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Weickert TW, Jacomb I, Lenroot R, Lappin J, Weinberg D, Brooks WS, Brown D, Pellen D, Kindler J, Mohan A, Wakefield D, Lloyd AR, Stanton C, O'Donnell M, Liu D, Galletly C, Shannon Weickert C. Adjunctive canakinumab reduces peripheral inflammation markers and improves positive symptoms in people with schizophrenia and inflammation: A randomized control trial. Brain Behav Immun 2024; 115:191-200. [PMID: 37848096 DOI: 10.1016/j.bbi.2023.10.012] [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: 04/24/2023] [Revised: 10/11/2023] [Accepted: 10/14/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Clinical trials of anti-inflammatories in schizophrenia do not show clear and replicable benefits, possibly because patients were not recruited based on elevated inflammation status. Interleukin 1-beta (IL-1β) mRNA and protein levels are increased in serum, plasma, cerebrospinal fluid, and brain of some chronically ill patients with schizophrenia, first episode psychosis, and clinical high-risk individuals. Canakinumab, an approved anti-IL-1β monoclonal antibody, interferes with the bioactivity of IL-1β and interrupts downstream signaling. However, the extent to which canakinumab reduces peripheral inflammation markers, such as, high sensitivity C-reactive protein (hsCRP) and symptom severity in schizophrenia patients with inflammation is unknown. TRIAL DESIGN We conducted a randomized, placebo-controlled, double-blind, parallel groups, 8-week trial of canakinumab in chronically ill patients with schizophrenia who had elevated peripheral inflammation. METHODS Twenty-seven patients with schizophrenia or schizoaffective disorder and elevated peripheral inflammation markers (IL-1β, IL-6, hsCRP and/or neutrophil to lymphocyte ratio: NLR) were randomized to a one-time, subcutaneous injection of canakinumab (150 mg) or placebo (normal saline) as an adjunctive antipsychotic treatment. Peripheral blood hsCRP, NLR, IL-1β, IL-6, IL-8 levels were measured at baseline (pre injection) and at 1-, 4- and 8-weeks post injection. Symptom severity was assessed at baseline and 4- and 8-weeks post injection. RESULTS Canakinumab significantly reduced peripheral hsCRP over time, F(3, 75) = 5.16, p = 0.003. Significant hsCRP reductions relative to baseline were detected only in the canakinumab group at weeks 1, 4 and 8 (p's = 0.0003, 0.000002, and 0.004, respectively). There were no significant hsCRP changes in the placebo group. Positive symptom severity scores were significantly reduced at week 8 (p = 0.02) in the canakinumab group and week 4 (p = 0.02) in the placebo group. The change in CRP between week 8 and baseline (b = 1.9, p = 0.0002) and between week 4 and baseline (b = 6.0, p = 0.001) were highly significant predictors of week 8 change in PANSS Positive Symptom severity scores. There were no significant changes in negative symptoms, general psychopathology or cognition in either group. Canakinumab was well tolerated and only 7 % discontinued. CONCLUSIONS Canakinumab quickly reduces peripheral hsCRP serum levels in patients with schizophrenia and inflammation; after 8 weeks of canakinumab treatment, the reductions in hsCRP are related to reduced positive symptom severity. Future studies should consider increased doses or longer-term treatment to confirm the potential benefits of adjunctive canakinumab in schizophrenia. Australian and New Zealand Clinical Trials Registry number: ACTRN12615000635561.
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Affiliation(s)
- Thomas W Weickert
- Neuroscience Research Australia, Sydney, New South Wales, Australia; School of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia.
