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Dopamine D2 Receptor Occupancy Estimated From Plasma Concentrations of Four Different Antipsychotics and the Subjective Experience of Physical and Mental Well-Being in Schizophrenia: Results From the Randomized NeSSy Trial. J Clin Psychopharmacol 2020; 39:550-560. [PMID: 31688449 DOI: 10.1097/jcp.0000000000001131] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Impaired subjective well-being in schizophrenia patients treated with antipsychotics has often been linked inter alia to the antidopaminergic effects of medication. Thus, it is important to capture the association between striatal dopamine D2 receptor occupancy (D2-RO) and global subjective well-being. We examined this association using data from our multicenter, randomized, double-blind Neuroleptic Strategy Study (NeSSy). METHODS An innovative double randomization process was used for allocation of patients to the specific treatment groups. Plasma drug concentrations were measured after 6 and 24 weeks of treatment to obtain the estimated D2-RO (eD2-RO) relative to literature values. We made an exploratory analysis of associations between eD2-RO and subjective well-being scores. One hundred two blood samples from 69 patients were available for the analysis. Because of the lack of a satisfactory occupancy model for quetiapine, only haloperidol, flupentixol, and olanzapine treatment groups were pooled, whereas aripiprazole data were analyzed separately, because of its partial agonistic properties. RESULTS In the pooled antagonist group, eD2-RO correlated negatively with the summarized well-being score. In a more detailed analysis, this association could be confirmed for all first-generation antipsychotic-treated patients, but not for the separate second-generation antipsychotic groups. In the aripiprazole group, higher eD2-RO was associated with impaired physical well-being, but had no association with mental well-being. CONCLUSIONS Our results suggest that high plasma levels and consequently high occupancy at D2 receptors are disadvantageous for subjective well-being, as distinct from the objective extrapyramidal side effects. To minimize patients' malaise, which disfavors adherence, implementation of therapeutic drug monitoring in the clinical routine may be useful.
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Model-Guided Antipsychotic Dose Reduction in Schizophrenia: A Pilot, Single-Blind Randomized Controlled Trial. J Clin Psychopharmacol 2020; 39:329-335. [PMID: 31188232 DOI: 10.1097/jcp.0000000000001046] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE/BACKGROUND Patients with schizophrenia as well as their psychiatrists are hesitant to reduce the antipsychotic dose in fear of relapse. To overcome such dilemmas, we developed models to individually calculate an oral dose that corresponds to a given target dopamine D2 receptor occupancy. METHODS/PROCEDURES In this pilot, 52-week single-blind randomized controlled trial, 35 clinically stable patients with schizophrenia receiving either risperidone or olanzapine monotherapy were randomly assigned to dose reduction (n = 17) or dose maintenance group (n = 18). In the former group, baseline doses were reduced to the doses corresponding to 65% D2 occupancy (the lower end of therapeutic window) at trough that were calculated from randomly collected plasma concentrations using our models. FINDINGS/RESULTS In the dose reduction group, doses of risperidone and olanzapine were decreased from 4.2 ± 1.9 to 1.4 ± 0.4 and 12.8 ± 3.9 to 6.7 ± 1.8 mg/d, whereas the doses in the dose maintenance group were 4.3 ± 1.9 and 15.8 ± 4.6 mg/d, respectively. Twelve subjects (70.5%) and 13 subjects (72.2%) in the dose reduction and dose maintenance groups completed the study (P = 0.604), whereas 3 subjects (18.8%) and none dropped out because of clinical worsening in the dose reduction and dose maintenance groups, respectively. There were not significant differences in score changes in Positive and Negative Syndrome Scale between the 2 groups but in Positive subscale scores in the Clinical Global Impression-Schizophrenia (0.4 ± 0.7 in the dose reduction group vs -0.1 ± 0.7 in the dose maintenance group, P = 0.029). IMPLICATIONS/CONCLUSIONS Although our model-guided dose reduction strategy was found to be comparable with no-dose change in terms of dropout rates, safety issues have to be further examined.
