1
|
de Bartolomeis A, Vellucci L, Barone A, Manchia M, De Luca V, Iasevoli F, Correll CU. Clozapine's multiple cellular mechanisms: What do we know after more than fifty years? A systematic review and critical assessment of translational mechanisms relevant for innovative strategies in treatment-resistant schizophrenia. Pharmacol Ther 2022; 236:108236. [PMID: 35764175 DOI: 10.1016/j.pharmthera.2022.108236] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 12/21/2022]
Abstract
Almost fifty years after its first introduction into clinical care, clozapine remains the only evidence-based pharmacological option for treatment-resistant schizophrenia (TRS), which affects approximately 30% of patients with schizophrenia. Despite the long-time experience with clozapine, the specific mechanism of action (MOA) responsible for its superior efficacy among antipsychotics is still elusive, both at the receptor and intracellular signaling level. This systematic review is aimed at critically assessing the role and specific relevance of clozapine's multimodal actions, dissecting those mechanisms that under a translational perspective could shed light on molecular targets worth to be considered for further innovative antipsychotic development. In vivo and in vitro preclinical findings, supported by innovative techniques and methods, together with pharmacogenomic and in vivo functional studies, point to multiple and possibly overlapping MOAs. To better explore this crucial issue, the specific affinity for 5-HT2R, D1R, α2c, and muscarinic receptors, the relatively low occupancy at dopamine D2R, the interaction with receptor dimers, as well as the potential confounder effects resulting in biased ligand action, and lastly, the role of the moiety responsible for lipophilic and alkaline features of clozapine are highlighted. Finally, the role of transcription and protein changes at the synaptic level, and the possibility that clozapine can directly impact synaptic architecture are addressed. Although clozapine's exact MOAs that contribute to its unique efficacy and some of its severe adverse effects have not been fully understood, relevant information can be gleaned from recent mechanistic understandings that may help design much needed additional therapeutic strategies for TRS.
Collapse
Affiliation(s)
- Andrea de Bartolomeis
- Section of Psychiatry, Laboratory of Translational and Molecular Psychiatry and Unit of Treatment Resistant Psychosis, Department of Neuroscience, Reproductive Science and Dentistry, University Medical School of Naples "Federico II", Naples, Italy.
| | - Licia Vellucci
- Section of Psychiatry, Laboratory of Translational and Molecular Psychiatry and Unit of Treatment Resistant Psychosis, Department of Neuroscience, Reproductive Science and Dentistry, University Medical School of Naples "Federico II", Naples, Italy
| | - Annarita Barone
- Section of Psychiatry, Laboratory of Translational and Molecular Psychiatry and Unit of Treatment Resistant Psychosis, Department of Neuroscience, Reproductive Science and Dentistry, University Medical School of Naples "Federico II", Naples, Italy
| | - Mirko Manchia
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy; Department of Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Felice Iasevoli
- Section of Psychiatry, Laboratory of Translational and Molecular Psychiatry and Unit of Treatment Resistant Psychosis, Department of Neuroscience, Reproductive Science and Dentistry, University Medical School of Naples "Federico II", Naples, Italy
| | - Christoph U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; Charité Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany
| |
Collapse
|
2
|
Gammon D, Cheng C, Volkovinskaia A, Baker GB, Dursun SM. Clozapine: Why Is It So Uniquely Effective in the Treatment of a Range of Neuropsychiatric Disorders? Biomolecules 2021; 11:1030. [PMID: 34356654 PMCID: PMC8301879 DOI: 10.3390/biom11071030] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/30/2021] [Accepted: 07/02/2021] [Indexed: 12/16/2022] Open
Abstract
Clozapine is superior to other antipsychotics as a therapy for treatment-resistant schizophrenia and schizoaffective disorder with increased risk of suicidal behavior. This drug has also been used in the off-label treatment of bipolar disorder, major depressive disorder (MDD), and Parkinson's disease (PD). Although usually reserved for severe and treatment-refractory cases, it is interesting that electroconvulsive therapy (ECT) has also been used in the treatment of these psychiatric disorders, suggesting some common or related mechanisms. A literature review on the applications of clozapine and electroconvulsive therapy (ECT) to the disorders mentioned above was undertaken, and this narrative review was prepared. Although both treatments have multiple actions, evidence to date suggests that the ability to elicit epileptiform activity and alter EEG activity, to increase neuroplasticity and elevate brain levels of neurotrophic factors, to affect imbalances in the relationship between glutamate and γ-aminobutyric acid (GABA), and to reduce inflammation through effects on neuron-glia interactions are common underlying mechanisms of these two treatments. This evidence may explain why clozapine is effective in a range of neuropsychiatric disorders. Future increased investigations into epigenetic and connectomic changes produced by clozapine and ECT should provide valuable information about these two treatments and the disorders they are used to treat.
