(s)
- Amber N Edinoff
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center Shreveport, Shreveport, LA, United States
| | - Amira S Odisho
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center Shreveport, Shreveport, LA, United States
| | - Kendall Lewis
- Louisiana State University Shreveport School of Medicine, Shreveport, LA, United States
| | - Amir Kaskas
- Louisiana State University Shreveport School of Medicine, Shreveport, LA, United States
| | - Grace Hunt
- Louisiana State University Shreveport School of Medicine, Shreveport, LA, United States
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, United States
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, United States
| | - Adam Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA, United States
| | - John Morgan
- Department of Obstetrics and Gynecology, Louisiana State University Health Shreveport, Shreveport, LA, United States
| | - P Scott Barrilleaux
- Department of Obstetrics and Gynecology, Louisiana State University Health Shreveport, Shreveport, LA, United States
| | - David Lewis
- Department of Obstetrics and Gynecology, Louisiana State University Health Shreveport, Shreveport, LA, United States
| | - Omar Viswanath
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA, United States.,University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, United States.,Valley Anesthesiology and Pain Consultants-Envision Physician Services, Phoenix, AZ, United States
| | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, United States.,Southcoast Health, Southcoast Physicians Group Pain Medicine, Wareham, MA, United States
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Hecking J, Davoudian PA, Wilkinson ST. Emerging Therapeutics Based on the Amino Acid Neurotransmitter System: An Update on the Pharmaceutical Pipeline for Mood Disorders. CHRONIC STRESS (THOUSAND OAKS, CALIF.) 2021; 5:24705470211020446. [PMID: 34124495 PMCID: PMC8175843 DOI: 10.1177/24705470211020446] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/08/2021] [Indexed: 11/16/2022]
Abstract
Mood disorders represent a pressing public health issue and significant source of disability throughout the world. The classical monoamine hypothesis, while useful in developing improved understanding and clinical treatments, has not fully captured the complex nature underlying mood disorders. Despite these shortcomings, the monoamine hypothesis continues to dominate the conceptual framework when approaching mood disorders. However, recent advances in basic and clinical research have led to a greater appreciation for the role that amino acid neurotransmitters play in the pathophysiology of mood disorders and as potential targets for novel therapies. In this article we review progress of compounds that focus on these systems. We cover both glutamate-targeting drugs such as: esketamine, AVP-786, REL-1017, AXS-05, rapastinel (GLYX-13), AV-101, NRX-101; as well as GABA-targeting drugs such as: brexanolone (SAGE-547), ganaxolone, zuranolone (SAGE-217), and PRAX-114. We focus the review on phase-II and phase-III clinical trials and evaluate the extant data and progress of these compounds.
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Affiliation(s)
- Julia Hecking
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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Hernandez GD, Solinsky CM, Mack WJ, Kono N, Rodgers KE, Wu C, Mollo AR, Lopez CM, Pawluczyk S, Bauer G, Matthews D, Shi Y, Law M, Rogawski MA, Schneider LS, Brinton RD. Safety, tolerability, and pharmacokinetics of allopregnanolone as a regenerative therapeutic for Alzheimer's disease: A single and multiple ascending dose phase 1b/2a clinical trial. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2020; 6:e12107. [PMID: 33344752 PMCID: PMC7744018 DOI: 10.1002/trc2.12107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/07/2020] [Accepted: 10/09/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Allopregnanolone is an endogenous neurosteroid with the potential to be a novel regenerative therapeutic for Alzheimer's disease (AD). Foundations of mechanistic understanding and well-established preclinical safety efficacy make it a viable candidate. METHODS A randomized, double-blinded, placebo-controlled, single and multiple ascending dose trial was conducted. Intravenous allopregnanolone or placebo was administered once-per-week for 12 weeks with a 1-month follow-up. Participants with early AD (mild cognitive impairment due to AD or mild AD), a Mini-Mental State Examination score of 20-26 inclusive, and age ≥55 years were randomized (6:2 to three allopregnanolone dosing cohorts or one placebo cohort). Primary endpoint was safety and