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Iasevoli F, Fagiolini A, Formato MV, Prinzivalli E, Giordano S, Balletta R, De Luca V, de Bartolomeis A. Assessing patient-rated vs. clinician-rated adherence to the therapy in treatment resistant schizophrenia, schizophrenia responders, and non-schizophrenia patients. Psychiatry Res 2017; 249:159-166. [PMID: 28104562 DOI: 10.1016/j.psychres.2017.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 11/27/2016] [Accepted: 01/03/2017] [Indexed: 01/23/2023]
Abstract
The present study evaluated consistency, reliability, and determinants of two real-world measures of adherence to prescription in 57 schizophrenia and 61 non-schizophrenia patients. Treatment resistant schizophrenia (TRS) was additionally diagnosed in 28 of the schizophrenia patients. Patients were screened for clinical severity, cognitive functioning, and adherence by 10-item Drug Attitude Inventory (DAI-10) or Adherence-to-Therapy (AtT), a clinician-rated tool developed by our group. DAI-10 and AtT scores showed a significant correlation (p=0.039; ρ=0.21; df=103). Compared to the DAI-10 scale, a higher number of variables were associated with AtT. In schizophrenia and TRS patients, substance abuse was the only significant predictor of lower DAI-10 score (p=0.027, F=5.2, R2=0.07, and p=0.06, F=8.9, R2=0.23, respectively). Lower AtT score was significantly associated with first-generation antipsychotic use (p=0.001, RR: 2.00 [1.40-2.87]), positive symptoms (p=0.02, RR: 1.63 [1.05-2.53]), impaired verbal fluency (p=0.01, RR: 1.88 [0.81-4.32]) or problem solving (p=0.01, RR: 2.14 [0.92-4.98]). AtT, but not DAI-10, score correlated with the score on the Personal and Social Performance scale (p=0.02, F=5.86, R2=0.08). Overall, AtT score was predicted by pharmacological, psychopathological, and cognitive factors, and predictive of psychosocial functioning. Therefore, AtT measure may represent a convenient and practical tool to evaluate schizophrenia patients' adherence.
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Affiliation(s)
- Felice Iasevoli
- Section of Psychiatry - Unit on Treatment Resistant Psychosis, and Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, University School of Medicine Federico II, Naples, Italy
| | | | - Maria Vittoria Formato
- Section of Psychiatry - Unit on Treatment Resistant Psychosis, and Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, University School of Medicine Federico II, Naples, Italy
| | - Emiliano Prinzivalli
- Section of Psychiatry - Unit on Treatment Resistant Psychosis, and Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, University School of Medicine Federico II, Naples, Italy
| | - Sara Giordano
- Section of Psychiatry - Unit on Treatment Resistant Psychosis, and Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, University School of Medicine Federico II, Naples, Italy
| | - Raffaele Balletta
- Section of Psychiatry - Unit on Treatment Resistant Psychosis, and Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, University School of Medicine Federico II, Naples, Italy
| | - Vincenzo De Luca
- Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Andrea de Bartolomeis
- Section of Psychiatry - Unit on Treatment Resistant Psychosis, and Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, University School of Medicine Federico II, Naples, Italy.
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Vardigan JD, Lange HS, Tye SJ, Fox SV, Smith SM, Uslaner JM. Behavioral and qEEG effects of the PDE10A inhibitor THPP-1 in a novel rhesus model of antipsychotic activity. Psychopharmacology (Berl) 2016; 233:2441-50. [PMID: 27117142 DOI: 10.1007/s00213-016-4290-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 04/03/2016] [Indexed: 12/13/2022]
Abstract
RATIONALE Much preclinical data, almost exclusively using rodent, supports the notion that phosphodiesterase 10A (PDE10A) inhibition may offer an alternative to the current standard of care in schizophrenia. However, concerns persist regarding the clinical translatability of these models for newer drug classes like PDE10A inhibitors. OBJECTIVES We therefore sought to characterize the clinical standard risperidone and the PDE10A inhibitor THPP-1 in nonhuman primate, both alone and when used as a combination therapy. METHODS THPP-1 and risperidone were tested in a novel rhesus model of stimulant-induced motor activity (SIMA) and in rhesus electroencephalography (EEG). RESULTS Consistent with rodent data, both THPP-1 and risperidone significantly attenuated the stimulant effects in SIMA when administered alone, though some differences were noted. Combination therapy with a low dose of risperidone produced significantly more robust effects. THPP-1 and risperidone also produced a marked reduction of wake cycle time and gamma frequency power in EEG. However, THPP-1 differed from risperidone by reducing spectral power of lower frequencies (delta). CONCLUSIONS SIMA results suggest that PDE10A inhibition produces antipsychotic-like effects in higher species, and that combination therapy with PDE10A inhibitors may produce more robust efficacy compared to monotherapies. EEG and qEEG results confirm that PDE10A inhibition does share some central signaling effects with clinically effective antipsychotics. The present combination therapy results may carry implications for the manner in which clinical testing of PDE10A inhibitors is conducted.