| | - Isabella Jacomb
- Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Rhoshel Lenroot
- Neuroscience Research Australia, Sydney, New South Wales, Australia; School of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Julia Lappin
- School of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia
| | | | - William S Brooks
- Neuroscience Research Australia, Sydney, New South Wales, Australia; School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - David Brown
- NSW Health Pathology-ICPMR, Centre for Immunology and Allergy Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Pellen
- Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Jochen Kindler
- Neuroscience Research Australia, Sydney, New South Wales, Australia; University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Adith Mohan
- School of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Denis Wakefield
- School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew R Lloyd
- Viral Immunology Systems Program, Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Clive Stanton
- Neuroscience Research Australia, Sydney, New South Wales, Australia; Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Maryanne O'Donnell
- Neuroscience Research Australia, Sydney, New South Wales, Australia; School of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia; Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Dennis Liu
- Discipline of Psychiatry, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Northern Adelaide Locah Health Network, Adelaide, South Australia, Australia
| | - Cherrie Galletly
- Discipline of Psychiatry, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Northern Adelaide Locah Health Network, Adelaide, South Australia, Australia
| | - Cynthia Shannon Weickert
- Neuroscience Research Australia, Sydney, New South Wales, Australia; School of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia
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2
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Bejerot S, Eklund D, Hesser H, Hietala MA, Kariis T, Lange N, Lebedev A, Montgomery S, Nordenskjöld A, Petrovic P, Söderbergh A, Thunberg P, Wikström S, Humble MB. Study protocol for a randomized controlled trial with rituximab for psychotic disorder in adults (RCT-Rits). BMC Psychiatry 2023; 23:771. [PMID: 37872497 PMCID: PMC10594806 DOI: 10.1186/s12888-023-05250-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 10/03/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND The role of inflammation in the aetiology of schizophrenia has gained wide attention and research on the association shows an exponential growth in the last 15 years. Autoimmune diseases and severe infections are risk factors for the later development of schizophrenia, elevated inflammatory markers in childhood or adolescence are associated with a greater risk of schizophrenia in adulthood, individuals with schizophrenia have increased levels of pro-inflammatory cytokines compared to healthy controls, and autoimmune diseases are overrepresented in schizophrenia. However, treatments with anti-inflammatory agents are so far of doubtful clinical relevance. The primary objective of this study is to test whether the monoclonal antibody rituximab, directed against the B-cell antigen CD20 ameliorates psychotic symptoms in adults with schizophrenia or schizoaffective disorder and to examine potential mechanisms. A secondary objective is to examine characteristics of inflammation-associated psychosis and to identify pre-treatment biochemical characteristics of rituximab responders. A third objective is to interview a subset of patients and informants on their experiences of the trial to obtain insights that rating scales may not capture. METHODS A proof-of-concept study employing a randomised, parallel-group, double-blind, placebo-controlled design testing the effect of B-cell depletion in patients with psychosis. 120 participants with a diagnosis of schizophrenia spectrum disorders (SSD) (ICD-10 codes F20, F25) will receive either one intravenous infusion of rituximab (1000 mg) or saline. Psychiatric measures and blood samples will be collected at baseline, week 12, and week 24 post-infusion. Brief assessments will also be made in weeks 2 and 7. Neuroimaging and lumbar puncture, both optional, will be performed at baseline and endpoints. Approximately 40 of the patients and their informants will be interviewed for qualitative analyses on the perceived changes in well-being and emotional qualities, in addition to their views on the research. DISCUSSION This is the first RCT investigating add-on treatment with rituximab in unselected SSD patients. If the treatment is helpful, it may transform the treatment of patients with psychotic disorders. It may also heighten the awareness of immune-psychiatric disorders and reduce stigma. TRIAL REGISTRATION NCT05622201, EudraCT-nr 2022-000220-37 version 2.1. registered 14th of October 2022.
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Affiliation(s)
- Susanne Bejerot
- Faculty of Health and Medical Sciences, University Health Care Research Centre, Örebro University, Örebro, Sweden.