tolerability. Secondary endpoints included pharmacokinetic (PK) parameters and maximally tolerated dose (MTD). Exploratory endpoints included cognitive and imaging biomarkers. RESULTS A total of 24 participants completed the trial. Allopregnanolone was safe and well tolerated in all study participants. No differences were observed between treatment arms in the occurrence and severity of adverse events (AE). Most common AE were mild to moderate in severity and included rash (n = 4 [22%]) and fatigue (n = 3 [17%]). A single non-serious AE, dizziness, was attributable to treatment. There was one serious AE not related to treatment. Pharmacokinetics indicated a predictable linear dose-response in plasma concentration of allopregnanolone after intravenous administration over 30 minutes. The maximum plasma concentrations for the 2 mg, 4 mg, 6 mg, and 10 mg dosages were 14.53 ng/mL (+/-7.31), 42.05 ng/mL (+/-14.55), 60.07 ng/mL (+/-12.8), and 137.48 ng/mL (+/-38.69), respectively. The MTD was established based on evidence of allopregnanolone-induced mild sedation at the highest doses; a sex difference in the threshold for sedation was observed (males 10 mg; females 14 mg). No adverse outcomes on cognition or magnetic resonance imaging-based imaging outcomes were evident. CONCLUSIONS Allopregnanolone was well tolerated and safe across all doses in persons with early AD. Safety, MTD, and PK profiles support advancement of allopregnanolone as a regenerative therapeutic for AD to a phase 2 efficacy trial. TRIAL REGISTRATION ClinicalTrials.gov-NCT02221622.
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Affiliation(s)
| | | | - Wendy J. Mack
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Naoko Kono
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCaliforniaUSA
| | | | - Chun‐Yi Wu
- Bioanalysis and Pharmacokinetics Core FacilityUniversity of California DavisSacramentoCaliforniaUSA
- TOMO Pharmacometrics LLCSan MateoCaliforniaUSA
| | | | - Claudia M. Lopez
- Center for Innovation in Brain ScienceUniversity of ArizonaTucsonArizonaUSA
| | - Sonia Pawluczyk
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Gerhard Bauer
- School of MedicineUniversity of California DavisSacramentoCaliforniaUSA
| | | | - Yonggang Shi
- USC Stevens Neuroimaging and Informatics InstituteUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Meng Law
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCaliforniaUSA
| | | | - Lon S. Schneider
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Roberta D. Brinton
- Center for Innovation in Brain ScienceUniversity of ArizonaTucsonArizonaUSA
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Abstract
OBJECTIVES To review the pharmacology, efficacy, and safety of Brexanolone and define its role in the treatment of postpartum depression. DATE SOURCES A MEDLINE/PubMed search was conducted (1980-May 2020) using the following keywords: postpartum depression, antidepressants, pharmacologic therapy, drug therapy, and brexanolone to identify relevant articles. STUDY SELECTION/DATA EXTRACTION Literature search was limited to human studies published in the English language. Phase I, II, and III studies evaluating the pharmacology, efficacy, safety of brexanolone for postpartum depression were included. Bibliographies of relevant articles evaluating postpartum depression and treatment were reviewed for additional citations and background information. DATA SYNTHESIS Brexanolone is a soluble, proprietary, injectable formulation of allopregnanolone, a neuroactive steroid that modulates neuronal excitability. Allopregnanolone levels increase during pregnancy and decrease substantially after birth. These fluctuations have profound effects on anxiety and depression. Three clinical trials established the efficacy and safety of brexanolone in the treatment of postpartum depression. In all 3 trials, brexanolone had an acceptable safety profile and was well tolerated. The most common adverse effects were loss of consciousness, sedation, dry mouth, headache, dizziness, and flushing. Due to sudden loss of consciousness and excessive sedation, continuous pulse oximetry is recommended. CONCLUSION Brexanolone has a novel mechanism of action and appears to be safe and effective for the treatment of moderate to severe postpartum depression. At present, high cost, serious adverse effects, and restricted access may limit its use in clinical practice.
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Affiliation(s)
- Edna Patatanian
- Southwestern Oklahoma State University College of Pharmacy, Weatherford, OK, USA
| | - David R Nguyen
- Southwestern Oklahoma State University College of Pharmacy, Weatherford, OK, USA
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