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Affiliation(s)
- Joshua D Vardigan
- Merck & Co., Inc., WP45-1114, 770 Sumneytown Pike, West Point, PA, 19486, USA
| | - Henry S Lange
- Merck & Co., Inc., WP45-1114, 770 Sumneytown Pike, West Point, PA, 19486, USA
| | - Spencer J Tye
- Merck & Co., Inc., WP45-1114, 770 Sumneytown Pike, West Point, PA, 19486, USA
| | - Steven V Fox
- Merck & Co., Inc., WP45-1114, 770 Sumneytown Pike, West Point, PA, 19486, USA
| | - Sean M Smith
- Merck & Co., Inc., WP45-1114, 770 Sumneytown Pike, West Point, PA, 19486, USA
| | - Jason M Uslaner
- Merck & Co., Inc., WP45-1114, 770 Sumneytown Pike, West Point, PA, 19486, USA.
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Lako IM, Taxis K, van den Heuvel ER, Leenaars CHC, Burger H, Wiersma D, Slooff CJ, Knegtering H, Bruggeman R. Altered emotional experiences attributed to antipsychotic medications - A potential link with estimated dopamine D2 receptor occupancy. Psychiatry Res 2016; 236:9-14. [PMID: 26791397 DOI: 10.1016/j.psychres.2016.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 10/09/2015] [Accepted: 01/05/2016] [Indexed: 12/31/2022]
Abstract
Altered emotional experiences in response to antipsychotics may increase the burden of disease in patients with schizophrenia. In a large cross-sectional study, patients with schizophrenia completed the Subjects Reaction to Antipsychotics questionnaire (SRA) to assess whether they attributed altered emotional experiences (flattened affect or depressive symptoms) to their antipsychotics. Association with antipsychotic D2 receptor affinity and occupancy was examined using logistic regression. We compared antipsychotic-attributed emotional experiences between patients using antipsychotic monotherapy and combination therapy. Of the 1298 included patients, 23% attributed flattened affect to their antipsychotics and 16% attributed depressive symptoms to their antipsychotics, based on the SRA. No differences were observed between antipsychotics in patients on monotherapy. We discuss that within these patients' relatively low dose range, altered emotional experiences did not appear to relate to the level of D2 receptor affinity of antipsychotic monotherapy. Patients using antipsychotic combination therapy (22%) were more likely to attribute depressive symptoms to their antipsychotics than patients using antipsychotic monotherapy (OR [95%CI]=1.443 [1.033-2.015]); possibly due to higher D2 receptor occupancies as estimated by dose equivalents.
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Affiliation(s)
- Irene M Lako
- Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen, The Netherlands
| | - Katja Taxis
- Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen, The Netherlands.
