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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 M, Kim E, Kim S, Manisalco 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 HS, 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 2024:1-123. [PMID: 38913780 DOI: 10.1080/15622975.2024.2366235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [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, specialized tools are used. Three tools have been proven useful to personalize 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 50 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 optimize treatment effects, minimize side effects and ultimately reduce the global burden of diseases, personalized drug treatment has not yet become the standard of care in psychiatry.
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Affiliation(s)
- X M Hart
- Central Institute of Mental Health, Department of Molecular Neuroimaging, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - G Gründer
- Central Institute of Mental Health, Department of Molecular Neuroimaging, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- German Center for Mental Health (DZPG), partner site Mannheim - Heidelberg - Ulm
| | - N Ansermot
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, Prilly, Switzerland
| | - A Conca
- Dipartimento di Psichiatria, Comprensorio Sanitario di Bolzano, Bolzano, Italy
| | - E Corruble
- Université Paris-Saclay, AP-HP, Service Hospitalo-Universitaire de Psychiatrie, Hôpital de Bicêtre
- Equipe MOODS, Inserm U1018, CESP (Centre de Recherche en Epidémiologie et Sante des Populations), Le Kremlin-Bicêtre, France
| | - S Crettol
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Prilly, Switzerland
| | - P Cumming
- Department of Nuclear Medicine, Bern University Hospital, Bern, Switzerland
- School of Psychology and Counseling, Queensland University of Technology, Brisbane, Australia
| | - G Hefner
- Vitos Clinic for Forensic Psychiatry, Forensic Psychiatry, Eltville, Germany
| | - A Frajerman
- Université Paris-Saclay, AP-HP, Service Hospitalo-Universitaire de Psychiatrie, Hôpital de Bicêtre
- Equipe MOODS, Inserm U1018, CESP (Centre de Recherche en Epidémiologie et Sante des Populations), Le Kremlin-Bicêtre, France
| | - O Howes
- Department of Psychosis Studies, IoPPN, King's College London, De Crespigny Park, London, SE5 8AF, UK
- Institute of Clinical Sciences (ICS), Faculty of Medicine, Imperial College London, Du Cane Road, London W12 0NN, UK
| | - M Jukic
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia and Pharmacogenetics Section, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
| | - E Kim
- Department of Psychiatry, Seoul National University College of Medicine, Republic of Korea
| | - S Kim
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Republic of Korea
| | - I Manisalco
- Dipartimento di Psichiatria, Comprensorio Sanitario di Bolzano, Bolzano, Italy
| | - S Moriguchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - D 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, and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - S Nakajima
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - M Osugo
- Department of Psychosis Studies, IoPPN, King's College London, De Crespigny Park, London, SE5 8AF, UK
- Institute of Clinical Sciences (ICS), Faculty of Medicine, Imperial College London, Du Cane Road, London W12 0NN, UK
| | - M Paulzen
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University
- JARA - Translational Brain Medicine, Aachen, Germany; Alexianer Center for Mental Health, Aachen, Germany
| | - H G Ruhe
- Department of psychiatry, Radboudumc, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, Netherlands
| | - M Scherf-Clavel
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
| | - G Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032 Zurich, Switzerland
| | - A Serretti
- Department of Medicine and Surgery, Kore University of Enna, Italy
| | - E Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - O Spigset
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway, and Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - W Steimer
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich, Munich, Germany
| | - H S Süzen
- Department of Pharmaceutic Toxicology, Faculty of Pharmacy, Ankara University, Ankara, Turkey
| | - H Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - S Unterecker
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
| | - F Vandenberghe
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, Prilly, Switzerland
| | - C Verstuyft
- Department of Molecular Genetics, Pharmacogenetics and Hormonology Bicêtre University Hospital Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, F-94275, France
- CESP, MOODS Team, INSERM UMR 1018, Medicine Faculty, Paris-Saclay University, Le Kremlin Bicêtre, France
| | - G Zernig
- Department of Pharmacology, Medical University Innsbruck; Private Practice for Psychotherapy and Court-Certified Witness, Hall in Tirol, Austria
| | - C Hiemke
- Department of Psychiatry and Psychotherapy and Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Germany
| | - C B Eap
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Department of Psychiatry, Centre for Psychiatric Neuroscience, Lausanne University Hospital, University of Lausanne, 1008 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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2
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Balzulat A, Zhu WF, Flauaus C, Hernandez‐Olmos V, Heering J, Sethumadhavan S, Dubiel M, Frank A, Menge A, Hebchen M, Metzner K, Lu R, Lukowski R, Ruth P, Knapp S, Müller S, Steinhilber D, Hänelt I, Stark H, Proschak E, Schmidtko A. Discovery of a Small Molecule Activator of Slack (Kcnt1) Potassium Channels That Significantly Reduces Scratching in Mouse Models of Histamine-Independent and Chronic Itch. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2307237. [PMID: 38350720 PMCID: PMC11022729 DOI: 10.1002/advs.202307237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/15/2024] [Indexed: 02/15/2024]
Abstract
Various disorders are accompanied by histamine-independent itching, which is often resistant to the currently available therapies. Here, it is reported that the pharmacological activation of Slack (Kcnt1, KNa1.1), a potassium channel highly expressed in itch-sensitive sensory neurons, has therapeutic potential for the treatment of itching. Based on the Slack-activating antipsychotic drug, loxapine, a series of new derivatives with improved pharmacodynamic and pharmacokinetic profiles is designed that enables to validate Slack as a pharmacological target in vivo. One of these new Slack activators, compound 6, exhibits negligible dopamine D2 and D3 receptor binding, unlike loxapine. Notably, compound 6 displays potent on-target antipruritic activity in multiple mouse models of acute histamine-independent and chronic itch without motor side effects. These properties make compound 6 a lead molecule for the development of new antipruritic therapies targeting Slack.
