1
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Walker LC, Huckstep KL, Becker HC, Langmead CJ, Lawrence AJ. Targeting muscarinic receptors for the treatment of alcohol use disorders: Opportunities and hurdles for clinical development. Br J Pharmacol 2024; 181:4385-4398. [PMID: 37005377 DOI: 10.1111/bph.16081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 04/04/2023] Open
Abstract
Emerging evidence suggests muscarinic acetylcholine receptors represent novel targets to treat alcohol use disorder. In this review, we draw from literature across medicinal chemistry, molecular biology, addiction and learning/cognition fields to interrogate the proposition for muscarinic receptor ligands in treating various aspects of alcohol use disorder, including cognitive dysfunction, motivation to consume alcohol and relapse. In support of this proposition, we describe cholinergic dysfunction in the pathophysiology of alcohol use disorder at a network level, including alcohol-induced adaptations present in both human post-mortem brains and reverse-translated rodent models. Preclinical behavioural pharmacology implicates specific muscarinic receptors, in particular, M4 and M5 receptors, as potential therapeutic targets worthy of further interrogation. We detail how these receptors can be selectively targeted in vivo by the use of subtype-selective allosteric modulators, a strategy that overcomes the issue of targeting a highly conserved orthosteric site bound by acetylcholine. Finally, we highlight the intense pharma interest in allosteric modulators of muscarinic receptors for other indications that provide an opportunity for repurposing into the alcohol use disorder space and provide some currently unanswered questions as a roadmap for future investigation.
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Affiliation(s)
- Leigh C Walker
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
- Florey Department of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Kade L Huckstep
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
- Florey Department of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Howard C Becker
- Charleston Alcohol Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Neuroscience, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Christopher J Langmead
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
- Neuromedicines Discovery Centre, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Andrew J Lawrence
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
- Florey Department of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
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2
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Paul SM, Yohn SE, Brannan SK, Neugebauer NM, Breier A. Muscarinic Receptor Activators as Novel Treatments for Schizophrenia. Biol Psychiatry 2024; 96:627-637. [PMID: 38537670 DOI: 10.1016/j.biopsych.2024.03.014] [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: 11/17/2023] [Revised: 03/08/2024] [Accepted: 03/17/2024] [Indexed: 05/26/2024]
Abstract
Achieving optimal treatment outcomes for individuals living with schizophrenia remains challenging, despite 70 years of drug development efforts. Many chemically distinct antipsychotics have been developed over the past 7 decades with improved safety and tolerability but with only slight variation in efficacy. All antipsychotics currently approved for the treatment of schizophrenia act as antagonists or partial agonists at the dopamine D2 receptor. With only a few possible exceptions, antipsychotic drugs have similar and modest efficacy for treating positive symptoms and are relatively ineffective in addressing the negative and cognitive symptoms of the disease. The development of novel treatments focused on targeting muscarinic acetylcholine receptors (mAChRs) has been of interest for more than 25 years following reports that treatment with a dual M1/M4-preferring mAChR agonist resulted in antipsychotic-like effects and procognitive properties in individuals living with Alzheimer's disease and schizophrenia; more recent clinical trials have confirmed these findings. In addition, advances in our understanding of the receptor binding and activation properties of xanomeline at specific mAChRs have the potential to inform future drug design targeting mAChRs.
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Affiliation(s)
- Steven M Paul
- Karuna Therapeutics, Boston, Massachusetts; Department of Psychiatry and Neurology, Washington University of St. Louis, St. Louis, Missouri.
| | | | | | | | - Alan Breier
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana
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3
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Howes OD, Dawkins E, Lobo MC, Kaar SJ, Beck K. New Drug Treatments for Schizophrenia: A Review of Approaches to Target Circuit Dysfunction. Biol Psychiatry 2024; 96:638-650. [PMID: 38815885 DOI: 10.1016/j.biopsych.2024.05.014] [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: 12/29/2023] [Revised: 04/23/2024] [Accepted: 05/14/2024] [Indexed: 06/01/2024]
Abstract
Schizophrenia is a leading cause of global disease burden. Current drug treatments are associated with significant side effects and have limited efficacy for many patients, highlighting the need to develop new approaches that target other aspects of the neurobiology of schizophrenia. Preclinical, in vivo imaging, postmortem, genetic, and pharmacological studies have highlighted the key role of cortical GABAergic (gamma-aminobutyric acidergic)-glutamatergic microcircuits and their projections to subcortical dopaminergic circuits in the pathoetiology of negative, cognitive, and psychotic symptoms. Antipsychotics primarily act downstream of the dopaminergic component of this circuit. However, multiple drugs are currently in development that could target other elements of this circuit to treat schizophrenia. These include drugs for GABAergic or glutamatergic targets, including glycine transporters, D-amino acid oxidase, sodium channels, or potassium channels. Other drugs in development are likely to primarily act on pathways that regulate the dopaminergic system, such as muscarinic or trace amine receptors or 5-HT2A receptors, while PDE10A inhibitors are being developed to modulate the downstream consequences of dopaminergic dysfunction. Our review considers where new drugs may act on this circuit and their latest clinical trial evidence in terms of indication, efficacy, and side effects. Limitations of the circuit model, including whether there are neurobiologically distinct subgroups of patients, and future directions are also considered. Several drugs based on the mechanisms reviewed have promising clinical data, with the muscarinic agonist KarXT most advanced. If these drugs are approved for clinical use, they have the potential to revolutionize understanding of the pathophysiology and treatment of schizophrenia.
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Affiliation(s)
- Oliver D Howes
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, United Kingdom.
| | - Eleanor Dawkins
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, United Kingdom
| | - Maria C Lobo
- South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, United Kingdom
| | - Stephen J Kaar
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Greater Manchester Mental Health National Health Service Foundation Trust, Manchester, United Kingdom
| | - Katherine Beck
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, United Kingdom
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4
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Coyle JT. Passing the torch: The ascendance of the glutamatergic synapse in the pathophysiology of schizophrenia. Biochem Pharmacol 2024; 228:116376. [PMID: 38906225 DOI: 10.1016/j.bcp.2024.116376] [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: 02/16/2024] [Revised: 06/11/2024] [Accepted: 06/18/2024] [Indexed: 06/23/2024]
Abstract
For nearly fifty years, the dopamine hypothesis has dominated our understanding of the pathophysiology of schizophrenia and provided the lone target for drug development. However, with the exception of clozapine, the dopamine D2 receptor antagonizing anti-psychotic drugs have little impact on the negative symptoms and cognitive deficits, aspects of the disorder that robustly predict outcome. Pathologic studies reveal cortical atrophy and wide-spread loss of glutamatergic synaptic spines, unexplained by dopaminergic malfunction. Recent genome-wide association studies indicate that at least thirty risk genes for schizophrenia encode proteins localized to the glutamatergic synapse and inhibit glutamate neurotransmission, especially at the NMDA receptor. To function, the NMDA receptor requires the binding of glycine (primarily in the cerebellum and brainstem) or D-serine (in forebrain) to the NR1 channel subunit of the NMDA receptor. Genetically silencing the gene (srr) encoding serine racemase, the biosynthetic enzyme for D-serine, results in forebrain NMDA receptor hypofunction. The srr-/- mice have 90 % loss of endogenous D-serine and approximately 70 % decrease in NMDA receptor function. Several animal models of schizophrenia are based on behavioral and pharmacologic strategies, which have negligible validity with regard to the fundamental etiology of schizophrenia. We summarize here the results of a mouse model, in which srr, one of the two dozen or more risk gene for schizophrenia that affect NMDA receptor function, has been inactivated. The srr-/- mice exhibit striking similarities to schizophrenia including cortical atrophy, loss of cortico-limbic glutamatergic synapses, increased sub-cortical dopamine release, EEG abnormalities, and cognitive impairments. The limited efficacy of drugs targeting the glutamatergic synapse on DSM-5 diagnosed criteria for schizophrenia used in clinical trials may reflect the fact that only 30 % of the patients have impaired glutamatergic neurotransmission, resulting from the genetic heterogeneity of the disorder.
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Affiliation(s)
- Joseph T Coyle
- Eben S Draper Professor of Psychiatry and Neuroscience Harvard Medical School (Emeritus), McLean Hospital, 115 Mill St, Belmont, MA 02478, United States.
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5
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Tobin AB. A golden age of muscarinic acetylcholine receptor modulation in neurological diseases. Nat Rev Drug Discov 2024; 23:743-758. [PMID: 39143241 DOI: 10.1038/s41573-024-01007-1] [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: 06/28/2024] [Indexed: 08/16/2024]
Abstract
Over the past 40 years, the muscarinic acetylcholine receptor family, particularly the M1-receptor and M4-receptor subtypes, have emerged as validated targets for the symptomatic treatment of neurological diseases such as schizophrenia and Alzheimer disease. However, despite considerable effort and investment, no drugs have yet gained clinical approval. This is largely attributable to cholinergic adverse effects that have halted the majority of programmes and resulted in a waning of interest in these G-protein-coupled receptor targets. Recently, this trend has been reversed. Driven by advances in structure-based drug design and an appreciation of the optimal pharmacological properties necessary to deliver clinical efficacy while minimizing adverse effects, a new generation of M1-receptor and M4-receptor orthosteric agonists and positive allosteric modulators are now entering the clinic. These agents offer the prospect of novel therapeutic solutions for 'hard to treat' neurological diseases, heralding a new era of muscarinic drug discovery.
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Affiliation(s)
- Andrew B Tobin
- Centre for Translational Pharmacology, School of Molecular Biosciences, The Advanced Research Centre, University of Glasgow, Glasgow, UK.
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6
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Uliana DL, Lisboa JRF, Gomes FV, Grace AA. The excitatory-inhibitory balance as a target for the development of novel drugs to treat schizophrenia. Biochem Pharmacol 2024; 228:116298. [PMID: 38782077 PMCID: PMC11410545 DOI: 10.1016/j.bcp.2024.116298] [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: 02/01/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
The intricate balance between excitation and inhibition (E/I) in the brain plays a crucial role in normative information processing. Dysfunctions in the E/I balance have been implicated in various psychiatric disorders, including schizophrenia (SCZ). In particular, abnormalities in GABAergic signaling, specifically in parvalbumin (PV)-containing interneurons, have been consistently observed in SCZ pathophysiology. PV interneuron function is vital for maintaining an ideal E/I balance, and alterations in PV interneuron-mediated inhibition contribute to circuit deficits observed in SCZ, including hippocampus hyperactivity and midbrain dopamine system overdrive. While current antipsychotic medications primarily target D2 dopamine receptors and are effective primarily in treating positive symptoms, novel therapeutic strategies aiming to restore the E/I balance could potentially mitigate not only positive symptoms but also negative symptoms and cognitive deficits. This could involve, for instance, increasing the inhibitory drive onto excitatory neurons or decreasing the putative enhanced pyramidal neuron activity due to functional loss of PV interneurons. Compounds targeting the glycine site at glutamate NMDA receptors and muscarinic acetylcholine receptors on PV interneurons that can increase PV interneuron drive, as well as drugs that increase the postsynaptic action of GABA, such as positive allosteric modulators of α5-GABA-A receptors, and decrease glutamatergic output, such as mGluR2/3 agonists, represent promising approaches. Preventive strategies aiming at E/I balance also represent a path to reduce the risk of transitioning to SCZ in high-risk individuals. Therefore, compounds with novel mechanisms targeting E/I balance provide optimism for more effective and tailored interventions in the management of SCZ.
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Affiliation(s)
- Daniela L Uliana
- Departments of Neuroscience, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joao Roberto F Lisboa
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Felipe V Gomes
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Anthony A Grace
- Departments of Neuroscience, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, USA.
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7
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Engers JL, Baker LA, Chang S, Luscombe VB, Rodriguez AL, Niswender CM, Cho HP, Bubser M, Gray AT, Jones CK, Peng W, Rook JM, Bridges TM, Boutaud O, Conn PJ, Engers DW, Lindsley CW, Temple KJ. Discovery of VU6016235: A Highly Selective, Orally Bioavailable, and Structurally Distinct Tricyclic M 4 Muscarinic Acetylcholine Receptor Positive Allosteric Modulator (PAM). ACS Chem Neurosci 2024. [PMID: 39316465 DOI: 10.1021/acschemneuro.4c00465] [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: 09/26/2024] Open
Abstract
Herein, we report structure-activity relationship (SAR) studies to develop novel tricyclic M4 PAM scaffolds with improved pharmacological properties. This endeavor involved a "tie-back" strategy to replace a 5-amino-2,4-dimethylthieno[2,3-d]pyrimidine-6-carboxamide core, which led to the discovery of two novel tricyclic cores. While both tricyclic cores displayed low nanomolar potency against both human and rat M4 and were highly brain-penetrant, the 2,4-dimethylpyrido[4',3':4,5]thieno[2,3-d]pyrimidine tricycle core provided lead compound, VU6016235, with an overall superior pharmacological and drug metabolism and pharmacokinetics (DMPK) profile, as well as efficacy in a preclinical antipsychotic animal model.
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Affiliation(s)
- Julie L Engers
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Logan A Baker
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Sichen Chang
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Vincent B Luscombe
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Alice L Rodriguez
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Colleen M Niswender
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Vanderbilt Kennedy Center, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Vanderbilt Brain Institute, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Hyekyung P Cho
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Michael Bubser
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Analisa Thompson Gray
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Carrie K Jones
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Weimin Peng
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Jerri M Rook
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Thomas M Bridges
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Olivier Boutaud
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - P Jeffrey Conn
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Vanderbilt Kennedy Center, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Darren W Engers
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Craig W Lindsley
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Department of Chemistry, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Biochemistry, Vanderbilt University, Nashville, Tennessee 37232, United States
| | - Kayla J Temple
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
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8
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Vita A, Barlati S, Cavallaro R, Mucci A, Riva MA, Rocca P, Rossi A, Galderisi S. Definition, assessment and treatment of cognitive impairment associated with schizophrenia: expert opinion and practical recommendations. Front Psychiatry 2024; 15:1451832. [PMID: 39371908 PMCID: PMC11450451 DOI: 10.3389/fpsyt.2024.1451832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 08/22/2024] [Indexed: 10/08/2024] Open
Abstract
A considerable proportion of patients with schizophrenia perform below population norms on standardized neuropsychological tests, and the performance of those performing within normal range is lower than predicted based on parental education. Cognitive impairment predates the onset of psychosis, is observed during symptom remission and in non-affected first-degree relatives of patients. At the present time, cognitive deficits are regarded as key features of schizophrenia, important determinants of poor psychosocial outcome and targets for both pharmacological and non-pharmacological treatment strategies. A group of eight key opinion leaders reviewed and discussed latest advances in scientific research and current good clinical practices on assessment, management, and treatment of CIAS. In the present paper they summarize the current evidence, identify main gaps between current knowledge and mental health services clinical practice, and provide practical recommendations to reduce the gap.