Collapse
Affiliation(s)
- Dara Gammon
- Saba University School of Medicine, Saba, The Netherlands; (D.G.); (A.V.)
| | - Catherine Cheng
- Neurochemical Research Unit and Bebensee Schizophrenia Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB T6G 2B7, Canada; (C.C.); (G.B.B.)
- Department of Psychiatry, University of Toronto, Toronto, ON M5T 1R8, Canada
| | - Anna Volkovinskaia
- Saba University School of Medicine, Saba, The Netherlands; (D.G.); (A.V.)
| | - Glen B. Baker
- Neurochemical Research Unit and Bebensee Schizophrenia Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB T6G 2B7, Canada; (C.C.); (G.B.B.)
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB T6G 2E1, Canada
| | - Serdar M. Dursun
- Neurochemical Research Unit and Bebensee Schizophrenia Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB T6G 2B7, Canada; (C.C.); (G.B.B.)
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB T6G 2E1, Canada
| |
Collapse
|
3
|
Li M. Antipsychotic-induced sensitization and tolerance: Behavioral characteristics, developmental impacts, and neurobiological mechanisms. J Psychopharmacol 2016; 30:749-70. [PMID: 27371498 PMCID: PMC4944179 DOI: 10.1177/0269881116654697] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Antipsychotic sensitization and tolerance refer to the increased and decreased drug effects due to past drug use, respectively. Both effects reflect the long-term impacts of antipsychotic treatment on the brain and result from the brain's adaptive response to the foreign property of the drug. In this review, clinical evidence of the behavioral aspect of antipsychotic sensitization and tolerance is selectively reviewed, followed by an overview of preclinical literature that examines these behavioral characteristics and the related pharmacological and nonpharmacological factors. Next, recent work on the developmental impacts of adolescent antipsychotic sensitization and tolerance is presented and recent research that delineates the neurobiological mechanisms of antipsychotic sensitization and tolerance is summarized. A theoretical framework based on "drug learning and memory" principles is proposed to account for the phenomena of antipsychotic sensitization and tolerance. It is maintained that antipsychotic sensitization and tolerance follow basic principles of learning or acquisition ("induction") and memory ("expression"). The induction and expression of both effects reflect the consequences of associative and nonassociative processing and are strongly influenced by various pharmacological, environmental, and behavioral factors. Drug-induced neuroplasticity, such as functional changes of striatal dopamine D2 and prefrontal serotonin (5-HT)2A receptors and their mediated signaling pathways, in principle, is responsible for antipsychotic sensitization and tolerance. Understanding the behavioral characteristics and neurobiological underpinnings of antipsychotic sensitization and tolerance has greatly enhanced our understanding of mechanisms of antipsychotic action, and may have important implications for future drug discovery and clinical practice.