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Affiliation(s)
- Annika Balzulat
- Institute of Pharmacology and Clinical PharmacyGoethe University FrankfurtMax‐von‐Laue‐Str. 960438Frankfurt am MainGermany
| | - W. Felix Zhu
- Institute of Pharmaceutical ChemistryGoethe University FrankfurtMax‐von‐Laue‐Str. 960438Frankfurt am MainGermany
| | - Cathrin Flauaus
- Institute of Pharmacology and Clinical PharmacyGoethe University FrankfurtMax‐von‐Laue‐Str. 960438Frankfurt am MainGermany
| | - Victor Hernandez‐Olmos
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPTheodor‐Stern‐Kai 760596Frankfurt am MainGermany
| | - Jan Heering
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPTheodor‐Stern‐Kai 760596Frankfurt am MainGermany
| | - Sunesh Sethumadhavan
- Institute of BiochemistryGoethe University FrankfurtMax‐von‐Laue‐Str. 960438Frankfurt am MainGermany
| | - Mariam Dubiel
- Institute of Pharmaceutical and Medicinal ChemistryHeinrich Heine University DüsseldorfUniversitätsstr. 140225DüsseldorfGermany
| | - Annika Frank
- Institute of Pharmaceutical and Medicinal ChemistryHeinrich Heine University DüsseldorfUniversitätsstr. 140225DüsseldorfGermany
| | - Amelie Menge
- Institute of Pharmaceutical ChemistryGoethe University FrankfurtMax‐von‐Laue‐Str. 960438Frankfurt am MainGermany
- Structural Genomics Consortium (SGC)Buchmann Institute for Molecular Life SciencesGoethe University FrankfurtMax‐von‐Laue‐Str. 1560438Frankfurt am MainGermany
| | - Maureen Hebchen
- Institute of Pharmacology and Clinical PharmacyGoethe University FrankfurtMax‐von‐Laue‐Str. 960438Frankfurt am MainGermany
| | - Katharina Metzner
- Institute of Pharmacology and Clinical PharmacyGoethe University FrankfurtMax‐von‐Laue‐Str. 960438Frankfurt am MainGermany
| | - Ruirui Lu
- Institute of Pharmacology and Clinical PharmacyGoethe University FrankfurtMax‐von‐Laue‐Str. 960438Frankfurt am MainGermany
| | - Robert Lukowski
- Department of PharmacologyToxicology and Clinical PharmacyInstitute of Pharmacy University of TübingenAuf der Morgenstelle 872076TübingenGermany
| | - Peter Ruth
- Department of PharmacologyToxicology and Clinical PharmacyInstitute of Pharmacy University of TübingenAuf der Morgenstelle 872076TübingenGermany
| | - Stefan Knapp
- Institute of Pharmaceutical ChemistryGoethe University FrankfurtMax‐von‐Laue‐Str. 960438Frankfurt am MainGermany
- Structural Genomics Consortium (SGC)Buchmann Institute for Molecular Life SciencesGoethe University FrankfurtMax‐von‐Laue‐Str. 1560438Frankfurt am MainGermany
| | - Susanne Müller
- Institute of Pharmaceutical ChemistryGoethe University FrankfurtMax‐von‐Laue‐Str. 960438Frankfurt am MainGermany
- Structural Genomics Consortium (SGC)Buchmann Institute for Molecular Life SciencesGoethe University FrankfurtMax‐von‐Laue‐Str. 1560438Frankfurt am MainGermany
| | - Dieter Steinhilber
- Institute of Pharmaceutical ChemistryGoethe University FrankfurtMax‐von‐Laue‐Str. 960438Frankfurt am MainGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPTheodor‐Stern‐Kai 760596Frankfurt am MainGermany
| | - Inga Hänelt
- Institute of BiochemistryGoethe University FrankfurtMax‐von‐Laue‐Str. 960438Frankfurt am MainGermany
| | - Holger Stark
- Institute of Pharmaceutical and Medicinal ChemistryHeinrich Heine University DüsseldorfUniversitätsstr. 140225DüsseldorfGermany
| | - Ewgenij Proschak
- Institute of Pharmaceutical ChemistryGoethe University FrankfurtMax‐von‐Laue‐Str. 960438Frankfurt am MainGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPTheodor‐Stern‐Kai 760596Frankfurt am MainGermany
| | - Achim Schmidtko
- Institute of Pharmacology and Clinical PharmacyGoethe University FrankfurtMax‐von‐Laue‐Str. 960438Frankfurt am MainGermany
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Sankara CS, Namboothiri INN. Hauser-Kraus Annulation Initiated Multi-Cascade Reactions for Facile Access to Functionalized and Fused Oxazepines, Carbazoles and Phenanthridinediones. Chemistry 2024; 30:e202303517. [PMID: 37946675 DOI: 10.1002/chem.202303517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 11/07/2023] [Accepted: 11/09/2023] [Indexed: 11/12/2023]
Abstract
The Hauser-Kraus (H-K) annulation of N-unsubstituted 3-olefinic oxindoles with 3-nucleophilic phthalides triggers a cascade of ring expansion and ring contraction reactions through several regioselective steps in one pot. While oxazepines were isolated in the presence of stoichiometric amounts of base at room temperature, carbazoles and phenanthridinediones were the products in the presence of excess base and microwave irradiation. Mechanistic studies guided by stepwise reactions and control experiments revealed that the isolable oxazepine intermediate, formed via ring expansion of the H-K adduct, is the key precursor to carbazole and phenanthridinedione via decarboxylative regioselective cyclizations.