| | - Edwin R van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Cathalijn H C Leenaars
- Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen, The Netherlands; Central Animal laboratory, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Huibert Burger
- Department of General Practice, University Medical Center Groningen, Groningen, The Netherlands
| | - Durk Wiersma
- Rob Giel Research center, University Medical Center Groningen, Groningen, The Netherlands
| | - Cees J Slooff
- Department of Psychotic Disorders, Mental Health Organization Drenthe, The Netherlands
| | - Henderikus Knegtering
- Rob Giel Research center, University Medical Center Groningen, Groningen, The Netherlands; Lentis Research, Center for Mental Health Groningen, Groningen, The Netherlands
| | - Richard Bruggeman
- Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen, The Netherlands; Rob Giel Research center, University Medical Center Groningen, Groningen, The Netherlands
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Szmulewicz A, Samamé C, Caravotta P, Martino DJ, Igoa A, Hidalgo-Mazzei D, Colom F, Strejilevich SA. Behavioral and emotional adverse events of drugs frequently used in the treatment of bipolar disorders: clinical and theoretical implications. Int J Bipolar Disord 2016; 4:6. [PMID: 26879750 PMCID: PMC4754238 DOI: 10.1186/s40345-016-0047-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 02/04/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Behavioral and emotional adverse events induced by drugs commonly prescribed to patients with bipolar disorders are of paramount importance to clinical practice and research. However, no reviews on the topic have been published so far. METHODS An extensive search was performed. Reports were reviewed if they described behavioral side effects related to pharmacological treatments for bipolar disorders in healthy subjects or patients with different neuropsychiatric disorders. For this review, lithium, antipsychotics, anticonvulsants and selective serotonin reuptake inhibitors were included. RESULTS Apathy or emotional blunting, diminished sexual desire, and inability to cry were reported to be associated with exposure to selective serotonin reuptake inhibitors. Neuroleptic-induced deficit syndrome/emotional detachment and obsessive-compulsive symptomatology and decision-making modifications. A lithium-related amotivational syndrome was also reported in the literature. Furthermore, hypersexuality and obsessive-compulsive symptoms have been noted in subjects treated with lamotrigine. LIMITATIONS Primary studies on drug-related adverse events are scant so far and most of the data currently available derive from case reports. Moreover, most of the evidence reviewed is based on studies performed on healthy subjects and patients with neuropsychiatric conditions other than bipolar disorders. DISCUSSION There is a remarkable dearth of data on behavioral adverse events of pharmacological treatment for bipolar disorders. However, the pieces of evidence available at present, though scant and scattered, suggest that different behavioral adverse events may be related to pharmacological treatment for these disorders. The implications of these findings for research and management of patients with mood disorders are discussed.
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Affiliation(s)
- Alejandro Szmulewicz
- Bipolar Disorder Program, Neurosciences Institute, Favaloro University, Buenos Aires, Argentina. .,Hospital de Emergencias Psiquiátricas Torcuato de Alvear (HEPTA), Buenos Aires, Argentina.
| | - Cecilia Samamé
- Bipolar Disorder Program, Neurosciences Institute, Favaloro University, Buenos Aires, Argentina. .,National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina.
| | - Pablo Caravotta
- Bipolar Disorder Program, Neurosciences Institute, Favaloro University, Buenos Aires, Argentina. .,National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina.
| | - Diego J Martino
- Bipolar Disorder Program, Neurosciences Institute, Favaloro University, Buenos Aires, Argentina. .,National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina.
| | - Ana Igoa
- Bipolar Disorder Program, Neurosciences Institute, Favaloro University, Buenos Aires, Argentina.
| | | | - Francesc Colom
- Bipolar Disorders Program, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain.
| | - Sergio A Strejilevich
- Bipolar Disorder Program, Neurosciences Institute, Favaloro University, Buenos Aires, Argentina. .,, Congreso 2477 Dto. D (1428), Buenos Aires, Argentina.