| | - Daniel Eklund
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Hugo Hesser
- School of Behavioural, Social and Legal Sciences, Örebro University, Örebro, Sweden
| | - Max Albert Hietala
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Tarmo Kariis
- Karlstad Central Hospital, Region Värmland, Karlstad, Sweden
| | - Niclas Lange
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Alexander Lebedev
- Center for Psychiatry Research (CPF), Center for Cognitive and Computational Neuropsychiatry (CCNP), Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Axel Nordenskjöld
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Predrag Petrovic
- Center for Psychiatry Research (CPF), Center for Cognitive and Computational Neuropsychiatry (CCNP), Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Annika Söderbergh
- Department of Rheumatology, Örebro University Hospital, Örebro, Sweden
| | - Per Thunberg
- Department of Radiology and Medical Physics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Center for Experimental and Biomedical Imaging in Örebro (CEBIO), Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Sverre Wikström
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
- Centre for Clinical Research, County Council of Värmland, Karlstad, Sweden
| | - Mats B Humble
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
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Nguyen KD, Amerio A, Aguglia A, Magnani L, Parise A, Conio B, Serafini G, Amore M, Costanza A. Microglia and Other Cellular Mediators of Immunological Dysfunction in Schizophrenia: A Narrative Synthesis of Clinical Findings. Cells 2023; 12:2099. [PMID: 37626909 PMCID: PMC10453550 DOI: 10.3390/cells12162099] [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: 07/11/2023] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
Schizophrenia is a complex psychiatric condition that may involve immune system dysregulation. Since most putative disease mechanisms in schizophrenia have been derived from genetic association studies and fluid-based molecular analyses, this review aims to summarize the emerging evidence on clinical correlates to immune system dysfunction in this psychiatric disorder. We conclude this review by attempting to develop a unifying hypothesis regarding the relative contributions of microglia and various immune cell populations to the development of schizophrenia. This may provide important translational insights that can become useful for addressing the multifaceted clinical presentation of schizophrenia.
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Affiliation(s)
- Khoa D. Nguyen
- Department of Microbiology and Immunology, Stanford University, Palo Alto, CA 94305, USA;
- Tranquis Therapeutics, Palo Alto, CA 94065, USA
| | - Andrea Amerio
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy; (A.A.); (A.A.); (B.C.); (G.S.); (M.A.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Andrea Aguglia
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy; (A.A.); (A.A.); (B.C.); (G.S.); (M.A.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Luca Magnani
- Department of Psychiatry, San Maurizio Hospital of Bolzano, 39100 Bolzano, Italy;
| | - Alberto Parise
- Geriatric-Rehabilitation Department, University Hospital of Parma, 43126 Parma, Italy;
| | - Benedetta Conio
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy; (A.A.); (A.A.); (B.C.); (G.S.); (M.A.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Gianluca Serafini
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy; (A.A.); (A.A.); (B.C.); (G.S.); (M.A.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Mario Amore
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy; (A.A.); (A.A.); (B.C.); (G.S.); (M.A.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Alessandra Costanza
- Department of Psychiatry, Adult Psychiatry Service, University Hospitals of Geneva (HUG), 1207 Geneva, Switzerland
- Department of Psychiatry, Faculty of Biomedical Sciences, University of Italian Switzerland (USI), 6900 Lugano, Switzerland
- Department of Psychiatry, Faculty of Medicine, University of Geneva (UNIGE), 1211 Geneva, Switzerland
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Messina A, Concerto C, Rodolico A, Petralia A, Caraci F, Signorelli MS. Is It Time for a Paradigm Shift in the Treatment of Schizophrenia? The Use of Inflammation-Reducing and Neuroprotective Drugs-A Review. Brain Sci 2023; 13:957. [PMID: 37371435 DOI: 10.3390/brainsci13060957] [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: 05/20/2023] [Revised: 06/03/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Comprehending the pathogenesis of schizophrenia represents a challenge for global mental health. To date, although it is evident that alterations in dopaminergic, serotonergic, and glutamatergic neurotransmission underlie the clinical expressiveness of the disease, neuronal disconnections represent only an epiphenomenon. In recent years, several clinical studies have converged on the hypothesis of microglia hyperactivation and a consequent neuroinflammatory state as a pathogenic substrate of schizophrenia. Prenatal, perinatal, and postnatal factors can cause microglia to switch from M2 anti-inflammatory to M1 pro-inflammatory states. A continuous mild neuroinflammatory state progressively leads to neuronal loss, a reduction in dendritic spines, and myelin degeneration. The augmentation of drugs that reduce neuroinflammation to antipsychotics could be an effective therapeutic modality in managing schizophrenia. This review will consider studies in which drugs with anti-inflammatory and neuroprotective properties have been used in addition to antipsychotic treatment in patients with schizophrenia.