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Affiliation(s)
- Antonio Vita
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Mental Health and Addiction Services, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili of, Brescia, Italy
| | - Stefano Barlati
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Mental Health and Addiction Services, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili of, Brescia, Italy
| | - Roberto Cavallaro
- Department of Clinical Neurosciences, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Armida Mucci
- Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Marco A. Riva
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
- Biological Psychiatry Unit, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Paola Rocca
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Turin, Italy
| | - Alessandro Rossi
- Department of Biotechnological and Applied Clinical Sciences, Section of Psychiatry, University of L’Aquila, L’Aquila, Italy
| | - Silvana Galderisi
- Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
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9
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Engers JL, Bollinger KA, Capstick RA, Long MF, Bender AM, Dickerson JW, Peng W, Presley CC, Cho HP, Rodriguez AL, Niswender CM, Moran SP, Xiang Z, Blobaum AL, Boutaud O, Rook JM, Engers DW, Conn PJ, Lindsley CW. Discovery of VU6007496: Challenges in the Development of an M 1 Positive Allosteric Modulator Backup Candidate. ACS Chem Neurosci 2024; 15:3421-3433. [PMID: 39197083 DOI: 10.1021/acschemneuro.4c00508] [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] [Indexed: 08/30/2024] Open
Abstract
Herein we report progress toward a backup clinical candidate to the M1 positive allosteric modulator (PAM) VU319/ACP-319. Scaffold-hopping from the pyrrolo[2,3-b]pyridine-based M1 PAM VU6007477 to isomeric pyrrolo[3,2-b]pyridine and thieno[3,2-b]pyridine congeners identified several backup contenders. Ultimately, VU6007496, a pyrrolo[3,2-b]pyridine, advanced into late stage profiling, only to be plagued with unanticipated, species-specific metabolism and active/toxic metabolites which were identified in our phenotypic seizure liability in vivo screen, preventing further development. However, VU6007496 proved to be a highly selective and CNS penetrant M1 PAM, with minimal agonism, that displayed excellent multispecies IV/PO pharmacokinetics (PK), CNS penetration, no induction of long-term depression (or cholinergic toxicity) and robust efficacy in novel object recognition (minimum effective dose = 3 mg/kg p.o.). Thus, VU6007496 can serve as another valuable in vivo tool compound in rats and nonhuman primates, but not mouse, to study selective M1 activation.
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Affiliation(s)
- Julie L Engers
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Katrina A Bollinger
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Rory A Capstick
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Madeline F Long
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Aaron M Bender
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Jonathan W Dickerson
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Weimin Peng
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Christopher C Presley
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Hyekyung P Cho
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Alice L Rodriguez
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Colleen M Niswender
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, Tennessee 37232, United States
- Vanderbilt Brain Institute, Vanderbilt University, Nashville, Tennessee 37232, United States
- Vanderbilt Institute of Chemical Biology, Vanderbilt University, Nashville, Tennessee 37232, United States
| | - Sean P Moran
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Zixiu Xiang
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Anna L Blobaum
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Olivier Boutaud
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Jerri M Rook
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Darren W Engers
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - P Jeffrey Conn
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, Tennessee 37232, United States
| | - Craig W Lindsley
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Department of Chemistry, Vanderbilt University, Nashville, Tennessee 37232, United States
- Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, Tennessee 37232, United States
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10
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Horan WP, Targum SD, Claxton A, Kaul I, Yohn SE, Marder SR, Miller AC, Brannan SK. Efficacy of KarXT on negative symptoms in acute schizophrenia: A post hoc analysis of pooled data from 3 trials. Schizophr Res 2024; 274:57-65. [PMID: 39260339 DOI: 10.1016/j.schres.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 06/06/2024] [Accepted: 08/08/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND Currently approved antipsychotics do not adequately treat negative symptoms (NS), which are a major determinant of functional disability in schizophrenia. KarXT, an M1 /M4 preferring muscarinic receptor agonist, has shown efficacy as a broad-spectrum monotherapy for the treatment of schizophrenia in participants with acute psychosis. Post hoc analyses evaluated the possibility that NS improve independently of positive symptoms with KarXT in a subgroup of participants with moderate-to-severe NS and no predominance of positive symptoms. METHODS Data were pooled from the three pivotal trials of KarXT monotherapy in people with schizophrenia with an acute exacerbation of psychosis. All 3 studies used similar 5-week randomized, double-blind, placebo-controlled designs (modified intention-to-treat sample N = 640). PANSS criteria proposed in the literature identified a subset of study participants (n = 64) with prominent NS. RESULTS KarXT was significantly better than placebo on PANSS Marder Negative Factor Scores in the full sample (p < .001; Cohen's d = 0.42) and more so in the prominent NS subgroup (p < .001; Cohen's d = 1.18). Further, the KarXT effect in the NS subgroup remained significant after accounting for changes in positive symptoms, depression/anxiety, disorganization, and hostility. CONCLUSIONS Participants with prominent NS revealed greater improvement of NS following KarXT therapy than the full sample that persisted after accounting for positive and other symptoms. While these findings must be interpreted with caution, they are consistent with the possibility that NS improvements associated with KarXT are not secondary to improvements in other symptom domains and support further investigation in larger, stable outpatient studies.
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Affiliation(s)
- William P Horan
- Bristol Myers Squibb, Princeton, NJ, USA; University of California, Los Angeles, CA, USA.
| | | | | | - Inder Kaul
- Bristol Myers Squibb, Princeton, NJ, USA
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11
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Okubo R, Okada M, Motomura E. Dysfunction of the NMDA Receptor in the Pathophysiology of Schizophrenia and/or the Pathomechanisms of Treatment-Resistant Schizophrenia. Biomolecules 2024; 14:1128. [PMID: 39334894 PMCID: PMC11430065 DOI: 10.3390/biom14091128] [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: 08/15/2024] [Revised: 08/29/2024] [Accepted: 09/02/2024] [Indexed: 09/30/2024] Open
Abstract
For several decades, the dopamine hypothesis contributed to the discovery of numerous typical and atypical antipsychotics and was the sole hypothesis for the pathophysiology of schizophrenia. However, neither typical nor atypical antipsychotics, other than clozapine, have been effective in addressing negative symptoms and cognitive impairments, which are indices for the prognostic and disability outcomes of schizophrenia. Following the development of atypical antipsychotics, the therapeutic targets for antipsychotics expanded beyond the blockade of dopamine D2 and serotonin 5-HT2A receptors to explore the partial agonism of the D2 receptor and the modulation of new targets, such as D3, 5-HT1A, 5-HT7, and metabotropic glutamate receptors. Despite these efforts, to date, psychiatry has not successfully developed antipsychotics with antipsychotic properties proven to be superior to those of clozapine. The glutamate hypothesis, another hypothesis regarding the pathophysiology/pathomechanism of schizophrenia, was proposed based on clinical findings that N-methyl-D-aspartate glutamate receptor (NMDAR) antagonists, such as phencyclidine and ketamine, induce schizophrenia-like psychotic episodes. Large-scale genome-wide association studies (GWASs) revealed that approximately 30% of the risk genes for schizophrenia (the total number was over one hundred) encode proteins associated with glutamatergic transmission. These findings supported the validation of the glutamate hypothesis, which was inspired by the clinical findings regarding NMDAR antagonists. Additionally, these clinical and genetic findings suggest that schizophrenia is possibly a syndrome with complicated pathomechanisms that are affected by multiple biological and genetic vulnerabilities. The glutamate hypothesis has been the most extensively investigated pathophysiology/pathomechanism hypothesis, other than the dopamine hypothesis. Studies have revealed the possibility that functional abnormalities of the NMDAR play important roles in the pathophysiology/pathomechanism of schizophrenia. However, no antipsychotics derived from the glutamatergic hypothesis have yet been approved for the treatment of schizophrenia or treatment-resistant schizophrenia. Considering the increasing evidence supporting the potential pro-cognitive effects of glutamatergic agents and the lack of sufficient medications to treat the cognitive impairments associated with schizophrenia, these previous setbacks cannot preclude research into potential novel glutamate modulators. Given this background, to emphasize the importance of the dysfunction of the NMDAR in the pathomechanism and/or pathophysiology of schizophrenia, this review introduces the increasing findings on the functional abnormalities in glutamatergic transmission associated with the NMDAR.
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Affiliation(s)
| | - Motohiro Okada
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan; (R.O.); (E.M.)
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12
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Hart XM, Gründer G, Ansermot N, Conca A, Corruble E, Crettol S, Cumming P, Hefner G, Frajerman A, Howes O, Jukic MM, Kim E, Kim S, Maniscalco I, Moriguchi S, Müller DJ, Nakajima S, Osugo M, Paulzen M, Ruhe HG, Scherf-Clavel M, Schoretsanitis G, Serretti A, Spina E, Spigset O, Steimer W, Süzen SH, Uchida H, Unterecker S, Vandenberghe F, Verstuyft C, Zernig G, Hiemke C, Eap CB. Optimisation of pharmacotherapy in psychiatry through therapeutic drug monitoring, molecular brain imaging and pharmacogenetic tests: Focus on antipsychotics. World J Biol Psychiatry 2024:1-86. [PMID: 38913780 DOI: 10.1080/15622975.2024.2366235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 05/12/2024] [Accepted: 06/06/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND For psychotic disorders (i.e. schizophrenia), pharmacotherapy plays a key role in controlling acute and long-term symptoms. To find the optimal individual dose and dosage strategy, specialised tools are used. Three tools have been proven useful to personalise drug treatments: therapeutic drug monitoring (TDM) of drug levels, pharmacogenetic testing (PG), and molecular neuroimaging. METHODS In these Guidelines, we provide an in-depth review of pharmacokinetics, pharmacodynamics, and pharmacogenetics for 45 antipsychotics. Over 30 international experts in psychiatry selected studies that have measured drug concentrations in the blood (TDM), gene polymorphisms of enzymes involved in drug metabolism, or receptor/transporter occupancies in the brain (positron emission tomography (PET)). RESULTS Study results strongly support the use of TDM and the cytochrome P450 (CYP) genotyping and/or phenotyping to guide drug therapies. Evidence-based target ranges are available for titrating drug doses that are often supported by PET findings. CONCLUSION All three tools discussed in these Guidelines are essential for drug treatment. TDM goes well beyond typical indications such as unclear compliance and polypharmacy. Despite its enormous potential to optimise treatment effects, minimise side effects and ultimately reduce the global burden of diseases, personalised drug treatment has not yet become the standard of care in psychiatry.
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Affiliation(s)
- Xenia Marlene Hart
- Department of Molecular Neuroimaging, Medical Faculty Mannheim, Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Gerhard Gründer
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
- German Center for Mental Health (DZPG), Partner Site Mannheim, Heidelberg, Germany
| | - Nicolas Ansermot
- Department of Psychiatry, Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Lausanne University Hospital, Prilly, Switzerland
| | - Andreas Conca
- Dipartimento di Psichiatria, Comprensorio Sanitario di Bolzano, Bolzano, Italy
| | - Emmanuelle Corruble
- Service Hospitalo-Universitaire de Psychiatrie, Hôpital de Bicêtre, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
- Equipe MOODS, Inserm U1018, CESP (Centre de Recherche en Epidémiologie et Sante des Populations), Le Kremlin-Bicêtre, France
| | - Severine Crettol
- Department of Psychiatry, Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Lausanne University Hospital, Prilly, Switzerland
| | - Paul Cumming
- Department of Nuclear Medicine, Bern University Hospital, Bern, Switzerland
- School of Psychology and Counseling, Queensland University of Technology, Brisbane, Australia
| | - Gudrun Hefner
- Forensic Psychiatry, Vitos Clinic for Forensic Psychiatry, Eltville, Germany
| | - Ariel Frajerman
- Service Hospitalo-Universitaire de Psychiatrie, Hôpital de Bicêtre, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
- Equipe MOODS, Inserm U1018, CESP (Centre de Recherche en Epidémiologie et Sante des Populations), Le Kremlin-Bicêtre, France
| | - Oliver Howes
- Department of Psychosis Studies, IoPPN, King's College London, London, UK
- Faculty of Medicine, Institute of Clinical Sciences (ICS), Imperial College London, London, UK
| | - Marin M Jukic
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
- Pharmacogenetics Section, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
| | - Euitae Kim
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seoyoung Kim
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Ignazio Maniscalco
- Dipartimento di Psichiatria, Comprensorio Sanitario di Bolzano, Bolzano, Italy
| | - Sho Moriguchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Daniel J Müller
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
- Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Shinichiro Nakajima
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Martin Osugo
- Department of Psychosis Studies, IoPPN, King's College London, London, UK
- Faculty of Medicine, Institute of Clinical Sciences (ICS), Imperial College London, London, UK
| | - Michael Paulzen
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany
- JARA - Translational Brain Medicine, Alexianer Center for Mental Health, Aachen, Germany
| | - Henricus Gerardus Ruhe
- Department of Psychiatry, Radboudumc, Nijmegen, Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, Netherlands
| | - Maike Scherf-Clavel
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | | | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Werner Steimer
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich, Munich, Germany
| | - Sinan H Süzen
- Department of Pharmaceutic Toxicology, Faculty of Pharmacy, Ankara University, Ankara, Turkey
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Stefan Unterecker
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
| | - Frederik Vandenberghe
- Department of Psychiatry, Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Lausanne University Hospital, Prilly, Switzerland
| | - Celine Verstuyft
- Equipe MOODS, Inserm U1018, CESP (Centre de Recherche en Epidémiologie et Sante des Populations), Le Kremlin-Bicêtre, France
- Department of Molecular Genetics, Pharmacogenetics and Hormonology, Bicêtre University Hospital Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Gerald Zernig
- Department of Pharmacology, Medical University Innsbruck, Hall in Tirol, Austria
- Private Practice for Psychotherapy and Court-Certified Witness, Hall in Tirol, Austria
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy and Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Mainz, Germany
| | - Chin B Eap
- Department of Psychiatry, Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Lausanne University Hospital, Prilly, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, University of Lausanne, Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Lausanne, Switzerland
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13
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Komatsu Y, Takehara M, Hart X, Takahashi Y, Hori S, Ueno F, Uchida H. Advancements in Non-Dopaminergic Treatments for Schizophrenia: A Systematic Review of Pipeline Developments. PHARMACOPSYCHIATRY 2024; 57:221-231. [PMID: 38710208 DOI: 10.1055/a-2307-6484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Conventional antipsychotic drugs that attenuate dopaminergic neural transmission are ineffective in approximately one-third of patients with schizophrenia. This necessitates the development of non-dopaminergic agents. METHODS A systematic search was conducted for completed phase II and III trials of compounds for schizophrenia treatment using the US Clinical Trials Registry and the EU Clinical Trials Register. Compounds demonstrating significant superiority over placebo in the primary outcome measure in the latest phase II and III trials were identified. Collateral information on the included compounds was gathered through manual searches in PubMed and press releases. RESULTS Sixteen compounds were identified; four compounds (ulotaront, xanomeline/trospium chloride, vabicaserin, and roluperidone) were investigated as monotherapy and the remaining 12 (pimavanserin, bitopertin, BI 425809, encenicline, tropisetron, pregnenolone, D-serine, estradiol, tolcapone, valacyclovir, cannabidiol, and rimonabant) were examined as add-on therapy. Compared to the placebo, ulotaront, xanomeline/trospium chloride, vabicaserin, bitopertin, estradiol, cannabidiol, rimonabant, and D-serine showed efficacy for positive symptoms; roluperidone and pimavanserin were effective for negative symptoms; and encenicline, tropisetron, pregnenolone, tolcapone, BI 425809, and valacyclovir improved cognitive function. DISCUSSION Compounds that function differently from existing antipsychotics may offer novel symptom-specific therapeutic strategies for patients with schizophrenia.