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Im DS, Capitanov M, VandenBerg AM. Loxapine in the Treatment of Manic and Psychotic Symptoms in an Individual Intolerant to Multiple Mood-Stabilizing and Antipsychotic Medications. Case Rep Psychiatry 2023; 2023:8887553. [PMID: 37332889 PMCID: PMC10276762 DOI: 10.1155/2023/8887553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/10/2023] [Accepted: 05/10/2023] [Indexed: 06/20/2023] Open
Abstract
First-line treatments for schizophrenia and schizoaffective disorder include antipsychotics and mood stabilizers, but their use may at times be limited due to severe adverse events. This case describes a 41-year-old male with a history of schizoaffective disorder and polysubstance use who was admitted to an inpatient psychiatry unit for acute manic and psychotic symptoms in the setting of absconding from his residential home and noncompliance with prescribed psychiatric medications. During his inpatient psychiatric hospitalization, he experienced DRESS (drug reaction with eosinophilia and systemic symptoms) with valproate, nephrogenic diabetes insipidus with lithium, potential neuroleptic malignant syndrome with risperidone, and orthostasis/tachycardia with clozapine. He ultimately achieved stabilization of manic and psychotic symptoms with loxapine without experiencing adverse events. This report highlights the potential utility of loxapine in individuals with schizoaffective disorder intolerant to standard mood-stabilizing and antipsychotic medications.
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Affiliation(s)
- David S. Im
- Department of Psychiatry, University of Michigan Medical School, USA
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5
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Bandala C, Cárdenas-Rodríguez N, Mendoza-Torreblanca JG, Contreras-García IJ, Martínez-López V, Cruz-Hernández TR, Carro-Rodríguez J, Vargas-Hernández MA, Ignacio-Mejía I, Alfaro-Rodriguez A, Lara-Padilla E. Therapeutic Potential of Dopamine and Related Drugs as Anti-Inflammatories and Antioxidants in Neuronal and Non-Neuronal Pathologies. Pharmaceutics 2023; 15:pharmaceutics15020693. [PMID: 36840015 PMCID: PMC9966027 DOI: 10.3390/pharmaceutics15020693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/11/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
Dopamine (DA), its derivatives, and dopaminergic drugs are compounds widely used in the management of diseases related to the nervous system. However, DA receptors have been identified in nonneuronal tissues, which has been related to their therapeutic potential in pathologies such as sepsis or septic shock, blood pressure, renal failure, diabetes, and obesity, among others. In addition, DA and dopaminergic drugs have shown anti-inflammatory and antioxidant properties in different kinds of cells. AIM To compile the mechanism of action of DA and the main dopaminergic drugs and show the findings that support the therapeutic potential of these molecules for the treatment of neurological and non-neurological diseases considering their antioxidant and anti-inflammatory actions. METHOD We performed a review article. An exhaustive search for information was carried out in specialized databases such as PubMed, PubChem, ProQuest, EBSCO, Scopus, Science Direct, Web of Science, Bookshelf, DrugBank, Livertox, and Clinical Trials. RESULTS We showed that DA and dopaminergic drugs have emerged for the management of neuronal and nonneuronal diseases with important therapeutic potential as anti-inflammatories and antioxidants. CONCLUSIONS DA and DA derivatives can be an attractive treatment strategy and a promising approach to slowing the progression of disorders through repositioning.
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Affiliation(s)
- Cindy Bandala
- Neurociencia Básica, Instituto Nacional de Rehabilitación LGII, Secretaría de Salud, Mexico City 14389, Mexico
- Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City 11340, Mexico
- Correspondence: (C.B.); (E.L.-P.); Tel.: +52-(55)-5999-1000 (ext. 19307) (C.B.); +52-(55)-57296000 (ext. 62712) (E.L.-P.)
| | - Noemi Cárdenas-Rodríguez
- Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City 11340, Mexico
- Laboratorio de Neurociencias, Subdirección de Medicina Experimental, Instituto Nacional de Pediatría, Mexico City 04530, Mexico
| | | | | | - Valentín Martínez-López
- Unidad de Ingeniería de Tejidos, Terapia Celular y Medicina Regenerativa, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City 14389, Mexico
| | | | - Jazmín Carro-Rodríguez
- Escuela de Biología Experimental, Unidad Iztapalapa, Universidad Autónoma Metropolitana, Mexico City 09340, Mexico
| | | | - Iván Ignacio-Mejía
- Laboratorio de Medicina Traslacional, Escuela Militar de Graduados de Sanidad, Mexico City 11200, Mexico
| | - Alfonso Alfaro-Rodriguez
- Neurociencia Básica, Instituto Nacional de Rehabilitación LGII, Secretaría de Salud, Mexico City 14389, Mexico
| | - Eleazar Lara-Padilla
- Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City 11340, Mexico
- Correspondence: (C.B.); (E.L.-P.); Tel.: +52-(55)-5999-1000 (ext. 19307) (C.B.); +52-(55)-57296000 (ext. 62712) (E.L.-P.)