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Affiliation(s)
- Antonino Messina
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, 95123 Catania, Italy
| | - Carmen Concerto
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, 95123 Catania, Italy
| | - Alessandro Rodolico
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, 95123 Catania, Italy
| | - Antonino Petralia
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, 95123 Catania, Italy
| | - Filippo Caraci
- Department of Drug and Health Sciences, University of Catania, 95123 Catania, Italy
- Unit of Translational Neuropharmacology and Translational Neurosciences, Oasi Research Institute-IRCCS, 94018 Troina, Italy
| | - Maria Salvina Signorelli
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, 95123 Catania, Italy
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5
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Karbalaee M, Jameie M, Amanollahi M, TaghaviZanjani F, Parsaei M, Basti FA, Mokhtari S, Moradi K, Ardakani MRK, Akhondzadeh S. Efficacy and safety of adjunctive therapy with fingolimod in patients with schizophrenia: A randomized, double-blind, placebo-controlled clinical trial. Schizophr Res 2023; 254:92-98. [PMID: 36805834 DOI: 10.1016/j.schres.2023.02.020] [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: 09/30/2022] [Revised: 02/05/2023] [Accepted: 02/13/2023] [Indexed: 02/21/2023]
Abstract
OBJECTIVES Studies have suggested that fingolimod, a sphingosine-1-phosphate receptor modulator, exerts neuroprotective and anti-inflammatory effects. Although fingolimod is approved for the treatment of relapsing-remitting multiple sclerosis, limited studies have investigated its effects in patients with schizophrenia. This study investigated the efficacy and safety of fingolimod adjuvant to risperidone in schizophrenia treatment. METHODS This eight-week, randomized, double-blinded, placebo-controlled trial included 80 (clinical trials registry code: IRCT20090117001556N137) patients with chronic schizophrenia. Participants were assigned to two equal arms and received risperidone plus either fingolimod (0.5 mg/day) or a matched placebo. The positive and negative symptom scale (PANSS) was used to measure and compare the effectiveness of treatment strategies at baseline and weeks 2, 4, 6, and 8. Treatment side effects were also compared. RESULTS Seventy participants completed the trial (35 in each arm). The baseline characteristics of the groups were comparable (P-value > 0.05). There were significant time-treatment interaction effects on negative symptoms (P-value = 0.003), general symptoms (P-value = 0.037), and the PANSS total score (P-value = 0.035), suggesting greater improvement in symptoms following the fingolimod adjuvant therapy. In contrast, the longitudinal changes in positive and depressive symptoms were similar between the groups (P-values > 0.05). Regarding the safety of treatments, there were no differences in extrapyramidal symptoms [assessed by the extrapyramidal symptom rating scale (ESRS)] or frequency of other complications between the fingolimod and the placebo groups (P-values > 0.05). CONCLUSIONS This study indicated that fingolimod is a safe and effective adjuvant agent for schizophrenia treatment. However, further clinical trials are required to suggest extensive clinical application.
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Affiliation(s)
- Monire Karbalaee
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Melika Jameie
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran; Neuroscience Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mobina Amanollahi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Fateme TaghaviZanjani
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Fatemeh A Basti
- Islamic Azad University, Tehran Medical Branch, Tehran, Iran
| | - Saba Mokhtari
- Department of Psychiatry, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Kamyar Moradi
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran; School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Shahin Akhondzadeh
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Fitton R, Sweetman J, Heseltine-Carp W, van der Feltz-Cornelis C. Anti-inflammatory medications for the treatment of mental disorders: A scoping review. Brain Behav Immun Health 2022; 26:100518. [PMID: 36217374 PMCID: PMC9547233 DOI: 10.1016/j.bbih.2022.100518] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 09/15/2022] [Accepted: 09/18/2022] [Indexed: 11/25/2022] Open
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