Collapse
Affiliation(s)
- Ming Li
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, USA
| |
Collapse
|
4
|
Lin KH, Chen YJ, Lin YT, Hsueh WC, Lu CL, Yen MH, Liao KC. Serious generalized tonic-clonic seizures induced by aripiprazole. Prog Neuropsychopharmacol Biol Psychiatry 2010; 34:231-2. [PMID: 19778573 DOI: 10.1016/j.pnpbp.2009.08.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Revised: 08/22/2009] [Accepted: 08/24/2009] [Indexed: 10/20/2022]
|
5
|
Ruscher K, Erickson A, Kuric E, Inácio AR, Wieloch T. Effects of chronic Clozapine administration on apolipoprotein D levels and on functional recovery following experimental stroke. Brain Res 2010; 1321:152-63. [PMID: 20083089 DOI: 10.1016/j.brainres.2010.01.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Revised: 01/07/2010] [Accepted: 01/09/2010] [Indexed: 10/20/2022]
Abstract
Elevated brain levels of apolipoprotein D (ApoD) correlate with improved neurological recovery after experimental stroke. Hence, a pharmacological induction of ApoD in the postischemic brain could be beneficial for recovery after stroke. Here we investigated the effect of Clozapine, a compound that increases the expression of ApoD, in two rat models of experimental stroke. Rats were subjected to permanent occlusion of the middle cerebral artery (pMCAO) and treated with Clozapine (i.p. 10 mg/kg body weight) or saline for 8 or 28 days starting on the second day after MCAO. ApoD levels increased by 35% in the peri-infarct area after 10 and 30 days after pMCAO, mainly in neuron-specific nuclear protein (NeuN) positive neurons and glial fibrillary acidic protein (GFAP) positive astrocytes. Clozapine did not affect the neurological deficit assessed by the rotating pole test and a grip strength test at 7 days, 14 days, 21 days, and 28 days after pMCAO. Functional outcome and the infarct size were similar in rats subjected to transient MCAO and injected with Clozapine (i.p. 10 mg/kg body weight) or saline for 26 days starting on the second day after tMCAO. We conclude that Clozapine affects cellular processes involved in peri-infarct tissue reorganization, but does not affect functional recovery after MCAO.
Collapse
Affiliation(s)
- Karsten Ruscher
- Laboratory for Experimental Brain Research, Wallenberg Neuroscience Center, University of Lund, BMC A13, S-22184 Lund, Sweden.
| | | | | | | | | |
Collapse
|
6
|
Costa-Campos L, Iwu M, Elisabetsky E. Lack of pro-convulsant activity of the antipsychotic alkaloid alstonine. JOURNAL OF ETHNOPHARMACOLOGY 2004; 93:307-310. [PMID: 15234769 DOI: 10.1016/j.jep.2004.03.056] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2004] [Revised: 02/27/2004] [Accepted: 03/26/2004] [Indexed: 05/24/2023]
Abstract
Psychiatry co-morbidity with epilepsy is common and often requires the combined use of psychotropic and antiepileptic drugs (AEDs). For schizophrenic patients, the occurrence of seizures with atypical agents is highest among antipsychotics, although these agents are more effective in alleviating symptoms (including negative symptoms) and are associated with fewer extrapiramidal effects. The indol alkaloid alstonine is the major component of plants used by traditional Nigerian psychiatrists as anti-dementia drugs. The alkaloid presents an experimental profile very similar to the atypical antipsychotic clozapine. This study aimed to compare the pro-convulsant activity of these two antipsychotic compounds. Through repetitive administration over a 30-day period in a kindling paradigm, it is shown that, unlike clozapine, alstonine does not possess pro-convulsant activity. The data adds to previous suggestions that alstonine deserves to be scrutinized as a model for the development of newer antipsychotics.
Collapse
Affiliation(s)
- Luciane Costa-Campos
- UNESC, Departmento de Farmacia, Av. Universitaria 1105, 88806-00 Criciuma, SC, Brazil.
| | | | | |
Collapse
|
7
|
Torta R, Monaco F. Atypical antipsychotics and serotoninergic antidepressants in patients with epilepsy: pharmacodynamic considerations. Epilepsia 2002; 43 Suppl 2:8-13. [PMID: 11903476 DOI: 10.1046/j.1528-1157.2002.043s2008.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To discuss the pharmacodynamic aspects of the administration of atypical antipsychotics (APs) and serotoninergic antidepressants (SSRIs) to patients with epilepsy. METHODS This article represents an overview of all studies concerning the administration of APs and SSRIs to people with epilepsy. In particular, it deals with the relationship between neuroleptics (NLTs), APs, SSRIs, serotonin, and dopamine, with special focus on the possible epileptogenic role of psychoactive drugs. RESULTS NLTs may induce seizures by blocking D2, H1, and.1 receptors, or by sexual hormone activation or a pharmacologic kindling mechanism. The difference among APs in their ability to induce seizures is related mainly to the percentage of D2-receptor occupancy and possibly also to their action on neurosteroids. Seizures occur at SSRIs therapeutic doses, with a 0.1-4% incidence. Coversely, in animal studies fluoxetine was claimed to exert an anticonvulsant action. CONCLUSIONS The study of the pharmacodynamic aspects of the administration of APs and SSRIs to patients with epilepsy can help to evaluate the importance of some mechanisms of action of several psychoactive drugs in relation to their pro- or anticonvulsant activity.