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Shad MU. Seventy Years of Antipsychotic Development: A Critical Review. Biomedicines 2023; 11:biomedicines11010130. [PMID: 36672638 PMCID: PMC9856208 DOI: 10.3390/biomedicines11010130] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/29/2022] [Accepted: 12/30/2022] [Indexed: 01/06/2023] Open
Abstract
Since the mid-1950s discovery of the first effective antipsychotic medications (APM), we have only been able to improve the tolerability but not the overall efficacy of currently available APMs, as reflected by effectiveness trials in Europe and the United States. This inability to develop more effective APMs is attributable to multiple factors, including failure to create and use assessment tools to assess core symptom domains in schizophrenia, move beyond the dopaminergic hypothesis and to develop "me too" drugs, imposing ill-defined research domain criteria, and lacking federal funding for clinical trials. The classification of APMs is also confusing, including second-generation, partial agonists, and multimodal APMs in the same class of APMs, despite significant differences in their mechanisms of action. Other factors stagnating drug development include inadequate sample sizes to address heterogeneity, lack of statistical measures correlating with clinical significance, using the atheoretical basis of psychiatric diagnoses, failure to control placebo response, and high cost of newer and perhaps more tolerable APMs. Furthermore, there has been a failure to develop early predictors of antipsychotic response and various tools to optimize an APM response. Finally, some mental health providers are also responsible for the suboptimal use of APMs, by using excessive maintenance doses, often with irrational polypharmacy, further compromising effectiveness and medication adherence. However, some bright spots in antipsychotic development include improved tolerability of APMs and long-acting injectables to address the high prevalence of medication nonadherence. This review critically reviews 70 years of antipsychotic development, the reasons behind the failure to develop more effective APMs, and suggestions for future direction.
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Affiliation(s)
- Mujeeb U. Shad
- UNLV School of Medicine, University of Nevada, Las Vegas, NV 89154, USA;
- College of Osteopathic Medicine, Touro University Nevada, Las Vegas, NV 89014, USA
- Psychiatry Residency Program, Graduate Medical Education, The Valley Health System, Las Vegas, NV 89118, USA
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7
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Lin HC, Wu YL, Hsu CY, Lin MY, Chen LH, Shiau CW, Chiu HC. Discovery of antipsychotic loxapine derivatives against intracellular multidrug-resistant bacteria. RSC Med Chem 2022; 13:1361-1366. [PMID: 36439974 PMCID: PMC9667769 DOI: 10.1039/d2md00182a] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/02/2022] [Indexed: 08/13/2023] Open
Abstract
The emergence and spread of multidrug-resistant bacteria highlight the need for new antibacterial interventions. A screening of 24 newly synthesized dibenzoxazepines identified a small molecule compound, SW14, with potent inhibitory activity against intracellular multidrug-resistant and fluoroquinolone-resistant strains of S. typhimurium in macrophages and epithelial cells. Moreover, intra-macrophagic Salmonella typhi, Yersinia enterocolitica, and Listeria monocytogenes and methicillin-resistant Staphylococcus aureus are also susceptible to SW14. Overall, our findings suggest that SW14 has a broad-spectrum activity against intracellular bacteria.
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Affiliation(s)
- Hsueh-Chun Lin
- Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University Taipei 10048 Taiwan
| | - Yi-Lun Wu
- Institute of Biopharmaceutical Sciences, National Yang Ming Chiao Tung University Taipei 11221 Taiwan
| | - Cheng-Yun Hsu
- Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University Taipei 10048 Taiwan
| | - Man-Yi Lin
- Institute of Biopharmaceutical Sciences, National Yang Ming Chiao Tung University Taipei 11221 Taiwan
| | - Ling-Han Chen
- Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University Taipei 10048 Taiwan
| | - Chung-Wai Shiau
- Institute of Biopharmaceutical Sciences, National Yang Ming Chiao Tung University Taipei 11221 Taiwan
| | - Hao-Chieh Chiu
- Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University Taipei 10048 Taiwan
- Department of Laboratory Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University Taipei 10021 Taiwan
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8
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Analyzing Indole-fused benzooxazepines as inhibitors of apoptosis pathway-related proteins using multifaceted computational medicinal chemistry. J Mol Struct 2022. [DOI: 10.1016/j.molstruc.2022.134541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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9
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Lio G, Ghazzai M, Haesebaert F, Dubreucq J, Verdoux H, Quiles C, Jaafari N, Chéreau-Boudet I, Legros-Lafarge E, Guillard-Bouhet N, Massoubre C, Gouache B, Plasse J, Barbalat G, Franck N, Demily C. Actionable Predictive Factors of Homelessness in a Psychiatric Population: Results from the REHABase Cohort Using a Machine Learning Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12268. [PMID: 36231571 PMCID: PMC9565981 DOI: 10.3390/ijerph191912268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND There is a lack of knowledge regarding the actionable key predictive factors of homelessness in psychiatric populations. Therefore, we used a machine learning model to explore the REHABase database (for rehabilitation database-n = 3416), which is a cohort of users referred to French psychosocial rehabilitation centers in France. METHODS First, we analyzed whether the different risk factors previously associated with homelessness in mental health were also significant risk factors in the REHABase. In the second step, we used unbiased classification and regression trees to determine the key predictors of homelessness. Post hoc analyses were performed to examine the importance of the predictors and to explore the impact of cognitive factors among the participants. RESULTS First, risk factors that were previously found to be associated with homelessness were also significant risk factors in the REHABase. Among all the variables studied with a machine learning approach, the most robust variable in terms of predictive value was the nature of the psychotropic medication (sex/sex relative mean predictor importance: 22.8, σ = 3.4). Post hoc analyses revealed that first-generation antipsychotics (15.61%; p < 0.05 FDR corrected), loxapine (16.57%; p < 0.05 FWER corrected) and hypnotics (17.56%; p < 0.05 FWER corrected) were significantly associated with homelessness. Antidepressant medication was associated with a protective effect against housing deprivation (9.21%; p < 0.05 FWER corrected). CONCLUSIONS Psychotropic medication was found to be an important predictor of homelessness in our REHABase cohort, particularly loxapine and hypnotics. On the other hand, the putative protective effect of antidepressants confirms the need for systematic screening of depression and anxiety in the homeless population.