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Affiliation(s)
- Yuki Komatsu
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
- Department of Psychiatry, Tokyo Metropolitan Matsuzawa Hospital, Tokyo, Japan
| | - Moe Takehara
- Division of Drug Informatics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Xenia Hart
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
- Department of Molecular Neuroimaging, Medical Faculty Mannheim, Central Institute of Mental Health, Heidelberg University, Mannheim, Germany
| | - Yuna Takahashi
- Division of Drug Informatics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Satoko Hori
- Division of Drug Informatics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Fumihiko Ueno
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
- Brain Health Imaging Centre, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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14
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Weinstein JJ, Moeller SJ, Perlman G, Gil R, Van Snellenberg JX, Wengler K, Meng J, Slifstein M, Abi-Dargham A. Imaging the Vesicular Acetylcholine Transporter in Schizophrenia: A Positron Emission Tomography Study Using [ 18F]-VAT. Biol Psychiatry 2024; 96:352-364. [PMID: 38309322 DOI: 10.1016/j.biopsych.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 01/10/2024] [Accepted: 01/23/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND Despite longstanding interest in the central cholinergic system in schizophrenia (SCZ), cholinergic imaging studies with patients have been limited to receptors. Here, we conducted a proof-of-concept positron emission tomography study using [18F]-VAT, a new radiotracer that targets the vesicular acetylcholine transporter as a proxy measure of acetylcholine transmission capacity, in patients with SCZ and explored relationships of vesicular acetylcholine transporter with clinical symptoms and cognition. METHODS A total of 18 adult patients with SCZ or schizoaffective disorder (the SCZ group) and 14 healthy control participants underwent a positron emission tomography scan with [18F]-VAT. Distribution volume (VT) for [18F]-VAT was derived for each region of interest, and group differences in VT were assessed with 2-sample t tests. Functional significance was explored through correlations between VT and scores on the Positive and Negative Syndrome Scale and a computerized neurocognitive battery (PennCNB). RESULTS No group differences in [18F]-VAT VT were observed. However, within the SCZ group, psychosis symptom severity was positively associated with VT in multiple regions of interest, with the strongest effects in the hippocampus, thalamus, midbrain, cerebellum, and cortex. In addition, in the SCZ group, working memory performance was negatively associated with VT in the substantia innominata and several cortical regions of interest including the dorsolateral prefrontal cortex. CONCLUSIONS In this initial study, the severity of 2 important features of SCZ-psychosis and working memory deficit-was strongly associated with [18F]-VAT VT in several cortical and subcortical regions. These correlations provide preliminary evidence of cholinergic activity involvement in SCZ and, if replicated in larger samples, could lead to a more complete mechanistic understanding of psychosis and cognitive deficits in SCZ and the development of therapeutic targets.
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Affiliation(s)
- Jodi J Weinstein
- Department of Psychiatry and Behavioral Health, Stony Brook University Renaissance School of Medicine, Stony Brook, New York; Department of Psychiatry, Columbia University Vagelos School of Medicine and New York State Psychiatric Institute, New York, New York.
| | - Scott J Moeller
- Department of Psychiatry and Behavioral Health, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Greg Perlman
- Department of Psychiatry and Behavioral Health, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Roberto Gil
- Department of Psychiatry and Behavioral Health, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Jared X Van Snellenberg
- Department of Psychiatry and Behavioral Health, Stony Brook University Renaissance School of Medicine, Stony Brook, New York; Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York; Department of Psychology, Stony Brook University, Stony Brook, New York
| | - Kenneth Wengler
- Department of Psychiatry, Columbia University Vagelos School of Medicine and New York State Psychiatric Institute, New York, New York; Department of Radiology, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Jiayan Meng
- Department of Psychiatry and Behavioral Health, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Mark Slifstein
- Department of Psychiatry and Behavioral Health, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Anissa Abi-Dargham
- Department of Psychiatry and Behavioral Health, Stony Brook University Renaissance School of Medicine, Stony Brook, New York; Department of Psychiatry, Columbia University Vagelos School of Medicine and New York State Psychiatric Institute, New York, New York
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15
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Dudzik P, Lustyk K, Pytka K. Beyond dopamine: Novel strategies for schizophrenia treatment. Med Res Rev 2024; 44:2307-2330. [PMID: 38653551 DOI: 10.1002/med.22042] [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: 01/26/2024] [Revised: 04/02/2024] [Accepted: 04/08/2024] [Indexed: 04/25/2024]
Abstract
Despite extensive research efforts aimed at discovering novel antipsychotic compounds, a satisfactory pharmacological strategy for schizophrenia treatment remains elusive. All the currently available drugs act by modulating dopaminergic neurotransmission, leading to insufficient management of the negative and cognitive symptoms of the disorder. Due to these challenges, several attempts have been made to design agents with innovative, non-dopaminergic mechanisms of action. Consequently, a number of promising compounds are currently progressing through phases 2 and 3 of clinical trials. This review aims to examine the rationale behind the most promising of these strategies while simultaneously providing a comprehensive survey of study results. We describe the versatility behind the cholinergic neurotransmission modulation through the activation of M1 and M4 receptors, exemplified by the prospective drug candidate KarXT. Our discussion extends to the innovative approach of activating TAAR1 receptors via ulotaront, along with the promising outcomes of iclepertin, a GlyT-1 inhibitor with the potential to become the first treatment option for cognitive impairment associated with schizophrenia. Finally, we evaluate the 5-HT2A antagonist paradigm, assessing two recently developed serotonergic agents, pimavanserin and roluperidone. We present the latest advancements in developing novel solutions to the complex challenges posed by schizophrenia, offering an additional perspective on the diverse investigated drug candidates.
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Affiliation(s)
- Paulina Dudzik
- Department of Pharmacodynamics, Faculty of Pharmacy, Jagiellonian University Medical College, Krakow, Poland
| | - Klaudia Lustyk
- Department of Pharmacodynamics, Faculty of Pharmacy, Jagiellonian University Medical College, Krakow, Poland
| | - Karolina Pytka
- Department of Pharmacodynamics, Faculty of Pharmacy, Jagiellonian University Medical College, Krakow, Poland
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16
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Capstick RA, Bollinger SR, Engers JL, Long MF, Chang S, Luscombe VB, Rodriguez AL, Niswender CM, Bridges TM, Boutaud O, Conn PJ, Engers DW, Lindsley CW, Temple KJ. Discovery of VU6008677: A Structurally Distinct Tricyclic M 4 Positive Allosteric Modulator with Improved CYP450 Profile. ACS Med Chem Lett 2024; 15:1358-1366. [PMID: 39140069 PMCID: PMC11318023 DOI: 10.1021/acsmedchemlett.4c00249] [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: 05/31/2024] [Revised: 06/27/2024] [Accepted: 07/01/2024] [Indexed: 08/15/2024] Open
Abstract
This Letter details our efforts to develop novel tricyclic muscarinic acetylcholine receptor subtype 4 (M4) positive allosteric modulator (PAM) scaffolds with improved pharmacological properties. This endeavor involved a "tie-back" strategy to replace the 3-amino-5-chloro-4,6-dimethylthieno[2,3-b]pyridine-2-carboxamide core, which led to the discovery of two novel tricyclic cores: an 8-chloro-9-methylpyrido[3',2':4,5]thieno[3,2-d]pyrimidin-4-amine core and 8-chloro-7,9-dimethylpyrido[3',2':4,5]furo[3,2-d]pyrimidin-4-amine core. Both tricyclic cores displayed low nanomolar potency against human M4 and greatly reduced cytochrome P450 inhibition when compared with parent compound ML253.
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Affiliation(s)
- Rory A. Capstick
- Warren
Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department
of Pharmacology, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
| | - Sean R. Bollinger
- Warren
Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department
of Pharmacology, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
| | - Julie L. Engers
- Warren
Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department
of Pharmacology, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
| | - Madeline F. Long
- Warren
Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department
of Pharmacology, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
| | - Sichen Chang
- Warren
Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department
of Pharmacology, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
| | - Vincent B. Luscombe
- Warren
Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department
of Pharmacology, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
| | - Alice L. Rodriguez
- Warren
Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department
of Pharmacology, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
| | - Colleen M. Niswender
- Warren
Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department
of Pharmacology, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
- Vanderbilt
Kennedy Center, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
- Vanderbilt
Brain Institute, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
| | - Thomas M. Bridges
- Warren
Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department
of Pharmacology, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
| | - Olivier Boutaud
- Warren
Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department
of Pharmacology, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
| | - P. Jeffrey Conn
- Warren
Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department
of Pharmacology, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
- Vanderbilt
Kennedy Center, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
| | - Darren W. Engers
- Warren
Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department
of Pharmacology, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
| | - Craig W. Lindsley
- Warren
Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department
of Pharmacology, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
- Department
of Chemistry, Vanderbilt University, Nashville, Tennessee 37232, United States
| | - Kayla J. Temple
- Warren
Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department
of Pharmacology, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
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17
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Kaul I, Sawchak S, Walling DP, Tamminga CA, Breier A, Zhu H, Miller AC, Paul SM, Brannan SK. Efficacy and Safety of Xanomeline-Trospium Chloride in Schizophrenia: A Randomized Clinical Trial. JAMA Psychiatry 2024; 81:749-756. [PMID: 38691387 PMCID: PMC11063924 DOI: 10.1001/jamapsychiatry.2024.0785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/22/2024] [Indexed: 05/03/2024]
Abstract
Importance A significant need exists for new antipsychotic medications with different mechanisms of action, greater efficacy, and better tolerability than existing agents. Xanomeline is a dual M1/M4 preferring muscarinic receptor agonist with no direct D2 dopamine receptor blocking activity. KarXT combines xanomeline with the peripheral muscarinic receptor antagonist trospium chloride with the goal of reducing adverse events due to xanomeline-related peripheral muscarinic receptor activation. In prior trials, xanomeline-trospium chloride was effective in reducing symptoms of psychosis and generally well tolerated in people with schizophrenia. Objective To evaluate the efficacy and safety of xanomeline-trospium vs placebo in adults with schizophrenia. Design, Setting, and Participants EMERGENT-3 (NCT04738123) was a phase 3, multicenter, randomized, double-blind, placebo-controlled, 5-week trial of xanomeline-trospium in people with schizophrenia experiencing acute psychosis, conducted between April 1, 2021, and December 7, 2022, at 30 inpatient sites in the US and Ukraine. Data were analyzed from February to June 2023. Interventions Participants were randomized 1:1 to receive xanomeline-trospium chloride (maximum dose xanomeline 125 mg/trospium 30 mg) or placebo for 5 weeks. Main Outcomes and Measures The prespecified primary end point was change from baseline to week 5 in Positive and Negative Syndrome Scale (PANSS) total score. Secondary outcome measures were change from baseline to week 5 in PANSS positive subscale score, PANSS negative subscale score, PANSS Marder negative factor score, Clinical Global Impression-Severity score, and proportion of participants with at least a 30% reduction in PANSS total score. Safety and tolerability were also evaluated. Results A total of 256 participants (mean [SD] age, 43.1 [11.8] years; 191 men [74.6%]; 156 of 256 participants [60.9%] were Black or African American, 98 [38.3%] were White, and 1 [0.4%] was Asian) were randomized (125 in xanomeline-trospium group and 131 in placebo group). At week 5, xanomeline-trospium significantly reduced PANSS total score compared with placebo (xanomeline-trospium , -20.6; placebo, -12.2; least squares mean difference, -8.4; 95% CI, -12.4 to -4.3; P < .001; Cohen d effect size, 0.60). Discontinuation rates due to treatment-emergent adverse events (TEAEs) were similar between the xanomeline-trospium (8 participants [6.4%]) and placebo (7 participants [5.5%]) groups. The most common TEAEs in the xanomeline-trospium vs placebo group were nausea (24 participants [19.2%] vs 2 participants [1.6%]), dyspepsia (20 participants [16.0%] vs 2 participants [1.6%]), vomiting (20 participants [16.0%] vs 1 participant [0.8%]), and constipation (16 participants [12.8%] vs 5 participants [3.9%]). Measures of extrapyramidal symptoms, weight gain, and somnolence were similar between treatment groups. Conclusions and Relevance Xanomeline-trospium was efficacious and well tolerated in people with schizophrenia experiencing acute psychosis. These findings, together with the previously reported and consistent results from the EMERGENT-1 and EMERGENT-2 trials, support the potential of xanomeline-trospium to be the first in a putative new class of antipsychotic medications without D2 dopamine receptor blocking activity. Trial Registration ClinicalTrials.gov Identifier: NCT04738123.
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Affiliation(s)
- Inder Kaul
- Karuna Therapeutics, Boston, Massachusetts
| | | | | | - Carol A. Tamminga
- Department of Psychiatry, University of Texas Southwestern Medical School, Dallas
| | - Alan Breier
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis
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18
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Allott K, Chopra S, Rogers J, Dauvermann MR, Clark SR. Advancing understanding of the mechanisms of antipsychotic-associated cognitive impairment to minimise harm: a call to action. Mol Psychiatry 2024; 29:2571-2574. [PMID: 38454078 DOI: 10.1038/s41380-024-02503-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 02/21/2024] [Accepted: 02/27/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Kelly Allott
- Orygen, Parkville, VIC, Australia.
- Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC, Australia.
| | - Sidhant Chopra
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Jack Rogers
- Institute for Mental Health, University of Birmingham, Birmingham, UK
| | | | - Scott Richard Clark
- University of Adelaide, Discipline of Psychiatry, Adelaide, SA, Australia
- Basil Hetzel Institute, Woodville South, SA, Australia
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19
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Witt K, Levin J, van Eimeren T, Hasan A, Ebersbach G. Diagnostics and treatment of impulse control disorders, psychosis and delirium: systemic review-based recommendations - guideline "Parkinson's disease" of the German Society of Neurology. J Neurol 2024:10.1007/s00415-024-12576-x. [PMID: 39046524 DOI: 10.1007/s00415-024-12576-x] [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: 05/23/2024] [Revised: 07/05/2024] [Accepted: 07/07/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND AND OBJECTIVE Impulse control disorders (ICD), psychosis and delirium are part of the spectrum of behavioural changes associated with Parkinson's disease (PD). The diagnostic and therapeutic management of these rather complex neuropsychiatric conditions has been updated in the clinical guideline by the German Society of Neurology (DGN). METHODS Recommendations are based on a systematic literature reviews, other relevant guidelines and expert opinion. RESULTS Patients receiving dopamine agonists (DA) therapy should be informed about the symptoms and risks of an ICD and should be routinely screened for ICD symptoms. In the presence of an ICD, DA should be reduced or discontinued and psychotherapeutic treatment may be considered. Non-oral therapies (levodopa/carbidopa intestinal gel infusion or deep brain stimulation) may also be an option for appropriate candidates. Psychosis in PD often has a gradual onset. Cognitive and affective disorders, psychiatric and medical comorbidities as well as polypharmacy are risk factors for a psychosis. Non-pharmacological treatments should be implemented as soon as possible and anti-parkinsonian medications should be adjusted/reduced if feasible. For psychosis associated with PD, quetiapine or clozapine should be used on an as-needed basis and for as short a time as is necessary, with safety monitoring. Delirium in PD may be underdiagnosed due to an overlap with chronic neuropsychiatric features of PD. Although transient by definition, delirium in PD can lead to permanent cognitive decline, motor impairment and increased mortality. Management of delirium includes pharmacological and non-pharmacological interventions. CONCLUSION The updated guideline encompasses the evidence-based diagnostic, non-pharmacological and pharmacological management of ICD, psychosis and delirium in PD.
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Affiliation(s)
- Karsten Witt
- Department of Neurology, School of Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Marienstrasse 15, 26121, Oldenburg, Germany.
- University Clinic of Neurology, Evangelical Hospital, Oldenburg, Germany.
- Center of Neurosensory Sciences, University of Oldenburg, Oldenburg, Germany.
| | - Johannes Levin
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- German Center for Neurodegenerative Diseases, Site Munich, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | | | - Alkomiet Hasan
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- DZPG (German Center for Mental Health), Partner Site München/Augsburg, Augsburg, Germany
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20
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Butler CR, Popiolek M, McAllister LA, LaChapelle EA, Kramer M, Beck EM, Mente S, Brodney MA, Brown M, Gilbert A, Helal C, Ogilvie K, Starr J, Uccello D, Grimwood S, Edgerton J, Garst-Orozco J, Kozak R, Lotarski S, Rossi A, Smith D, O'Connor R, Lazzaro J, Steppan C, Steyn SJ. Design and Synthesis of Clinical Candidate PF-06852231 (CVL-231): A Brain Penetrant, Selective, Positive Allosteric Modulator of the M 4 Muscarinic Acetylcholine Receptor. J Med Chem 2024; 67:10831-10847. [PMID: 38888621 DOI: 10.1021/acs.jmedchem.4c00293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
Selective activation of the M4 muscarinic acetylcholine receptor subtype offers a novel strategy for the treatment of psychosis in multiple neurological disorders. Although the development of traditional muscarinic activators has been stymied due to pan-receptor activation, muscarinic receptor subtype selectivity can be achieved through the utilization of a subtype of a unique allosteric site. A major challenge in capitalizing on this allosteric site to date has been achieving a balance of suitable potency and brain penetration. Herein, we describe the design of a brain penetrant series of M4 selective positive allosteric modulators (PAMs), ultimately culminating in the identification of 21 (PF-06852231, now CVL-231/emraclidine), which is under active clinical development as a novel mechanism and approach for the treatment of schizophrenia.
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Affiliation(s)
- Christopher R Butler
- Medicine Design, Medicinal Chemistry, Pfizer Inc., Cambridge, Massachusetts 02139, United States
| | - Michael Popiolek
- Internal Medicine, Pfizer Inc., Cambridge, Massachusetts 02139, United States
| | - Laura A McAllister
- Medicine Design, Medicinal Chemistry, Pfizer Inc., Cambridge, Massachusetts 02139, United States
| | - Erik A LaChapelle
- Medicine Design, Medicinal Chemistry, Pfizer Inc., Groton, Connecticut 06340, United States
| | - Melissa Kramer
- Medicine Design, Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Groton, Connecticut 06340, United States
| | - Elizabeth M Beck
- Medicine Design, Medicinal Chemistry, Pfizer Inc., Cambridge, Massachusetts 02139, United States
| | - Scot Mente
- Medicine Design, Medicinal Chemistry, Pfizer Inc., Cambridge, Massachusetts 02139, United States
| | - Michael A Brodney
- Medicine Design, Medicinal Chemistry, Pfizer Inc., Cambridge, Massachusetts 02139, United States
| | - Matthew Brown
- Medicine Design, Medicinal Chemistry, Pfizer Inc., Groton, Connecticut 06340, United States
| | - Adam Gilbert
- Medicine Design, Medicinal Chemistry, Pfizer Inc., Groton, Connecticut 06340, United States
| | - Chris Helal
- Medicine Design, Medicinal Chemistry, Pfizer Inc., Groton, Connecticut 06340, United States
| | - Kevin Ogilvie
- Medicine Design, Medicinal Chemistry, Pfizer Inc., Groton, Connecticut 06340, United States
| | - Jeremy Starr
- Medicine Design, Medicinal Chemistry, Pfizer Inc., Groton, Connecticut 06340, United States
| | - Daniel Uccello
- Medicine Design, Medicinal Chemistry, Pfizer Inc., Groton, Connecticut 06340, United States
| | - Sarah Grimwood
- Internal Medicine, Pfizer Inc., Cambridge, Massachusetts 02139, United States
| | - Jeremy Edgerton
- Internal Medicine, Pfizer Inc., Cambridge, Massachusetts 02139, United States
| | | | - Rouba Kozak
- Internal Medicine, Pfizer Inc., Cambridge, Massachusetts 02139, United States
| | - Susan Lotarski
- Internal Medicine, Pfizer Inc., Cambridge, Massachusetts 02139, United States
| | - Amie Rossi
- Internal Medicine, Pfizer Inc., Cambridge, Massachusetts 02139, United States
| | - Deborah Smith
- Internal Medicine, Pfizer Inc., Cambridge, Massachusetts 02139, United States
| | - Rebecca O'Connor
- Discovery Sciences, Primary Pharmacology, Pfizer Inc., Groton, Connecticut 06340, United States
| | - John Lazzaro
- Discovery Sciences, Primary Pharmacology, Pfizer Inc., Groton, Connecticut 06340, United States
| | - Claire Steppan
- Discovery Sciences, Primary Pharmacology, Pfizer Inc., Groton, Connecticut 06340, United States
| | - Stefanus J Steyn
- Medicine Design, Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Groton, Connecticut 06340, United States
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21
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Saito A, Alvi S, Valant C, Christopoulos A, Carbone SE, Poole DP. Therapeutic potential of allosteric modulators for the treatment of gastrointestinal motility disorders. Br J Pharmacol 2024; 181:2232-2246. [PMID: 36565295 DOI: 10.1111/bph.16023] [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: 09/21/2022] [Revised: 11/24/2022] [Accepted: 12/09/2022] [Indexed: 12/25/2022] Open
Abstract
Gastrointestinal motility is tightly regulated by the enteric nervous system (ENS). Disruption of coordinated enteric nervous system activity can result in dysmotility. Pharmacological treatment options for dysmotility include targeting of G protein-coupled receptors (GPCRs) expressed by neurons of the enteric nervous system. Current GPCR-targeting drugs for motility disorders bind to the highly conserved endogenous ligand-binding site and promote indiscriminate activation or inhibition of the target receptor throughout the body. This can be associated with significant side-effect liability and a loss of physiological tone. Allosteric modulators of GPCRs bind to a distinct site from the endogenous ligand, which is typically less conserved across multiple receptor subtypes and can modulate endogenous ligand signalling. Allosteric modulation of GPCRs that are important for enteric nervous system function may provide effective relief from motility disorders while limiting side-effects. This review will focus on how allosteric modulators of GPCRs may influence gastrointestinal motility, using 5-hydroxytryptamine (5-HT), acetylcholine (ACh) and opioid receptors as examples. LINKED ARTICLES: This article is part of a themed issue Therapeutic Targeting of G Protein-Coupled Receptors: hot topics from the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists 2021 Virtual Annual Scientific Meeting. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v181.14/issuetoc.
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Affiliation(s)
- Ayame Saito
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Sadia Alvi
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Celine Valant
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Arthur Christopoulos
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Simona E Carbone
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Daniel P Poole
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
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22
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McCutcheon RA, Weber LAE, Nour MM, Cragg SJ, McGuire PM. Psychosis as a disorder of muscarinic signalling: psychopathology and pharmacology. Lancet Psychiatry 2024; 11:554-565. [PMID: 38795721 DOI: 10.1016/s2215-0366(24)00100-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/15/2024] [Accepted: 03/20/2024] [Indexed: 05/28/2024]
Abstract
Dopaminergic receptor antagonism is a crucial component of all licensed treatments for psychosis, and dopamine dysfunction has been central to pathophysiological models of psychotic symptoms. Some clinical trials, however, indicate that drugs that act through muscarinic receptor agonism can also be effective in treating psychosis, potentially implicating muscarinic abnormalities in the pathophysiology of psychosis. Here, we discuss understanding of the central muscarinic system, and we examine preclinical, behavioural, post-mortem, and neuroimaging evidence for its involvement in psychosis. We then consider how altered muscarinic signalling could contribute to the genesis and maintenance of psychotic symptoms, and we review the clinical evidence for muscarinic agents as treatments. Finally, we discuss future research that could clarify the relationship between the muscarinic system and psychotic symptoms.
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Affiliation(s)
- Robert A McCutcheon
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health, Oxford Health NHS Foundation Trust, Oxford, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
| | - Lilian A E Weber
- Department of Psychiatry, University of Oxford, Oxford, UK; Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Matthew M Nour
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health, Oxford Health NHS Foundation Trust, Oxford, UK; Max Planck UCL Centre for Computational Psychiatry and Ageing Research, University College London, London, UK
| | - Stephanie J Cragg
- Department of Physiology, Anatomy and Genetics, Centre for Cellular and Molecular Neurobiology, University of Oxford, UK; Aligning Science Across Parkinson's Collaborative Research Network, Chevy Chase, MD, USA
| | - Philip M McGuire
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health, Oxford Health NHS Foundation Trust, Oxford, UK
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23
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Agid O, Crespo-Facorro B, de Bartolomeis A, Fagiolini A, Howes OD, Seppälä N, Correll CU. Overcoming the barriers to identifying and managing treatment-resistant schizophrenia and to improving access to clozapine: A narrative review and recommendation for clinical practice. Eur Neuropsychopharmacol 2024; 84:35-47. [PMID: 38657339 DOI: 10.1016/j.euroneuro.2024.04.012] [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: 02/05/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/26/2024]
Abstract
Clozapine is the only approved antipsychotic for treatment-resistant schizophrenia (TRS). Although a large body of evidence supports its efficacy and favorable risk-benefit ratio in individuals who have failed two or more antipsychotics, clozapine remains underused. However, variations in clozapine utilization across geographic and clinical settings suggest that it could be possible to improve its use. In this narrative review and expert opinion, we summarized information available in the literature on the mechanisms of action, effectiveness, and potential adverse events of clozapine. We identified barriers leading to discouragement in clozapine prescription internationally, and we proposed practical solutions to overcome each barrier. One of the main obstacles identified to the use of clozapine is the lack of appropriate training for physicians: we highlighted the need to develop specific professional programs to train clinicians, both practicing and in residency, on the relevance and efficacy of clozapine in TRS treatment, initiation, maintenance, and management of potential adverse events. This approach would facilitate physicians to identify eligible patients and offer clozapine as a treatment option in the early stage of the disease. We also noted that increasing awareness of the benefits of clozapine among healthcare professionals, people with TRS, and their caregivers can help promote the use of clozapine. Educational material, such as leaflets or videos, could be developed and distributed to achieve this goal. The information provided in this article may be useful to improve disease burden and support healthcare professionals, patients, and caregivers navigating the complex pathways to TRS management.
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Affiliation(s)
- Ofer Agid
- Centre for Addiction and Mental Health, University of Toronto, Canada
| | - Benedicto Crespo-Facorro
- Department of Psychiatry, School of Medicine, University Hospital Virgen del Rocío-IBiS-CSIC, Sevilla, Spain, Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Sevilla, Spain
| | - Andrea de Bartolomeis
- University of Naples Federico II, Department of Neuroscience, Reproductive Science, and Odontostomatology. Laboratory of Molecular and Translational Psychiatry. Unit of Treatment Resistant Psychosis, Naples, Italy; Staff Unesco Chair at University of Naples Federico II, Italy
| | | | - Oliver D Howes
- IoPPN, King's College London, De Crespigny Park, London, United Kingdom; Institute of Clinical Sciences (ICS), Faculty of Medicine, Imperial College London, Du Cane Road, London, United Kingdom
| | - Niko Seppälä
- Wellbeing Services in Satakunta, Department of Psychiatry, Pori, Finland and Medical Consultant, Viatris, Finland
| | - Christoph U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, New York, United States; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, New York, United States; Charité - Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Augustenburger Platz 1, Berlin 13353, Germany; German Center for Mental Health (DZPG), Partner Site Berlin, Berlin, Germany.
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24
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Lu Y, Hatzipantelis CJ, Langmead CJ, Stewart GD. Molecular insights into orphan G protein-coupled receptors relevant to schizophrenia. Br J Pharmacol 2024; 181:2095-2113. [PMID: 37605621 DOI: 10.1111/bph.16221] [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: 01/11/2023] [Revised: 06/25/2023] [Accepted: 07/23/2023] [Indexed: 08/23/2023] Open
Abstract
Schizophrenia remains a sizable socio-economic burden that continues to be treated with therapeutics based on 70-year old science. All currently approved therapeutics primarily target the dopamine D2 receptor to achieve their efficacy. Whilst dopaminergic dysregulation is a key feature in this disorder, the targeting of dopaminergic machinery has yielded limited efficacy and an appreciable side effect burden. Over the recent decades, numerous drugs that engage non-dopaminergic G protein-coupled receptors (GPCRs) have yielded a promise of efficacy without the deleterious side effect profile, yet none have successfully completed clinical studies and progressed to the market. More recently, there has been increased attention around non-dopaminergic GPCR-targeting drugs, which demonstrated efficacy in some schizophrenia symptom domains. This provides renewed hope that effective schizophrenia treatment may lie outside of the dopaminergic space. Despite the potential for muscarinic receptor- (and other well-characterised GPCR families) targeting drugs to treat schizophrenia, they are often plagued with complications such as lack of receptor subtype selectivity and peripheral on-target side effects. Orphan GPCR studies have opened a new avenue of exploration with many demonstrating schizophrenia-relevant mechanisms and a favourable expression profile, thus offering potential for novel drug development. This review discusses centrally expressed orphan GPCRs: GPR3, GPR6, GPR12, GPR52, GPR85, GPR88 and GPR139 and their relationship to schizophrenia. We review their expression, signalling mechanisms and cellular function, in conjunction with small molecule development and structural insights. We seek to provide a snapshot of the growing evidence and development potential of new classes of schizophrenia therapeutics. LINKED ARTICLES: This article is part of a themed issue Therapeutic Targeting of G Protein-Coupled Receptors: hot topics from the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists 2021 Virtual Annual Scientific Meeting. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v181.14/issuetoc.