Collapse
|
8
|
Abstract
We present the case of a never medicated patient with a diagnosis of DSM-IV paranoid schizophrenia in which olanzapine therapy induced manic symptoms. The latter remitted after drug discontinuation.
Collapse
Affiliation(s)
- L Lykouras
- Department of Psychiatry, Athens University Medical School, Eginition Hospital, 74 Vas. Sophias Avenue, 115 28, Athens, Greece.
| | | | | |
Collapse
|
9
|
Michel FJ, Trudeau LE. Clozapine inhibits synaptic transmission at GABAergic synapses established by ventral tegmental area neurones in culture. Neuropharmacology 2000; 39:1536-43. [PMID: 10854898 DOI: 10.1016/s0028-3908(99)00239-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Elucidation of the mechanism of action of the atypical antipsychotic clozapine is complicated by the finding that this molecule interacts with multiple targets including dopaminergic and serotonergic receptors. Binding studies have suggested that clozapine also antagonises GABA(A) receptors, but physiological evidence for such a block at functional synapses is lacking. In this study, we explored this antagonism by using electrophysiological techniques on GABAergic neurones of the ventral tegmental area in culture. Inhibitory post-synaptic currents (IPSCs) evoked in isolated GABAergic neurones were found to be dose-dependently inhibited by clozapine. Compatible with a post-synaptic mechanism, we found that membrane currents evoked by exogenous applications of GABA were similarly dose-dependently inhibited by clozapine. An analysis of miniature inhibitory post-synaptic currents (mIPSCs) showed that clozapine reduced the amplitude of quantal events in a way similar to SR-95531, a specific GABA(A) receptor antagonist. Both drugs caused a similar leftward shift of the cumulative probability distribution of mIPSC amplitudes. This suggests that clozapine acts on both synaptic and extrasynaptic GABA(A) receptors. In conclusion, our work demonstrates that clozapine produces a functional antagonism of GABA(A) receptors at synapses. Because this effect occurs at concentrations that could be found in the brain of patients treated with clozapine, a reduction in GABAergic synaptic transmission could be implicated in the therapeutic actions and/or side-effects of clozapine.
Collapse
Affiliation(s)
- F J Michel
- Départements de Pharmacologie et de Psychiatrie, Faculté de Médecine, Université de Montréal, H3C 3J7, Montréal, Québec, Canada
| | | |
Collapse
|
10
|
Torta R, Keller R. Behavioral, psychotic, and anxiety disorders in epilepsy: etiology, clinical features, and therapeutic implications. Epilepsia 1999; 40 Suppl 10:S2-20. [PMID: 10609602 DOI: 10.1111/j.1528-1157.1999.tb00883.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This chapter deals with some aspects of psychiatric disturbances in people with epilepsy. Because depression and its treatment are extensively described later in this issue, they are not discussed here. The same pertains to forced normalization.
Collapse
Affiliation(s)
- R Torta
- Department of Neurosciences, University of Turin, Italy
| | | |
Collapse
|
11
|
Abstract
Propagation and prolongation of rapid neuronal discharge underlies the epilepsies. However, episodic focal rapid neuronal discharges limited to discrete nuclei and pathways of the amygdala-hippocampal-septal-hypothalamic networks are the language of physiologic message systems for endocrine regulation and reproductive activities vital to the survival of the organism and the species. To prevent prolongation and propagation of physiologic pulsed excitation to areas outside specific networks and resultant epileptic seizures, these discharges must be limited in extent and time by powerful inhibitory processes. The nucleus accumbens, a unit of the extended amygdala, and the monoamines and GABA are components of the inhibitory networks that restrict physiologic rapid discharge in duration and in location. In parallel to the relationship of excessive neuronal excitation to epilepsy, evidence will be presented that excessive inhibition via one or more components of these inhibitory networks or diminished excitation underlies development of some psychoses, including schizophrenia.
Collapse
Affiliation(s)
- J R Stevens
- Department of Neurology and Psychiatry, Oregon Health Sciences University, Portland 97201, USA.
| |
Collapse
|