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Affiliation(s)
- Guillaume Lio
- Centre d’Excellence Autisme iMIND, pôle HU-ADIS, Hôpital le Vinatier, 69678 Bron, France
- Equipe «Disorders of the Brain», Institut Marc Jeannerod, UMR 5229, CNRS & Université Lyon 1, 69100 Villeurbanne, France
| | - Malek Ghazzai
- Centre d’Excellence Autisme iMIND, pôle HU-ADIS, Hôpital le Vinatier, 69678 Bron, France
| | | | - Julien Dubreucq
- Centre Hospitalier Universitaire de Saint-Etienne, 42270 Saint-Priest-en-Jarez, France
| | - Hélène Verdoux
- Hôpital Charles Perrens, Université de Bordeaux, 33405 Talence, France
| | - Clélia Quiles
- Hôpital Charles Perrens, Université de Bordeaux, 33405 Talence, France
| | - Nemat Jaafari
- CREATIV & URC Pierre Deniker, Centre Hospitalier Laborit, Université de Poitiers, 86000 Poitiers, France
| | - Isabelle Chéreau-Boudet
- Centre Référent Conjoint de Réhabilitation (CRCR), Centre Hospitalier Universitaire de Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Emilie Legros-Lafarge
- Centre Référent de Réhabilitation Psychosociale de Limoges (C2RL), 87000 Limoges, France
| | | | - Catherine Massoubre
- Centre Hospitalier Universitaire de Saint-Etienne, 42270 Saint-Priest-en-Jarez, France
- Faculté de Médecine, Université de Saint-Etienne, 42023 Saint-Etienne, France
| | | | - Julien Plasse
- Pôle Centre Rive Gauche, Hôpital Le Vinatier, 69678 Bron, France
- Centre Ressource de Réhabilitation Psychosociale et de Remédiation Cognitive (CRR), CH le Vinatier et Institut Marc Jeannerod, UMR 5229 & Université Lyon 1, 69100 Bron, France
| | - Guillaume Barbalat
- Pôle Centre Rive Gauche, Hôpital Le Vinatier, 69678 Bron, France
- Centre Ressource de Réhabilitation Psychosociale et de Remédiation Cognitive (CRR), CH le Vinatier et Institut Marc Jeannerod, UMR 5229 & Université Lyon 1, 69100 Bron, France
| | - Nicolas Franck
- Pôle Centre Rive Gauche, Hôpital Le Vinatier, 69678 Bron, France
- Centre Ressource de Réhabilitation Psychosociale et de Remédiation Cognitive (CRR), CH le Vinatier et Institut Marc Jeannerod, UMR 5229 & Université Lyon 1, 69100 Bron, France
| | - Caroline Demily
- Centre d’Excellence Autisme iMIND, pôle HU-ADIS, Hôpital le Vinatier, 69678 Bron, France
- Equipe «Disorders of the Brain», Institut Marc Jeannerod, UMR 5229, CNRS & Université Lyon 1, 69100 Villeurbanne, France
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10
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Nuss P, Corruble E, Baloche E, Garay R, Llorca PM. Fifty years of experience with loxapine for the rapid non-coercive tranquilization of acute behavioral disturbances in schizophrenia patients, and beyond. Expert Rev Neurother 2022; 22:639-653. [PMID: 35913401 DOI: 10.1080/14737175.2022.2108706] [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: 11/04/2022]
Abstract
INTRODUCTION Acute behavioral disturbances in psychosis, including agitation, comprise a heterogeneous group of manifestations varying in intensity and duration they last for. They require rapid, non-coercive treatments ranging from verbal de-escalation to the calming effect of pharmacological agents. The treatment goals are reduction of patient suffering and prevention of disease deterioration. Stabilizing rather than sedating is preferred to ensure improved compliance and a stronger therapeutic alliance. Furthermore, animal pharmacology and clinical studies on agitation reveal the robust calming and anxiolytic properties of loxapine. AREAS COVERED This review covers the pharmacological and clinical history of loxapine along with research developments. It emphasizes the advantages of its multiple formulations ranging from injectable forms and tablets to orally inhaled forms to attain rapid and fine-tuned tranquilization. EXPERT OPINION Rapid tranquillization is achieved within 2-6 hours using liquid orally-consumed loxapine, and within an hour or less with its IM or orally inhaled forms. Loxapine has been adopted in the management of a wide range of acute disturbances, such as agitation in psychosis. In the context of personalized medicine, key cellular and molecular elements of the schizophrenia phenotype were recently shown to be improved with loxapine.