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Tsuboi T, Suzuki T, Bies RR, Remington G, Pollock BG, Mimura M, Uchida H. Challenging the need for sustained blockade of dopamine D₂ receptor estimated from antipsychotic plasma levels in the maintenance treatment of schizophrenia: A single-blind, randomized, controlled study. Schizophr Res 2015; 164:149-54. [PMID: 25864950 DOI: 10.1016/j.schres.2015.03.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 02/27/2015] [Accepted: 03/22/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Blockade of dopamine D₂ receptors with antipsychotics above 65% is associated with optimal chance of clinical response although recent data suggest a lower threshold for the maintenance treatment of schizophrenia. The objective of this study was to prospectively examine whether such continuous high blockade would be necessary for maintenance treatment. METHOD In this single-blind, 52-week, randomized controlled trial, clinically stable patients with schizophrenia receiving risperidone or olanzapine were randomly assigned to the continuous D₂ blockade (i.e. an estimated trough D2 blockade of >65%) or non-continuous blockade group (i.e. an estimated peak level of >65% with an estimated trough level of <65%). Oral doses corresponding to the assigned blockade levels were estimated from random plasma drug concentrations, using the models we developed; antipsychotic doses were then adjusted accordingly. Psychopathology and side effects were assessed at baseline and one year with the Positive and Negative Syndrome Scale (PANSS), Simpson-Angus Scale (SAS), and Abnormal Involuntary Movement Scale (AIMS). RESULTS Sixty-eight subjects (34 in each group) were enrolled. Twenty-six (76.5%) and thirty-one (91.2%) subjects completed the study in the continuous and non-continuous blockade groups, respectively, without any significant group difference. No significant differences were found on any of the assessment scales between the two groups. The degree of dosage change was small in both groups. CONCLUSION These results offer support that the threshold for D₂ receptor blockade in the maintenance treatment can be lower than 65%. However, these preliminary findings have to be confirmed through double-blind, larger scale trials with longer follow-up periods.
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Affiliation(s)
- Takashi Tsuboi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Takefumi Suzuki
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Department of Psychiatry, Inokashira Hospital, Tokyo, Japan
| | - Robert R Bies
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana Clinical and Translational Sciences Institute, Indianapolis, IN, USA; Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Gary Remington
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Bruce G Pollock
- Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.
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Li CH, Stratford RE, Velez de Mendizabal N, Cremers TIFH, Pollock BG, Mulsant BH, Remington G, Bies RR. Prediction of brain clozapine and norclozapine concentrations in humans from a scaled pharmacokinetic model for rat brain and plasma pharmacokinetics. J Transl Med 2014; 12:203. [PMID: 25142323 PMCID: PMC4261612 DOI: 10.1186/1479-5876-12-203] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 07/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clozapine is highly effective in treatment-resistant schizophrenia, although, there remains significant variability in the response to this drug. To better understand this variability, the objective of this study was to predict brain extracellular fluid (ECF) concentrations and receptor occupancy of clozapine and norclozapine in human central nervous system by translating plasma and brain ECF pharmacokinetic (PK) relationships in the rat and coupling these with known human disposition of clozapine in the plasma. METHODS Unbound concentrations of clozapine and norclozapine were measured in rat brain ECF using quantitative microdialysis after subcutaneous administration of a 10 mg/kg single dose of clozapine or norclozapine. These data were linked with plasma concentrations obtained in the same rats to develop a plasma-brain ECF compartmental model. Parameters describing brain ECF disposition were then allometrically scaled and linked with published human plasma PK to predict human ECF concentrations. Subsequently, prediction of human receptor occupancy at several CNS receptors was based on an effect model that related the predicted ECF concentrations to published concentration-driven receptor occupancy parameters. RESULTS A one compartment model with first order absorption and elimination best described clozapine and norclozapine plasma concentrations in rats. A delay in the transfer of clozapine and norclozapine from plasma to the brain ECF compartment was captured using a transit compartment model approach. Human clozapine and norclozapine concentrations in brain ECF were simulated, and from these the median percentage of receptor occupancy of dopamine-2, serotonin-2A, muscarinic-1, alpha-1 adrenergic, alpha-2 adrenergic and histamine-1 for clozapine, and dopamine-2 for norclozapine were consistent with values reported in the literature. CONCLUSIONS A PK model that relates clozapine and norclozapine disposition in rat plasma and brain, including blood-brain barrier transport, was developed. Using allometry and published human plasma PK, the model was successfully translated to predict clozapine and norclozapine concentrations and accordant receptor occupancy of both agents in human brain. These predicted exposure and occupancy measures at several receptors that bind clozapine may be employed to extend our understanding of clozapine's complex behavioral effects in humans.
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Affiliation(s)
| | | | | | | | | | | | | | - Robert R Bies
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, 1001 W, 10th Street W7138, Indianapolis, IN 46202, USA.
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