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Affiliation(s)
- Yao Lu
- Drug Discovery Biology and Neuroscience & Mental Health Therapeutic Program Area, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
- ARC Centre for Cryo-electron Microscopy of Membrane Proteins, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | | | - Christopher J Langmead
- Drug Discovery Biology and Neuroscience & Mental Health Therapeutic Program Area, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
- ARC Centre for Cryo-electron Microscopy of Membrane Proteins, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
- Neuromedicines Discovery Centre, Monash University, Parkville, Australia
- Phrenix Therapeutics, Parkville, Australia
| | - Gregory D Stewart
- Drug Discovery Biology and Neuroscience & Mental Health Therapeutic Program Area, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
- ARC Centre for Cryo-electron Microscopy of Membrane Proteins, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
- Neuromedicines Discovery Centre, Monash University, Parkville, Australia
- Phrenix Therapeutics, Parkville, Australia
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25
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Nguyen HTM, van der Westhuizen ET, Langmead CJ, Tobin AB, Sexton PM, Christopoulos A, Valant C. Opportunities and challenges for the development of M 1 muscarinic receptor positive allosteric modulators in the treatment for neurocognitive deficits. Br J Pharmacol 2024; 181:2114-2142. [PMID: 36355830 DOI: 10.1111/bph.15982] [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: 07/06/2022] [Revised: 09/22/2022] [Accepted: 10/18/2022] [Indexed: 11/12/2022] Open
Abstract
Targeting allosteric sites of M1 muscarinic acetylcholine receptors (M1 receptors) is a promising strategy to treat neurocognitive disorders, such as Alzheimer's disease and schizophrenia. Indeed, the last two decades have seen an impressive body of work focussing on the design and development of positive allosteric modulators (PAMs) for the M1 receptor. This has led to the identification of a structurally diverse range of highly selective M1 PAMs. In preclinical models, M1 PAMs have shown rescue of cognitive deficits and improvement of endpoints predictive of symptom domains of schizophrenia. Yet, to date only a few M1 PAMs have reached early-stage clinical trials, with many of them failing to progress further due to on-target mediated cholinergic adverse effects that have plagued the development of this class of ligand. This review covers the recent preclinical and clinical studies in the field of M1 receptor drug discovery for the treatment of Alzheimer's disease and schizophrenia, with a specific focus on M1 PAM, highlighting both the undoubted potential but also key challenges for the successful translation of M1 PAMs from bench-side to bedside. LINKED ARTICLES: This article is part of a themed issue Therapeutic Targeting of G Protein-Coupled Receptors: hot topics from the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists 2021 Virtual Annual Scientific Meeting. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v181.14/issuetoc.
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Affiliation(s)
- Huong T M Nguyen
- Drug Discovery Biology, Monash University, Parkville, Melbourne, VIC, Australia
- Department of Biochemistry, Hanoi University of Pharmacy, Hanoi, Vietnam
| | | | - Christopher J Langmead
- Drug Discovery Biology, Monash University, Parkville, Melbourne, VIC, Australia
- Neuromedicines Discovery Centre, Monash University, Parkville, Melbourne, VIC, Australia
- ARC Centre for Cryo-electron Microscopy of Membrane Proteins, Monash University, Parkville, Melbourne, VIC, Australia
| | - Andrew B Tobin
- Centre for Translational Pharmacology, University of Glasgow, Glasgow, UK
| | - Patrick M Sexton
- Drug Discovery Biology, Monash University, Parkville, Melbourne, VIC, Australia
- ARC Centre for Cryo-electron Microscopy of Membrane Proteins, Monash University, Parkville, Melbourne, VIC, Australia
| | - Arthur Christopoulos
- Drug Discovery Biology, Monash University, Parkville, Melbourne, VIC, Australia
- Neuromedicines Discovery Centre, Monash University, Parkville, Melbourne, VIC, Australia
- ARC Centre for Cryo-electron Microscopy of Membrane Proteins, Monash University, Parkville, Melbourne, VIC, Australia
| | - Celine Valant
- Drug Discovery Biology, Monash University, Parkville, Melbourne, VIC, Australia
- Neuromedicines Discovery Centre, Monash University, Parkville, Melbourne, VIC, Australia
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26
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Azargoonjahromi A. Current Findings and Potential Mechanisms of KarXT (Xanomeline-Trospium) in Schizophrenia Treatment. Clin Drug Investig 2024; 44:471-493. [PMID: 38904739 DOI: 10.1007/s40261-024-01377-9] [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: 06/10/2024] [Indexed: 06/22/2024]
Abstract
Standard schizophrenia treatment involves antipsychotic medications that target D2 dopamine receptors. However, these drugs have limitations in addressing all symptoms and can lead to adverse effects such as motor impairments, metabolic effects, sedation, sexual dysfunction, cognitive impairment, and tardive dyskinesia. Recently, KarXT has emerged as a novel drug for schizophrenia. KarXT combines xanomeline, a muscarinic receptor M1 and M4 agonist, with trospium, a nonselective antimuscarinic agent. Of note, xanomeline can readily cross blood-brain barrier (BBB) and, thus, enter into the brain, thereby stimulating muscarinic receptors (M1 and M4). By doing so, xanomeline has been shown to target negative symptoms and potentially improve positive symptoms. Trospium, on the other hand, is not able to cross BBB, thereby not affecting M1 and M4 receptors; instead, it acts as an antimuscarinic agent and, hence, diminishes peripheral activity of muscarinic receptors to minimize side effects probably stemming from xanomeline in other organs. Accordingly, ongoing clinical trials investigating KarXT's efficacy in schizophrenia have demonstrated positive outcomes, including significant improvements in the Positive and Negative Syndrome Scale (PANSS) total score and cognitive function compared with placebo. These findings emphasize the potential of KarXT as a promising treatment for schizophrenia, providing symptom relief while minimizing side effects associated with xanomeline monotherapy. Despite such promising evidence, further research is needed to confirm the efficacy, safety, and tolerability of KarXT in managing schizophrenia. This review article explores the current findings and potential mechanisms of KarXT in the treatment of schizophrenia.
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Affiliation(s)
- Ali Azargoonjahromi
- Shiraz University of Medical Sciences, Janbazan Blv, 14th Alley, Jahrom, Shiraz, 7417773539, Fars, Iran.
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IsHak WW, Meyer A, Freire L, Totlani J, Murphy N, Renteria S, Salem M, Chang T, Abdelsalam R, Khan R, Chandy T, Parrish T, Hirsch D, Patel B, Steiner AJ, Kim S, Hedrick R, Pechnick RN, Danovitch I. Overview of Psychiatric Medications in the Pipeline in Phase III Trials as of June 1, 2024: A Systematic Review. INNOVATIONS IN CLINICAL NEUROSCIENCE 2024; 21:27-47. [PMID: 39329027 PMCID: PMC11424068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
Objective This systematic review provides an overview of psychiatric medications in the late stages of development (Phase III clinical trials) as of June 1, 2024. It details the mechanisms of action, efficacy, dosing, and adverse effects of these medications. Methods We searched the PubMed database for Phase III studies of psychiatric medications published until June 1, 2024, using the keywords "psychiatric" OR "psychopharm*" AND "medic*" OR "pharm*". Our review encompassed medications currently undergoing Phase III clinical trials and those that have completed Phase III but are awaiting approval from the United States Food and Drug Administration (FDA). We independently analyzed the identified studies and reached a consensus on the medications to be included in this systematic review. Results As of June 1, 2024, a total of 89 pipeline drug trials were identified, including nine for schizophrenia, five for bipolar disorders, 25 for depressive disorders, 11 for anxiety disorders, five for post-traumatic stress disorder (PTSD), one for obsessive compulsive disorder (OCD), two for eating disorders, two for sleep-wake disorders, three for sexual dysfunctions, one for substance-related and addictive disorders, 22 for neurocognitive disorders, and three for neurodevelopmental disorders, specifically attention deficit hyperactivity disorder (ADHD). Conclusion The psychiatric medications in the pipeline as of June 1, 2024, demonstrate significant promise in treating psychiatric disorders.
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Affiliation(s)
- Waguih William IsHak
- Drs. IsHak, Murphy, Renteria, Abdelsalam, Khan, Kim, Hedrick, and Danovitch; Mr. Salem; Ms. Chang; Mr. Parrish; and Mr. Hirsch are with Cedars-Sinai Health System in Los Angeles, California
- Dr. IsHak is also with David Geffen School of Medicine at UCLA in Los Angeles, California
| | - Ashley Meyer
- Ms. Meyer is with University of California Irvine, School of Medicine in Irvine, California
| | - Luiza Freire
- Dr. Freire is with Faculdade Pernambucana de Saude in Recife, PE, Brazil
| | - Jayant Totlani
- Drs. Totlani and Pechnick and Ms. Patel are with Western University of Health Sciences in Pomona, California
| | - Nathalie Murphy
- Drs. IsHak, Murphy, Renteria, Abdelsalam, Khan, Kim, Hedrick, and Danovitch; Mr. Salem; Ms. Chang; Mr. Parrish; and Mr. Hirsch are with Cedars-Sinai Health System in Los Angeles, California
| | - Sabrina Renteria
- Drs. IsHak, Murphy, Renteria, Abdelsalam, Khan, Kim, Hedrick, and Danovitch; Mr. Salem; Ms. Chang; Mr. Parrish; and Mr. Hirsch are with Cedars-Sinai Health System in Los Angeles, California
| | - Mohamed Salem
- Drs. IsHak, Murphy, Renteria, Abdelsalam, Khan, Kim, Hedrick, and Danovitch; Mr. Salem; Ms. Chang; Mr. Parrish; and Mr. Hirsch are with Cedars-Sinai Health System in Los Angeles, California
| | - Tiffany Chang
- Drs. IsHak, Murphy, Renteria, Abdelsalam, Khan, Kim, Hedrick, and Danovitch; Mr. Salem; Ms. Chang; Mr. Parrish; and Mr. Hirsch are with Cedars-Sinai Health System in Los Angeles, California
| | - Rasha Abdelsalam
- Drs. IsHak, Murphy, Renteria, Abdelsalam, Khan, Kim, Hedrick, and Danovitch; Mr. Salem; Ms. Chang; Mr. Parrish; and Mr. Hirsch are with Cedars-Sinai Health System in Los Angeles, California
| | - Rida Khan
- Drs. IsHak, Murphy, Renteria, Abdelsalam, Khan, Kim, Hedrick, and Danovitch; Mr. Salem; Ms. Chang; Mr. Parrish; and Mr. Hirsch are with Cedars-Sinai Health System in Los Angeles, California
| | - Thomas Chandy
- Dr. Chandy is with Loma Linda University in Loma Lina, California
| | - Thomas Parrish
- Drs. IsHak, Murphy, Renteria, Abdelsalam, Khan, Kim, Hedrick, and Danovitch; Mr. Salem; Ms. Chang; Mr. Parrish; and Mr. Hirsch are with Cedars-Sinai Health System in Los Angeles, California
| | - Drew Hirsch
- Drs. IsHak, Murphy, Renteria, Abdelsalam, Khan, Kim, Hedrick, and Danovitch; Mr. Salem; Ms. Chang; Mr. Parrish; and Mr. Hirsch are with Cedars-Sinai Health System in Los Angeles, California
| | - Bhumika Patel
- Drs. Totlani and Pechnick and Ms. Patel are with Western University of Health Sciences in Pomona, California
| | - Alexander J Steiner
- Dr. Steiner is with Executive Mental Health, Inc. in Los Angeles, California
| | - Sarah Kim
- Drs. IsHak, Murphy, Renteria, Abdelsalam, Khan, Kim, Hedrick, and Danovitch; Mr. Salem; Ms. Chang; Mr. Parrish; and Mr. Hirsch are with Cedars-Sinai Health System in Los Angeles, California
| | - Rebecca Hedrick
- Drs. IsHak, Murphy, Renteria, Abdelsalam, Khan, Kim, Hedrick, and Danovitch; Mr. Salem; Ms. Chang; Mr. Parrish; and Mr. Hirsch are with Cedars-Sinai Health System in Los Angeles, California
| | - Robert N Pechnick
- Drs. Totlani and Pechnick and Ms. Patel are with Western University of Health Sciences in Pomona, California
| | - Itai Danovitch
- Drs. IsHak, Murphy, Renteria, Abdelsalam, Khan, Kim, Hedrick, and Danovitch; Mr. Salem; Ms. Chang; Mr. Parrish; and Mr. Hirsch are with Cedars-Sinai Health System in Los Angeles, California
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Lawn T, Giacomel A, Martins D, Veronese M, Howard M, Turkheimer FE, Dipasquale O. Normative modelling of molecular-based functional circuits captures clinical heterogeneity transdiagnostically in psychiatric patients. Commun Biol 2024; 7:689. [PMID: 38839931 PMCID: PMC11153627 DOI: 10.1038/s42003-024-06391-3] [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: 12/01/2023] [Accepted: 05/27/2024] [Indexed: 06/07/2024] Open
Abstract
Advanced methods such as REACT have allowed the integration of fMRI with the brain's receptor landscape, providing novel insights transcending the multiscale organisation of the brain. Similarly, normative modelling has allowed translational neuroscience to move beyond group-average differences and characterise deviations from health at an individual level. Here, we bring these methods together for the first time. We used REACT to create functional networks enriched with the main modulatory, inhibitory, and excitatory neurotransmitter systems and generated normative models of these networks to capture functional connectivity deviations in patients with schizophrenia, bipolar disorder (BPD), and ADHD. Substantial overlap was seen in symptomatology and deviations from normality across groups, but these could be mapped into a common space linking constellations of symptoms through to underlying neurobiology transdiagnostically. This work provides impetus for developing novel biomarkers that characterise molecular- and systems-level dysfunction at the individual level, facilitating the transition towards mechanistically targeted treatments.
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Affiliation(s)
- Timothy Lawn
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Alessio Giacomel
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Daniel Martins
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Division of Adult Psychiatry, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
| | - Mattia Veronese
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Department of Information Engineering, University of Padua, Padua, Italy
| | - Matthew Howard
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Federico E Turkheimer
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ottavia Dipasquale
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
- Department of Research & Development Advanced Applications, Olea Medical, La Ciotat, France.