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Affiliation(s)
- Philippe Nuss
- Department of Adult Psychiatry and Medical Psychology, Sorbonne University, Saint-Antoine Hospital, Paris, France & Inserm UMR-S938, Saint-Antoine Research Centre, Sorbonne University, Paris, France
| | - Emmanuelle Corruble
- INSERM CESP-Team 'Moods', Paris-Saclay University & Department of Psychiatry, Bicetre Hospital & School of Medicine Paris-Saclay, Le Kremlin Bicetre, France
| | | | - Ricardo Garay
- Department of Pharmacology and Therapeutics, Craven, France; CNRS, National Centre of Scientific Research, Paris, France
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11
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Risk of Drug-induced Movement Disorders with Newer Antipsychotic Agents. Tremor Other Hyperkinet Mov (N Y) 2022; 12:19. [PMID: 35836971 PMCID: PMC9187243 DOI: 10.5334/tohm.695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/27/2022] [Indexed: 01/19/2023] Open
Abstract
Background: The last decade has seen development of numerous novel antipsychotic drugs with unique mechanisms including long-acting formulations for clinical use. A comparative assessment of these new drugs with each other and previous antipsychotics have not been performed with regards to risk for drug-induced movement disorders (DIMD). Methods: Medline was searched from January 2010 to February 2022 for primary research articles and review articles in English using the search terms “extrapyramidal” and “tardive” with individual drug names of novel antipsychotics. Results: We identified articles describing the risk of DIMD with 6 novel antipsychotics, 4 novel formulations, and 3 experimental antipsychotics. Both short- and long-term data generally showed comparable to lower risk of DIMD with novel antipsychotics and recent long-acting formulations compared to previously marketed antipsychotics. Discussion: Several novel antipsychotics, particularly lumateperone and pimavanserin, show promise in being able to treat psychosis while reducing the risk of DIMD. Long-acting paliperidone may reduce risk of DIMD while other long-acting injectable formulations of SGA have similar risk of DIMD compared to oral formulations. New drug targets for treating psychosis without dopamine blockade also show promise.
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12
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Merino D, Fernandez A, Gérard AO, Ben Othman N, Rocher F, Askenazy F, Verstuyft C, Drici MD, Thümmler S. Adverse Drug Reactions of Olanzapine, Clozapine and Loxapine in Children and Youth: A Systematic Pharmacogenetic Review. Pharmaceuticals (Basel) 2022; 15:ph15060749. [PMID: 35745668 PMCID: PMC9230864 DOI: 10.3390/ph15060749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 01/27/2023] Open
Abstract
Children and youth treated with antipsychotic drugs (APs) are particularly vulnerable to adverse drug reactions (ADRs) and prone to poor treatment response. In particular, interindividual variations in drug exposure can result from differential metabolism of APs by cytochromes, subject to genetic polymorphism. CYP1A2 is pivotal in the metabolism of the APs olanzapine, clozapine, and loxapine, whose safety profile warrants caution. We aimed to shed some light on the pharmacogenetic profiles possibly associated with these drugs’ ADRs and loss of efficacy in children and youth. We conducted a systematic review relying on four databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 recommendations and checklist, with a quality assessment. Our research yielded 32 publications. The most frequent ADRs were weight gain and metabolic syndrome (18; 56.3%), followed by lack of therapeutic effect (8; 25%) and neurological ADRs (7; 21.8%). The overall mean quality score was 11.3/24 (±2.7). In 11 studies (34.3%), genotyping focused on the study of cytochromes. Findings regarding possible associations were sometimes conflicting. Nonetheless, cases of major clinical improvement were fostered by genotyping. Yet, CYP1A2 remains poorly investigated. Further studies are required to improve the assessment of the risk–benefit balance of prescription for children and youth treated with olanzapine, clozapine, and/or loxapine.
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Affiliation(s)
- Diane Merino
- Department of Child and Adolescent Psychiatry, Children’s Hospitals of Nice CHU-Lenval, 06200 Nice, France; (D.M.); (A.F.); (F.A.)
- CoBTek Laboratory, Université Côte d’Azur, 06100 Nice, France
- Department of Pharmacology and Pharmacovigilance Center, University Hospital of Nice, 06000 Nice, France; (A.O.G.); (N.B.O.); (F.R.); (M.-D.D.)
| | - Arnaud Fernandez
- Department of Child and Adolescent Psychiatry, Children’s Hospitals of Nice CHU-Lenval, 06200 Nice, France; (D.M.); (A.F.); (F.A.)