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McKenna A, Tice JA, Whittington MD, Wright AC, Richardson M, Raymond FR, Pearson SD, Rind DM, Agboola F. KarXT for schizophrenia-effectiveness and value: A summary from the Institute for Clinical and Economic Review's New England Comparative Effectiveness Public Advisory Council. J Manag Care Spec Pharm 2024; 30:624-628. [PMID: 38824622 PMCID: PMC11144989 DOI: 10.18553/jmcp.2024.30.6.624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Affiliation(s)
- Avery McKenna
- Institute for Clinical and Economic Review, Boston, MA
| | - Jeffrey A. Tice
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco
| | | | | | | | | | | | - David M. Rind
- Institute for Clinical and Economic Review, Boston, MA
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30
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Sutera N. Xanomeline-Trospium in schizophrenia: A detailed review and comparison with the Institute for Clinical and Economic Review's analysis. J Manag Care Spec Pharm 2024; 30:629-632. [PMID: 38824628 PMCID: PMC11144999 DOI: 10.18553/jmcp.2024.30.6.629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Affiliation(s)
- Nathan Sutera
- Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha
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31
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Strube W, Wagner E, Luykx JJ, Hasan A. A review on side effect management of second-generation antipsychotics to treat schizophrenia: a drug safety perspective. Expert Opin Drug Saf 2024; 23:715-729. [PMID: 38676922 DOI: 10.1080/14740338.2024.2348561] [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: 11/09/2023] [Accepted: 04/24/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Effective side effects management present a challenge in antipsychotic treatment with second-generation antipsychotics (SGAs). In recent years, most of the commonly used SGAs, except for clozapine, have been shown to differ only slightly in their effectiveness, but considerably regarding perceived side effects, safety profiles, and compatibility to preexisting medical conditions. AREAS COVERED The current state of available evidence on side-effect management in SGA treatment of patients with schizophrenia spectrum disorders (SSD) is reviewed. In addition, current guideline recommendations are summarized, highlighting evidence gaps. EXPERT OPINION SGA safety and side effects needs to be considered in treatment planning. Shared decision-making assistants (SDMA) can support patients, practitioners and relatives to orient their decisions toward avoiding side effects relevant to patients' adherence. Alongside general measures like psychosocial and psychotherapeutic care, switching to better tolerated SGAs can be considered a relatively safe strategy. By contrast, novel meta-analytical evidence emphasizes that dose reduction of SGAs can statistically increase the risk of relapse and other unfavorable outcomes. Further, depending on the type and severity of SGA-related side effects, specific treatments can be used to alleviate induced side effects (e.g. add-on metformin to reduce weight-gain). Finally, discontinuation should be reserved for acute emergencies.
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Affiliation(s)
- Wolfgang Strube
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Augsburg, Augsburg, Germany
| | - Elias Wagner
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Augsburg, Augsburg, Germany
- Evidence-based psychiatry and psychotherapy, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Jurjen J Luykx
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands
- Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
- Outpatient second opinion clinic, GGNet Mental Health, Warnsveld, The Netherlands
| | - Alkomiet Hasan
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Augsburg, Augsburg, Germany
- DZPG (German Center for Mental Health), partner site München/Augsburg, Augsburg, Germany
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32
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Chan SKW, Pang TSW, Tsui HKH, Suen YN, Yan WC, Tsui CF, Poon LT, Chan CWH, Lo A, Cheung KM, Hui CLM, Chang WC, Lee EHM, Chen EYH, Honer WG. Modeling the effects of treatment resistance and anticholinergic burden on cognitive function domains in patients with schizophrenia. Psychiatry Res 2024; 337:115985. [PMID: 38820652 DOI: 10.1016/j.psychres.2024.115985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 05/16/2024] [Accepted: 05/26/2024] [Indexed: 06/02/2024]
Abstract
The contribution of anticholinergic burden to cognitive function in patients with treatment resistant schizophrenia (TRS) is uncertain. This case-control study aims to comprehensively examine the association between treatment resistance and cognitive functions and the contribution of anticholinergic burden in patients with schizophrenia. Anticholinergic burden of all patients was calculated using the Anticholinergic Cognitive Burden scale. Exploratory Factor Analysis of 11 cognitive assessments identified four cognitive domains: verbal memory, attention and general cognitive functions, visual memory and processing speed, and executive function. Two structural equation models (SEM) examined the relationship of TRS and these cognitive functions with, and without considering anticholinergic burden. A total of 288 participants were included (TRS N=111, non-TRS N=177). Patients with TRS performed poorer than the non-TRS group only in the executive function domain. Anticholinergic burden contributed significantly to the attention and general cognitive functions, visual memory and processing speed, and executive function. The impact of TRS on executive function was no longer significant after adding anticholinergic burden to the SEM. Results suggested that anticholinergic burden contributes to a wide range of cognitive function impairment in patients with schizophrenia and is likely to be part of the apparent differences of cognitive function between TRS and non-TRS.
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Affiliation(s)
- Sherry Kit Wa Chan
- Department of Psychiatry, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR; The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR.
| | - Tiffanie Sze Wing Pang
- Department of Psychiatry, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Harry Kam Hung Tsui
- Department of Psychiatry, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Yi Nam Suen
- Department of Psychiatry, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Wai Ching Yan
- Department of Psychiatry, Kowloon Hospital, Hong Kong SAR
| | - Chi Fong Tsui
- Department of Psychiatry, Kowloon Hospital, Hong Kong SAR
| | - Lap-Tak Poon
- Department of Psychiatry, United Christian Hospital. Hong Kong SAR
| | | | - Alison Lo
- Department of Psychiatry, Kwai Chung Hospital, Hong Kong SAR
| | | | - Christy Lai Ming Hui
- Department of Psychiatry, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Wing Chung Chang
- Department of Psychiatry, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR; The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR
| | - Edwin Ho Ming Lee
- Department of Psychiatry, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Eric Yu Hai Chen
- Department of Psychiatry, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
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Metz CN, Brines M, Pavlov VA. Bridging cholinergic signalling and inflammation in schizophrenia. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2024; 10:51. [PMID: 38734678 PMCID: PMC11088617 DOI: 10.1038/s41537-024-00472-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024]
Affiliation(s)
- Christine N Metz
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, 11550, USA
- Elmezzi Graduate School of Molecular Medicine, 350 Community Drive, Manhasset, NY, 11030, USA
| | - Michael Brines
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA
| | - Valentin A Pavlov
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA.
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, 11550, USA.
- Elmezzi Graduate School of Molecular Medicine, 350 Community Drive, Manhasset, NY, 11030, USA.
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Vasiliu O, Budeanu B, Cătănescu MȘ. The New Horizon of Antipsychotics beyond the Classic Dopaminergic Hypothesis-The Case of the Xanomeline-Trospium Combination: A Systematic Review. Pharmaceuticals (Basel) 2024; 17:610. [PMID: 38794180 PMCID: PMC11124398 DOI: 10.3390/ph17050610] [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: 04/15/2024] [Revised: 05/01/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Although the dopamine hypothesis of schizophrenia explains the effects of all the available antipsychotics in clinical use, there is an increasing need for developing new drugs for the treatment of the positive, negative, and cognitive symptoms of chronic psychoses. Xanomeline-trospium (KarXT) is a drug combination that is based on the essential role played by acetylcholine in the regulation of cognitive processes and the interactions between this neurotransmitter and other signaling pathways in the central nervous system, with a potential role in the onset of schizophrenia, Alzheimer's disease, and substance use disorders. A systematic literature review that included four electronic databases (PubMed, Cochrane, Clarivate/Web of Science, and Google Scholar) and the US National Library of Medicine database for clinical trials detected twenty-one sources referring to fourteen studies focused on KarXT, out of which only four have available results. Based on the results of these trials, the short-term efficacy and tolerability of xanomeline-trospium are good, but more data are needed before this drug combination may be recommended for clinical use. However, on a theoretical level, the exploration of KarXT is useful for increasing the interest of researchers in finding new, non-dopaminergic, antipsychotics that could be used either as monotherapy or as add-on drugs.
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Affiliation(s)
- Octavian Vasiliu
- Department of Psychiatry, “Dr. Carol Davila” University Emergency Central Military Hospital, 010816 Bucharest, Romania
| | - Beatrice Budeanu
- Faculty of Medicine, « Carol Davila » University of Medicine and Pharmacy, 050474 Bucharest, Romania; (B.B.); (M.-Ș.C.)
| | - Mihai-Ștefan Cătănescu
- Faculty of Medicine, « Carol Davila » University of Medicine and Pharmacy, 050474 Bucharest, Romania; (B.B.); (M.-Ș.C.)
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Kotov R, Carpenter WT, Cicero DC, Correll CU, Martin EA, Young JW, Zald DH, Jonas KG. Psychosis superspectrum II: neurobiology, treatment, and implications. Mol Psychiatry 2024; 29:1293-1309. [PMID: 38351173 DOI: 10.1038/s41380-024-02410-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 12/24/2023] [Accepted: 01/04/2024] [Indexed: 02/16/2024]
Abstract
Alternatives to traditional categorical diagnoses have been proposed to improve the validity and utility of psychiatric nosology. This paper continues the companion review of an alternative model, the psychosis superspectrum of the Hierarchical Taxonomy of Psychopathology (HiTOP). The superspectrum model aims to describe psychosis-related psychopathology according to data on distributions and associations among signs and symptoms. The superspectrum includes psychoticism and detachment spectra as well as narrow subdimensions within them. Auxiliary domains of cognitive deficit and functional impairment complete the psychopathology profile. The current paper reviews evidence on this model from neurobiology, treatment response, clinical utility, and measure development. Neurobiology research suggests that psychopathology included in the superspectrum shows similar patterns of neural alterations. Treatment response often mirrors the hierarchy of the superspectrum with some treatments being efficacious for psychoticism, others for detachment, and others for a specific subdimension. Compared to traditional diagnostic systems, the quantitative nosology shows an approximately 2-fold increase in reliability, explanatory power, and prognostic accuracy. Clinicians consistently report that the quantitative nosology has more utility than traditional diagnoses, but studies of patients with frank psychosis are currently lacking. Validated measures are available to implement the superspectrum model in practice. The dimensional conceptualization of psychosis-related psychopathology has implications for research, clinical practice, and public health programs. For example, it encourages use of the cohort study design (rather than case-control), transdiagnostic treatment strategies, and selective prevention based on subclinical symptoms. These approaches are already used in the field, and the superspectrum provides further impetus and guidance for their implementation. Existing knowledge on this model is substantial, but significant gaps remain. We identify outstanding questions and propose testable hypotheses to guide further research. Overall, we predict that the more informative, reliable, and valid characterization of psychopathology offered by the superspectrum model will facilitate progress in research and clinical care.
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Affiliation(s)
- Roman Kotov
- Department of Psychiatry and Behavioral Health, Stony Brook University, Stony Brook, NY, USA.
| | | | - David C Cicero
- Department of Psychology, University of North Texas, Denton, TX, USA
| | - Christoph U Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Child and Adolescent Psychiatry, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Elizabeth A Martin
- Department of Psychological Science, University of California, Irvine, Irvine, CA, USA
| | - Jared W Young
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA
| | - David H Zald
- Rutgers University, The State University of New Jersey, New Brunswick, NJ, USA
| | - Katherine G Jonas
- Department of Psychiatry and Behavioral Health, Stony Brook University, Stony Brook, NY, USA
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36
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Fu L, Luo Y, Niu L, Lin Y, Chen X, Zhang J, Tang W, Chen Y, Jiao Y. M 1/M 4 receptors as potential therapeutic treatments for schizophrenia: A comprehensive study. Bioorg Med Chem 2024; 105:117728. [PMID: 38640587 DOI: 10.1016/j.bmc.2024.117728] [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: 02/23/2024] [Revised: 04/03/2024] [Accepted: 04/15/2024] [Indexed: 04/21/2024]
Abstract
Muscarinic acetylcholine receptors (mAChRs) play a significant role in the pathophysiology of schizophrenia. Although activating mAChRs holds potential in addressing the full range of schizophrenia symptoms, clinical application of many non-selective mAChR agonists in cognitive deficits, positive and negative symptoms is hindered by peripheral side effects (gastrointestinal disturbances and cardiovascular effects) and dosage restrictions. Ligands binding to the allosteric sites of mAChRs, particularly the M1 and M4 subtypes, demonstrate activity in improving cognitive function and amelioration of positive and negative symptoms associated with schizophrenia, enhancing our understanding of schizophrenia. The article aims to critically examine current design concepts and clinical advancements in synthesizing and designing small molecules targeting M1/M4, providing theoretical insights and empirical support for future research in this field.
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Affiliation(s)
- Lingsheng Fu
- School of Science, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, PR China
| | - Yi Luo
- School of Science, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, PR China
| | - Longyan Niu
- School of Science, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, PR China
| | - Ying Lin
- School of Science, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, PR China
| | - Xingru Chen
- School of Science, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, PR China
| | - Junhao Zhang
- School of Science, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, PR China
| | - Weifang Tang
- School of Science, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, PR China..
| | - Yadong Chen
- School of Science, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, PR China..
| | - Yu Jiao
- School of Science, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, PR China..
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Selman CJ, Lee KJ, Ferguson KN, Whitehead CL, Manley BJ, Mahar RK. Statistical analyses of ordinal outcomes in randomised controlled trials: a scoping review. Trials 2024; 25:241. [PMID: 38582924 PMCID: PMC10998402 DOI: 10.1186/s13063-024-08072-2] [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: 07/02/2023] [Accepted: 03/22/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) aim to estimate the causal effect of one or more interventions relative to a control. One type of outcome that can be of interest in an RCT is an ordinal outcome, which is useful to answer clinical questions regarding complex and evolving patient states. The target parameter of interest for an ordinal outcome depends on the research question and the assumptions the analyst is willing to make. This review aimed to provide an overview of how ordinal outcomes have been used and analysed in RCTs. METHODS The review included RCTs with an ordinal primary or secondary outcome published between 2017 and 2022 in four highly ranked medical journals (the British Medical Journal, New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association) identified through PubMed. Details regarding the study setting, design, the target parameter, and statistical methods used to analyse the ordinal outcome were extracted. RESULTS The search identified 309 studies, of which 144 were eligible for inclusion. The most used target parameter was an odds ratio, reported in 78 (54%) studies. The ordinal outcome was dichotomised for analysis in 47 ( 33 % ) studies, and the most common statistical model used to analyse the ordinal outcome on the full ordinal scale was the proportional odds model (64 [ 44 % ] studies). Notably, 86 (60%) studies did not explicitly check or describe the robustness of the assumptions for the statistical method(s) used. CONCLUSIONS The results of this review indicate that in RCTs that use an ordinal outcome, there is variation in the target parameter and the analytical approaches used, with many dichotomising the ordinal outcome. Few studies provided assurance regarding the appropriateness of the assumptions and methods used to analyse the ordinal outcome. More guidance is needed to improve the transparent reporting of the analysis of ordinal outcomes in future trials.