- CoBTek Laboratory, Université Côte d’Azur, 06100 Nice, France
| | - Alexandre O. Gérard
- Department of Pharmacology and Pharmacovigilance Center, University Hospital of Nice, 06000 Nice, France; (A.O.G.); (N.B.O.); (F.R.); (M.-D.D.)
| | - Nouha Ben Othman
- Department of Pharmacology and Pharmacovigilance Center, University Hospital of Nice, 06000 Nice, France; (A.O.G.); (N.B.O.); (F.R.); (M.-D.D.)
| | - Fanny Rocher
- Department of Pharmacology and Pharmacovigilance Center, University Hospital of Nice, 06000 Nice, France; (A.O.G.); (N.B.O.); (F.R.); (M.-D.D.)
| | - Florence Askenazy
- Department of Child and Adolescent Psychiatry, Children’s Hospitals of Nice CHU-Lenval, 06200 Nice, France; (D.M.); (A.F.); (F.A.)
- CoBTek Laboratory, Université Côte d’Azur, 06100 Nice, France
| | - Céline Verstuyft
- Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpital Bicêtre, Groupe Hospitalier Paris Saclay, AP–HP, 94270 Le Kremlin-Bicêtre, France;
- CESP/UMR-S1178, Inserm, Université Paris-Sud, 92290 Paris, France
| | - Milou-Daniel Drici
- Department of Pharmacology and Pharmacovigilance Center, University Hospital of Nice, 06000 Nice, France; (A.O.G.); (N.B.O.); (F.R.); (M.-D.D.)
| | - Susanne Thümmler
- Department of Child and Adolescent Psychiatry, Children’s Hospitals of Nice CHU-Lenval, 06200 Nice, France; (D.M.); (A.F.); (F.A.)
- CoBTek Laboratory, Université Côte d’Azur, 06100 Nice, France
- Correspondence:
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13
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Gao AY, Link PA, Bakri SJ, Haak AJ. Dopamine Receptor Signaling Regulates Fibrotic Activation of Retinal Pigmented Epithelial Cells. Am J Physiol Cell Physiol 2022; 323:C116-C124. [PMID: 35544697 DOI: 10.1152/ajpcell.00468.2021] [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: 11/22/2022]
Abstract
Retinal pigmented epithelial (RPE) cells play an important role in retinal fibrotic diseases such as proliferative vitreoretinopathy (PVR). The purpose of this study was to elucidate the involvement of dopamine receptor signaling in regulating the fibrotic activation of RPE cells. Dopamine receptor expression, the effect of dopamine on fibrotic activity, and dopamine production were measured in the human RPE cell line ARPE-19. The fibrotic activation of RPE cells was evaluated in response to treatments with selective dopamine receptor agonists and antagonists by measuring gene expression, migration, proliferation, and fibronectin deposition. DRD2 and DRD5 are the dominant dopaminergic receptors expressed in ARPE-19 cells and TGFβ stimulates enhances autocrine release of dopamine which we show further exasperates fibrotic activation. Finally, treatment with D2 dopamine receptor antagonists or D5 dopamine receptor agonists inhibits profibrotic gene expression, migration, proliferation, and fibronectin deposition and thus may serve as effective mechanisms for treating retinal fibrosis including PVR.
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Affiliation(s)
- Ashley Y Gao
- Mayo Clinic, Department of Ophthalmology, Rochester, MN, United States
| | - Patrick A Link
- Mayo Clinic, Department of Physiology and Biomedical Engineering, Rochester, MN, United States
| | - Sophie J Bakri
- Mayo Clinic, Department of Ophthalmology, Rochester, MN, United States
| | - Andrew J Haak
- Mayo Clinic, Department of Physiology and Biomedical Engineering, Rochester, MN, United States
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14
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Tai W, Kwok PCL. Recent advances in drug delivery to the central nervous system by inhalation. Expert Opin Drug Deliv 2022; 19:539-558. [PMID: 35532357 DOI: 10.1080/17425247.2022.2074975] [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: 11/04/2022]
Abstract
INTRODUCTION Drugs need to enter the systemic circulation efficiently before they can cross the blood-brain barrier and reach the central nervous system. Although the respiratory tract is not a common route of administration for delivering drugs to the central nervous system, it has attracted increasing interest in recent years for this purpose. AREAS COVERED In this article, we compare pulmonary delivery to three other common routes (parenteral, oral, and intranasal) for delivering drugs to the central nervous system, followed by summarising the devices used to aerosolise neurological drugs. Recent studies delivering drugs for different neurological disorders via inhalation are then discussed to illustrate the strengths of pulmonary delivery. EXPERT OPINION Recent studies provide strong evidence and rationale to support inhaling neurological drugs. Since inhalation can achieve improved pharmacokinetics and rapid onset of action for multiple drugs, it is a non-invasive and efficient method to deliver drugs to the central nervous system. Future research should focus on delivering other small and macro-molecules via the lungs for different neurological conditions.