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Affiliation(s)
- Chris J Selman
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia.
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Kristin N Ferguson
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Clare L Whitehead
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Newborn Research, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Robert K Mahar
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, 3052, Australia
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Direktor M, Gass P, Inta D. Understanding the Therapeutic Action of Antipsychotics: From Molecular to Cellular Targets With Focus on the Islands of Calleja. Int J Neuropsychopharmacol 2024; 27:pyae018. [PMID: 38629703 PMCID: PMC11046981 DOI: 10.1093/ijnp/pyae018] [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: 11/22/2023] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
The understanding of the pathophysiology of schizophrenia as well as the mechanisms of action of antipsychotic drugs remains a challenge for psychiatry. The demonstration of the therapeutic efficacy of several new atypical drugs targeting multiple different receptors, apart from the classical dopamine D2 receptor as initially postulated unique antipsychotic target, complicated even more conceptualization efforts. Here we discuss results suggesting a main role of the islands of Calleja, still poorly studied GABAergic granule cell clusters in the ventral striatum, as cellular targets of several innovative atypical antipsychotics (clozapine, cariprazine, and xanomeline/emraclidine) effective in treating also negative symptoms of schizophrenia. We will emphasize the potential role of dopamine D3 and M4 muscarinic acetylcholine receptor expressed at the highest level by the islands of Calleja, as well as their involvement in schizophrenia-associated neurocircuitries. Finally, we will discuss the implications of new data showing ongoing adult neurogenesis of the islands of Calleja as a very promising antipsychotic target linking long-life neurodevelopment and dopaminergic dysfunction in the striatum.
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Affiliation(s)
- Merve Direktor
- RG Animal Models in Psychiatry, Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Germany (Mrs Direktor and Dr Gass)
| | - Peter Gass
- RG Animal Models in Psychiatry, Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Germany (Mrs Direktor and Dr Gass)
| | - Dragos Inta
- Translational Psychiatry, Department of Community Health , and Food Research and Innovation Center (FRIC)
- University of Fribourg, Switzerland
- Department of Biomedicine, University of Basel, Switzerland
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Vanegas-Arroyave N, Caroff SN, Citrome L, Crasta J, McIntyre RS, Meyer JM, Patel A, Smith JM, Farahmand K, Manahan R, Lundt L, Cicero SA. An Evidence-Based Update on Anticholinergic Use for Drug-Induced Movement Disorders. CNS Drugs 2024; 38:239-254. [PMID: 38502289 PMCID: PMC10980662 DOI: 10.1007/s40263-024-01078-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 03/21/2024]
Abstract
Drug-induced movement disorders (DIMDs) are associated with use of dopamine receptor blocking agents (DRBAs), including antipsychotics. The most common forms are drug-induced parkinsonism (DIP), dystonia, akathisia, and tardive dyskinesia (TD). Although rare, neuroleptic malignant syndrome (NMS) is a potentially life-threatening consequence of DRBA exposure. Recommendations for anticholinergic use in patients with DIMDs were developed on the basis of a roundtable discussion with healthcare professionals with extensive expertise in DIMD management, along with a comprehensive literature review. The roundtable agreed that "extrapyramidal symptoms" is a non-specific term that encompasses a range of abnormal movements. As such, it contributes to a misconception that all DIMDs can be treated in the same way, potentially leading to the misuse and overprescribing of anticholinergics. DIMDs are neurobiologically and clinically distinct, with different treatment paradigms and varying levels of evidence for anticholinergic use. Whereas evidence indicates anticholinergics can be effective for DIP and dystonia, they are not recommended for TD, akathisia, or NMS; nor are they supported for preventing DIMDs except in individuals at high risk for acute dystonia. Anticholinergics may induce serious peripheral adverse effects (e.g., urinary retention) and central effects (e.g., impaired cognition), all of which can be highly concerning especially in older adults. Appropriate use of anticholinergics therefore requires careful consideration of the evidence for efficacy (e.g., supportive for DIP but not TD) and the risks for serious adverse events. If used, anticholinergic medications should be prescribed at the lowest effective dose and for limited periods of time. When discontinued, they should be tapered gradually.
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Affiliation(s)
- Nora Vanegas-Arroyave
- Department of Neurology, Baylor College of Medicine, 7200 Cambridge Street, Suite 9A, Houston, TX, 77030, USA.
| | - Stanley N Caroff
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Roger S McIntyre
- Department of Psychiatry and Pharmacology, University of Toronto, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Jonathan M Meyer
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Amita Patel
- Dayton Psychiatric Associations, Dayton, OH, USA
- Joint Township District Memorial Hospital, St. Marys, OH, USA
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40
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Castle D, Copolov D, Singh B, Bastiampillai T. Seven decades of antipsychotic drugs: Why is the life of Australians with schizophrenia still so suboptimal? Aust N Z J Psychiatry 2024; 58:201-206. [PMID: 38130026 DOI: 10.1177/00048674231209840] [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] [Indexed: 12/23/2023]
Abstract
The advent of dopamine (D2) receptor-blocking medications over 70 years ago, ushered in a new era of biological treatment for schizophrenia. However, we argue that little subsequent progress has been made in translating this into fulfilled and fulfilling lives for people with schizophrenia. This Viewpoint asks why this is the case, and suggests ways forward for capitalising on extant and emerging new treatments for psychotic disorders, to the betterment of the lives of people living with schizophrenia.
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Affiliation(s)
- David Castle
- Department of Psychiatry, University of Tasmania, Hobart, TAS, Australia
| | - David Copolov
- Department of Psychiatry, Monash University, Clayton, VIC, Australia
| | - Bruce Singh
- Department of Psychiatry, The Melbourne Clinic, The University of Melbourne, Richmond, VIC, Australia
| | - Tarun Bastiampillai
- Department of Psychiatry, Monash University, Clayton, VIC, Australia
- Department of Psychiatry, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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41
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Leber A, Ramachandra R, Ceban F, Kwan ATH, Rhee TG, Wu J, Cao B, Jawad MY, Teopiz KM, Ho R, Le GH, Ramachandra D, McIntyre RS. Efficacy, safety, and tolerability of xanomeline for schizophrenia spectrum disorders: a systematic review. Expert Opin Pharmacother 2024; 25:467-476. [PMID: 38515004 DOI: 10.1080/14656566.2024.2334424] [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: 01/19/2024] [Accepted: 03/20/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION We systematically reviewed extant studies evaluating the efficacy and tolerability of xanomeline and xanomeline-trospium (KarXT) for treatment of adults with schizophrenia. METHODS In accordance with PRISMA guidelines, articles were systematically searched for in databases and clinical trial registries. RESULTS A total of 4 preclinical trials and 3 randomized controlled trials (RCTs) were included in this review. A 4-week RCT observed a difference of 24.0 points (SD 21.0) in the Positive and Negative Syndrome Scale (PANSS) total score between xanomeline and placebo groups (p = 0.039). A 5-week RCT observed PANSS total score changes from baseline to week 5, including -17.4 and -5.9 points in KarXT and placebo groups, respectively (LSMD -11.6 points; 95% CI -16.1 to -7.1; p < 0.001; d = 0.75). Another 5-week RCT observed PANSS total score changes from baseline to week 5, including -21.2 (SE 1.7) and -11.6 (SE 1.6) points in KarXT and placebo groups, respectively (LSMD -9.6; 95% CI -13.9 to -5.2; p < 0.0001; d = 0.61). Side effects include constipation, nausea, vomiting, dyspepsia, and dry mouth. CONCLUSION KarXT offers an innovative non-D2 blocking approach, representing a promising treatment avenue for schizophrenia.
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Affiliation(s)
- Alexia Leber
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
- Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada
| | - Ranuk Ramachandra
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
- Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada
| | - Felicia Ceban
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
- Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Angela T H Kwan
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
- Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Jie Wu
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Bing Cao
- School of Psychology and Key Laboratory of Cognition and Personality (Ministry of Education), Southwest University, Chongqing, P. R. China
| | - Muhammad Youshay Jawad
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
- Institute for Mental Health Policy Research, Centre for Addictions and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry and Behavioral Health, Penn State University College of Medicine, Hershey, PA, USA
| | - Kayla M Teopiz
- Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore
| | - Gia Han Le
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
- Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Diluk Ramachandra
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
- Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Palma JA. Muscarinic control of cardiovascular function in humans: a review of current clinical evidence. Clin Auton Res 2024; 34:31-44. [PMID: 38305989 PMCID: PMC10994193 DOI: 10.1007/s10286-024-01016-5] [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: 10/10/2023] [Accepted: 01/11/2024] [Indexed: 02/03/2024]
Abstract
PURPOSE To review the available evidence on the impact of muscarinic receptor modulation on cardiovascular control in humans. METHODS In this narrative Review we summarize data on cardiovascular endpoints from clinical trials of novel subtype-selective or quasi-selective muscarinic modulators, mostly PAMs, performed in the last decade. We also review the cardiovascular phenotype in recently described human genetic and autoimmune disorders affecting muscarinic receptors. RESULTS Recent advancements in the development of compounds that selectively target muscarinic acetylcholine receptors are expanding our knowledge about the physiological function of each muscarinic receptor subtype (M1, M2, M3, M4, M5). Among these novel compounds, positive allosteric modulators (PAMs) have emerged as the preferred therapeutic to regulate muscarinic receptor subtype function. Many muscarinic allosteric and orthosteric modulators (including but not limited to xanomeline-trospium and emraclidine) are now in clinical development and approaching regulatory approval for multiple indications, including the treatment of cognitive and psychiatric symptoms in patients with schizophrenia as well as Alzheimer's disease and other dementias. The results of these clinical trials provide an opportunity to understand the influence of muscarinic modulation on cardiovascular autonomic control in humans. While the results and the impact of each of these therapies on heart rate and blood pressure control have been variable, in part because the clinical trials were not specifically designed to measure cardiovascular endpoints, the emerging data is valuable to elucidate the relative cardiovascular contributions of each muscarinic receptor subtype. CONCLUSION Understanding the muscarinic control of cardiovascular function is of paramount importance and may contribute to the development of novel therapeutic strategies for treating cardiovascular disease.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, NYU Dysautonomia Center, New York University School of Medicine, 530 First Av, Suite 9Q, New York, 10016, USA.
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Tandon R, Nasrallah H, Akbarian S, Carpenter WT, DeLisi LE, Gaebel W, Green MF, Gur RE, Heckers S, Kane JM, Malaspina D, Meyer-Lindenberg A, Murray R, Owen M, Smoller JW, Yassin W, Keshavan M. The schizophrenia syndrome, circa 2024: What we know and how that informs its nature. Schizophr Res 2024; 264:1-28. [PMID: 38086109 DOI: 10.1016/j.schres.2023.11.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/23/2023] [Accepted: 11/29/2023] [Indexed: 03/01/2024]
Abstract
With new data about different aspects of schizophrenia being continually generated, it becomes necessary to periodically revisit exactly what we know. Along with a need to review what we currently know about schizophrenia, there is an equal imperative to evaluate the construct itself. With these objectives, we undertook an iterative, multi-phase process involving fifty international experts in the field, with each step building on learnings from the prior one. This review assembles currently established findings about schizophrenia (construct, etiology, pathophysiology, clinical expression, treatment) and posits what they reveal about its nature. Schizophrenia is a heritable, complex, multi-dimensional syndrome with varying degrees of psychotic, negative, cognitive, mood, and motor manifestations. The illness exhibits a remitting and relapsing course, with varying degrees of recovery among affected individuals with most experiencing significant social and functional impairment. Genetic risk factors likely include thousands of common genetic variants that each have a small impact on an individual's risk and a plethora of rare gene variants that have a larger individual impact on risk. Their biological effects are concentrated in the brain and many of the same variants also increase the risk of other psychiatric disorders such as bipolar disorder, autism, and other neurodevelopmental conditions. Environmental risk factors include but are not limited to urban residence in childhood, migration, older paternal age at birth, cannabis use, childhood trauma, antenatal maternal infection, and perinatal hypoxia. Structural, functional, and neurochemical brain alterations implicate multiple regions and functional circuits. Dopamine D-2 receptor antagonists and partial agonists improve psychotic symptoms and reduce risk of relapse. Certain psychological and psychosocial interventions are beneficial. Early intervention can reduce treatment delay and improve outcomes. Schizophrenia is increasingly considered to be a heterogeneous syndrome and not a singular disease entity. There is no necessary or sufficient etiology, pathology, set of clinical features, or treatment that fully circumscribes this syndrome. A single, common pathophysiological pathway appears unlikely. The boundaries of schizophrenia remain fuzzy, suggesting the absence of a categorical fit and need to reconceptualize it as a broader, multi-dimensional and/or spectrum construct.
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Affiliation(s)
- Rajiv Tandon
- Department of Psychiatry, WMU Homer Stryker School of Medicine, Kalamazoo, MI 49008, United States of America.
| | - Henry Nasrallah
- Department of Psychiatry, University of Cincinnati College of Medicine Cincinnati, OH 45267, United States of America
| | - Schahram Akbarian
- Department of Psychiatry, Icahn School of Medicine at Mt. Sinai, New York, NY 10029, United States of America
| | - William T Carpenter
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, United States of America
| | - Lynn E DeLisi
- Department of Psychiatry, Cambridge Health Alliance and Harvard Medical School, Cambridge, MA 02139, United States of America
| | - Wolfgang Gaebel
- Department of Psychiatry and Psychotherapy, LVR-Klinikum Dusseldorf, Heinrich-Heine University, Dusseldorf, Germany
| | - Michael F Green
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute of Neuroscience and Human Behavior, UCLA, Los Angeles, CA 90024, United States of America; Greater Los Angeles Veterans' Administration Healthcare System, United States of America
| | - Raquel E Gur
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States of America
| | - Stephan Heckers
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN 37232, United States of America
| | - John M Kane
- Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Glen Oaks, NY 11004, United States of America
| | - Dolores Malaspina
- Department of Psychiatry, Neuroscience, Genetics, and Genomics, Icahn School of Medicine at Mt. Sinai, New York, NY 10029, United States of America
| | - Andreas Meyer-Lindenberg
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Mannhein/Heidelberg University, Mannheim, Germany
| | - Robin Murray
- Institute of Psychiatry, Psychology, and Neuroscience, Kings College, London, UK
| | - Michael Owen
- Centre for Neuropsychiatric Genetics and Genomics, and Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Jordan W Smoller
- Center for Precision Psychiatry, Department of Psychiatry, Psychiatric and Neurodevelopmental Unit, Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States of America
| | - Walid Yassin
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, United States of America
| | - Matcheri Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, United States of America
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44
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Lawrence RE, Appelbaum PS. Ethics in placebo-controlled, acute treatment trials in schizophrenia: Two rival ethical frameworks. Schizophr Res 2024; 264:372-377. [PMID: 38237358 DOI: 10.1016/j.schres.2024.01.018] [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: 09/08/2021] [Revised: 01/05/2024] [Accepted: 01/06/2024] [Indexed: 03/01/2024]
Abstract
Placebo-controlled, acute treatment trials in schizophrenia enroll acutely symptomatic persons, randomize them to receive placebo or antipsychotic medication for several weeks, and evaluate whether symptoms improve. These trials can have scientific benefits, especially when they test drugs with novel mechanisms of action. However, the use of placebo is ethically problematic inasmuch as standard treatment is withheld and participants are subjected to prolonged psychotic symptoms and associated risks. We propose that both deontological (duty-based) and utilitarian analyses are relevant, that it may be impossible to satisfy the ideals of both frameworks, and that researchers who conduct these trials will unavoidably encounter ethical tension and criticism even when they give careful attention to ethical aspects of study design.
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Affiliation(s)
- Ryan E Lawrence
- Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, United States of America.
| | - Paul S Appelbaum
- Center for Law, Ethics, and Psychiatry, Department of Psychiatry, Columbia University Vagelos College of Physicians & Surgeons and New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States of America.
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45
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Sohal VS. Neurobiology of schizophrenia. Curr Opin Neurobiol 2024; 84:102820. [PMID: 38091860 DOI: 10.1016/j.conb.2023.102820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/23/2023] [Accepted: 11/19/2023] [Indexed: 02/18/2024]
Affiliation(s)
- Vikaas S Sohal
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, Kavli Institute for Fundamental Neuroscience, Center for Integrative Neuroscience, University of California, San Francisco, San Francisco, CA 94143-0444, USA.
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Nunes EJ, Addy NA, Conn PJ, Foster DJ. Targeting the Actions of Muscarinic Receptors on Dopamine Systems: New Strategies for Treating Neuropsychiatric Disorders. Annu Rev Pharmacol Toxicol 2024; 64:277-289. [PMID: 37552895 PMCID: PMC10841102 DOI: 10.1146/annurev-pharmtox-051921-023858] [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] [Indexed: 08/10/2023]
Abstract
Cholinergic regulation of dopamine (DA) signaling has significant implications for numerous disorders, including schizophrenia, substance use disorders, and mood-related disorders. The activity of midbrain DA neurons and DA release patterns in terminal regions are tightly regulated by cholinergic neurons found in both the striatum and the hindbrain. These cholinergic neurons can modulate DA circuitry by activating numerous receptors, including muscarinic acetylcholine receptor (mAChR) subtypes. This review specifically focuses on the complex role of M2, M4, and M5 mAChR subtypes in regulating DA neuron activity and DA release and the potential clinical implications of targeting these mAChR subtypes.
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Affiliation(s)
- Eric J Nunes
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nii A Addy
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Cellular and Molecular Physiology, Interdepartmental Neuroscience Program, and Wu Tsai Institute, Yale University, New Haven, Connecticut, USA
| | - P Jeffrey Conn
- Department of Pharmacology and Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee, USA
| | - Daniel J Foster
- Department of Pharmacology, Physiology and Neuroscience, University of South Carolina School of Medicine, Columbia, South Carolina, USA;
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47
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Costello H, Husain M, Roiser JP. Apathy and Motivation: Biological Basis and Drug Treatment. Annu Rev Pharmacol Toxicol 2024; 64:313-338. [PMID: 37585659 DOI: 10.1146/annurev-pharmtox-022423-014645] [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] [Indexed: 08/18/2023]
Abstract
Apathy is a disabling syndrome associated with poor functional outcomes that is common across a broad range of neurological and psychiatric conditions. Currently, there are no established therapies specifically for the condition, and safe and effective treatments are urgently needed. Advances in the understanding of motivation and goal-directed behavior in humans and animals have shed light on the cognitive and neurobiological mechanisms contributing to apathy, providing an important foundation for the development of new treatments. Here, we review the cognitive components, neural circuitry, and pharmacology of apathy and motivation, highlighting converging evidence of shared transdiagnostic mechanisms. Though no pharmacological treatments have yet been licensed, we summarize trials of existing and novel compounds to date, identifying several promising candidates for clinical use and avenues of future drug development.
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Affiliation(s)
- Harry Costello
- Institute of Cognitive Neuroscience, University College London, London, United Kingdom;
| | - Masud Husain
- Nuffield Department of Clinical Neurosciences and Department of Experimental Psychology, Oxford University, Oxford, United Kingdom
| | - Jonathan P Roiser
- Institute of Cognitive Neuroscience, University College London, London, United Kingdom;
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48
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Kaul I, Sawchak S, Correll CU, Kakar R, Breier A, Zhu H, Miller AC, Paul SM, Brannan SK. Efficacy and safety of the muscarinic receptor agonist KarXT (xanomeline-trospium) in schizophrenia (EMERGENT-2) in the USA: results from a randomised, double-blind, placebo-controlled, flexible-dose phase 3 trial. Lancet 2024; 403:160-170. [PMID: 38104575 DOI: 10.1016/s0140-6736(23)02190-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND New treatments with new mechanisms are urgently needed for people with schizophrenia. Xanomeline is a dual M1 and M4-preferring muscarinic receptor agonist that does not block D2 dopamine receptors, unlike all currently approved treatments for schizophrenia. Xanomeline-trospium (KarXT) combines xanomeline with the peripherally restricted muscarinic receptor antagonist trospium chloride with the goal of ameliorating xanomeline-related adverse events associated with peripheral muscarinic receptors. The EMERGENT-2 trial aimed to assess the efficacy and safety of KarXT in people with schizophrenia experiencing acute psychosis. METHODS EMERGENT-2 was a randomised, double-blind, placebo-controlled, flexible-dose, 5-week, inpatient, phase 3 trial in people with schizophrenia. Participants were adults aged 18-65 years with a diagnosis of schizophrenia who had a recent worsening of psychosis warranting hospital admission, a Positive and Negative Syndrome Scale (PANSS) score of 80 or higher, and a Clinical Global Impression-Severity score of 4 or higher. The participants were recruited from 22 inpatient sites in the USA, and were randomly assigned (1:1) to KarXT or placebo twice per day. Participants randomly assigned to KarXT received 50 mg xanomeline and 20 mg trospium twice per day for the first 2 days and then 100 mg xanomeline and 20 mg trospium twice per day for days 3-7. Beginning on day 8, KarXT dosing was flexible with an optional increase to 125 mg xanomeline and 30 mg trospium twice per day and the option to return to 100 mg xanomeline and 20 mg trospium based on tolerability. The primary endpoint was change from baseline to week 5 in PANSS total score. Efficacy analyses used the modified intention-to-treat population (all randomly assigned participants who received at least one trial medication dose and had at least one post-baseline PANSS assessment). Least squares mean change from baseline, SE, and least squares mean difference between the KarXT and placebo groups at week 5, along with the 95% CI and two-sided p values were calculated for the primary and secondary continuous efficacy endpoints. Safety analyses included all participants receiving at least one trial medication dose and used descriptive statistics. This trial is registered with ClinicalTrials.gov (NCT04659161). FINDINGS From Dec 16, 2020, to April 13, 2022, of 407 people who were screened, 252 participants meeting enrolment criteria were randomly assigned to the KarXT (n=126) or placebo (n=126). Baseline PANSS total scores were 98·3 (KarXT; n=126) and 97·9 (placebo; n=125). The trial met the primary endpoint with a mean change from baseline to week 5 in PANSS total score that favoured KarXT (-21·2 points, SE 1·7) versus placebo (-11·6 points, 1·6; least squares mean difference -9·6; 95% CI -13·9 to -5·2; p<0·0001, Cohen's d effect size=0·61). All secondary endpoints were also met, and favoured KarXT versus placebo (p<0·05). The most common adverse events with KarXT versus placebo were constipation (27 [21%] vs 13 [10%]), dyspepsia (24 [19%] vs 10 [8%]), headache (17 [14%] vs 15 [12%]), nausea (24 [19%] vs seven [6%]), vomiting (18 [14%] vs one [1%]), hypertension (12 [10%] vs one [1%]), dizziness (11 [9%] vs four [3%]), gastro-oesophageal reflux disease (eight [6%] vs zero [0%]), and diarrhoea (seven [6%] vs four [3%]). Treatment-emergent adverse event rates of extrapyramidal motor symptoms (KarXT, zero [0%] vs placebo, zero [0%]), akathisia (one [1%] vs one [1%]), weight gain (zero [0%] vs one [1%]), and somnolence (six [5%] vs five [4%]) were similar between the KarXT and placebo groups, as were adverse event-related discontinuation rates (nine [7%] vs seven [6%]). INTERPRETATION In the EMERGENT-2 trial, KarXT was effective in reducing positive and negative symptoms and was generally well tolerated. These results support the potential for KarXT to represent a new class of effective and well tolerated antipsychotic medicines based on activating muscarinic receptors, not the D2 dopamine receptor-blocking mechanism of all current antipsychotic medications. Results from additional trials, including the identical EMERGENT-3 trial and the 52-week, open-label EMERGENT-4 and EMERGENT-5 trials, will provide additional information on the efficacy and safety of KarXT in people with schizophrenia. FUNDING Karuna Therapeutics.
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Affiliation(s)
| | | | - Christoph U Correll
- Department of Psychiatry, Zucker Hillside Hospital, Glen Oaks, NY, USA; Departments of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Alan Breier
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
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McIntyre RS, Kwan ATH, Rosenblat JD, Teopiz KM, Mansur RB. Psychotropic Drug-Related Weight Gain and Its Treatment. Am J Psychiatry 2024; 181:26-38. [PMID: 38161305 DOI: 10.1176/appi.ajp.20230922] [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] [Indexed: 01/03/2024]
Abstract
Psychotropic drug-related weight gain (PDWG) is a common occurrence and is highly associated with non-initiation, discontinuation, and dissatisfaction with psychiatric drugs. Moreover, PDWG intersects with the elevated risk for obesity and associated morbidity that has been amply reported in the psychiatric population. Evidence indicates that differential liability for PDWG exists for antipsychotics, antidepressants, and anticonvulsants. During the past two decades, agents within these classes have become available with significantly lower or no liability for PDWG and as such should be prioritized. Although lithium is associated with weight gain, the overall extent of weight gain is significantly lower than previously estimated. The benefit of lifestyle and behavioral modification for obesity and/or PDWG in psychiatric populations is established, with effectiveness similar to that in the general population. Metformin is the most studied pharmacological treatment in the prevention and treatment of PDWG, and promising data are emerging for glucagon-like peptide-1 (GLP-1) receptor agonists (e.g., liraglutide, exenatide, semaglutide). Most pharmacologic antidotes for PDWG are supported with low-confidence data (e.g., topiramate, histamine-2 receptor antagonists). Future vistas for pharmacologic treatment for PDWG include large, adequately controlled studies with GLP-1 receptor agonists and possibly GLP-1/glucose-dependent insulinotropic polypeptide co-agonists (e.g., tirzepatide) as well as specific dietary modifications.
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Affiliation(s)
- Roger S McIntyre
- Department of Psychiatry (McIntyre, Rosenblat, Mansur) and Department of Pharmacology and Toxicology (McIntyre, Rosenblat, Mansur), University of Toronto, Toronto; Brain and Cognition Discovery Foundation, Toronto (McIntyre, Kwan, Teopiz); Faculty of Medicine, University of Ottawa, Ottawa (Kwan)
| | - Angela T H Kwan
- Department of Psychiatry (McIntyre, Rosenblat, Mansur) and Department of Pharmacology and Toxicology (McIntyre, Rosenblat, Mansur), University of Toronto, Toronto; Brain and Cognition Discovery Foundation, Toronto (McIntyre, Kwan, Teopiz); Faculty of Medicine, University of Ottawa, Ottawa (Kwan)
| | - Joshua D Rosenblat
- Department of Psychiatry (McIntyre, Rosenblat, Mansur) and Department of Pharmacology and Toxicology (McIntyre, Rosenblat, Mansur), University of Toronto, Toronto; Brain and Cognition Discovery Foundation, Toronto (McIntyre, Kwan, Teopiz); Faculty of Medicine, University of Ottawa, Ottawa (Kwan)
| | - Kayla M Teopiz
- Department of Psychiatry (McIntyre, Rosenblat, Mansur) and Department of Pharmacology and Toxicology (McIntyre, Rosenblat, Mansur), University of Toronto, Toronto; Brain and Cognition Discovery Foundation, Toronto (McIntyre, Kwan, Teopiz); Faculty of Medicine, University of Ottawa, Ottawa (Kwan)
| | - Rodrigo B Mansur
- Department of Psychiatry (McIntyre, Rosenblat, Mansur) and Department of Pharmacology and Toxicology (McIntyre, Rosenblat, Mansur), University of Toronto, Toronto; Brain and Cognition Discovery Foundation, Toronto (McIntyre, Kwan, Teopiz); Faculty of Medicine, University of Ottawa, Ottawa (Kwan)
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Vita A, Nibbio G, Barlati S. Pharmacological Treatment of Cognitive Impairment Associated With Schizophrenia: State of the Art and Future Perspectives. SCHIZOPHRENIA BULLETIN OPEN 2024; 5:sgae013. [PMID: 39144119 PMCID: PMC11207676 DOI: 10.1093/schizbullopen/sgae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
Cognitive Impairment Associated with Schizophrenia (CIAS) represents one of the core dimensions of Schizophrenia Spectrum Disorders (SSD), with an important negative impact on real-world functional outcomes of people living with SSD. Treatment of CIAS represents a therapeutic goal of considerable importance, and while cognition-oriented evidence-based psychosocial interventions are available, effective pharmacological treatment could represent a game-changer in the lives of people with SSD. The present critical review reports and discusses the evidence regarding the effects of several pharmacological agents that are available in clinical practice or are under study, commenting on both current and future perspectives of CIAS treatment. In particular, the effects on CIAS of antipsychotic medications, anticholinergic medications, benzodiazepines, which are currently commonly used in the treatment of SSD, and of iclepertin, d-serine, luvadaxistat, xanomeline-trospium, ulotaront, anti-inflammatory molecules, and oxytocin, which are undergoing regulatory trials or can be considered as experimental agents, will be reported and discussed. Currently, available pharmacological agents do not appear to provide substantial benefits on CIAS, but accurate management of antipsychotic medications and avoiding treatments that can further exacerbate CIAS represent important strategies. Some molecules that are currently being investigated in Phase 2 and Phase 3 trials have provided very promising preliminary results, but more information is currently required to assess their effectiveness in real-world contexts and to provide clear recommendations regarding their use in clinical practice. The results of ongoing and future studies will reveal whether any of these molecules represents the awaited pharmacological game-changer in the treatment of CIAS.
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Affiliation(s)
- Antonio Vita
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Gabriele Nibbio
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Stefano Barlati
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Brescia, Italy
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