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Affiliation(s)
- Waiting Tai
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
| | - Philip Chi Lip Kwok
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
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15
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Farhid H, Nazeri MT, Rostami MM, Shaabani A, Notash B. Consecutive Betti/Bargellini multicomponent reactions: an efficient strategy for the synthesis of naphtho[1,2-f][1,4]oxazepine scaffolds. CHEMICAL PAPERS 2022. [DOI: 10.1007/s11696-021-01924-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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16
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Effect of Novel Antipsychotics on Energy Metabolism - In Vitro Study in Pig Brain Mitochondria. Mol Neurobiol 2021; 58:5548-5563. [PMID: 34365585 DOI: 10.1007/s12035-021-02498-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/15/2021] [Indexed: 10/20/2022]
Abstract
The identification and quantification of mitochondrial effects of novel antipsychotics (brexpiprazole, cariprazine, loxapine, and lurasidone) were studied in vitro in pig brain mitochondria. Selected parameters of mitochondrial metabolism, electron transport chain (ETC) complexes, citrate synthase (CS), malate dehydrogenase (MDH), monoamine oxidase (MAO), mitochondrial respiration, and total ATP and reactive oxygen species (ROS) production were evaluated and associated with possible adverse effects of drugs. All tested antipsychotics decreased the ETC activities (except for complex IV, which increased in activity after brexpiprazole and loxapine addition). Both complex I- and complex II-linked respiration were dose-dependently inhibited, and significant correlations were found between complex I-linked respiration and both complex I activity (positive correlation) and complex IV activity (negative correlation). All drugs significantly decreased mitochondrial ATP production at higher concentrations. Hydrogen peroxide production was significantly increased at 10 µM brexpiprazole and lurasidone and at 100 µM cariprazine and loxapine. All antipsychotics acted as partial inhibitors of MAO-A, brexpiprazole and loxapine partially inhibited MAO-B. Based on our results, novel antipsychotics probably lacked oxygen uncoupling properties. The mitochondrial effects of novel antipsychotics might contribute on their adverse effects, which are mostly related to decreased ATP production and increased ROS production, while MAO-A inhibition might contribute to their antidepressant effect, and brexpiprazole- and loxapine-induced MAO-B inhibition might likely promote neuroplasticity and neuroprotection. The assessment of drug-induced mitochondrial dysfunctions is important in development of new drugs as well as in the understanding of molecular mechanism of adverse or side drug effects.
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17
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Inhaled Loxapine as an Option for Psychomotor Agitation in Complex Patients. J Clin Psychopharmacol 2021; 40:645-647. [PMID: 33065716 DOI: 10.1097/jcp.0000000000001290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Erley J, Goldsborough S, VandenBerg A, Audu A. Loxapine in patient with clozapine-resistant psychosis. Ment Health Clin 2021; 11:263-266. [PMID: 34316424 PMCID: PMC8287867 DOI: 10.9740/mhc.2021.07.263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/21/2021] [Indexed: 01/08/2023] Open
Abstract
Clozapine is recognized as the drug of choice for treatment-refractory schizophrenia, but use may be limited because of strict monitoring requirements and adverse effects including severe neutropenia, seizures, and myocarditis. Loxapine is a first-generation antipsychotic with similarities to clozapine in both structure and receptor binding. This case describes a 57-year-old male with a history of severe paranoid schizophrenia despite treatment with clozapine and other psychotropic agents, who experienced clinical improvement after a cross titration from clozapine to loxapine. Loxapine may be a reasonable alternative in patients with treatment-refractory schizophrenia who do not tolerate or respond to clozapine.
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Affiliation(s)
- Jennifer Erley
- Psychiatry Pharmacy Resident, Michigan Medicine & University of Michigan College of Pharmacy, Ann Arbor, Michigan.,Psychiatry Pharmacy Specialist, Michigan Medicine & University of Michigan College of Pharmacy, Ann Arbor, Michigan.,Psychiatry Resident, Michigan Medicine, Ann Arbor, Michigan
| | - Sarah Goldsborough
- Psychiatry Pharmacy Resident, Michigan Medicine & University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Amy VandenBerg
- Psychiatry Pharmacy Specialist, Michigan Medicine & University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Alexandra Audu
- Psychiatry Resident, Michigan Medicine, Ann Arbor, Michigan
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19
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Shrestha S, Agha RS, Khan Z, Shah K, Jain S. Considering Loxapine Instead of Clozapine: A Case Series and Literature Review. Cureus 2021; 13:e12919. [PMID: 33654602 PMCID: PMC7906363 DOI: 10.7759/cureus.12919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
This case series highlights the importance of loxapine in psychiatric disorders when clozapine is unable to control agitation and psychotic symptoms due to medication noncompliance, intolerable side effects, or inadequate clinical outcomes. Loxapine is classified as a first-generation typical antipsychotic but displays atypical antipsychotic-like characteristics with structural similarity to clozapine. However, since the inception of second-generation antipsychotic medications, the role of loxapine in modern psychiatric practice has become limited. Loxapine has been underutilized due to concerns of side effects and lack of in-depth research about its safety, tolerability, and efficacy. This report revisits loxapine’s clinical utility through two well-studied long-term inpatient cases, where it played a crucial role in controlling psychotic symptoms and achieving better medication compliance by eliminating significant barriers, including monitoring regular differential complete blood counts. We aim to add to the current evidence and literature about the advantage of using loxapine for specific clinical scenarios in psychiatric practice.
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Affiliation(s)
- Shristi Shrestha
- Psychiatry, Texas Tech University Health Sciences Center, Midland, USA
| | - Raafae S Agha
- Psychiatry, Texas Tech University Health Sciences Center, Midland, USA
| | - Zershana Khan
- Psychiatry, Texas Tech University Health Sciences Center, Midland, USA
| | - Kaushal Shah
- Psychiatry, Griffin Memorial Hospital, Norman, USA
| | - Shailesh Jain
- Psychiatry, Texas Tech University Health Sciences Center, Midland, USA
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20
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Zheng X, Liu B, Yang F, Hu Q, Yao L, Hu Y. Access to Benzoxazepines and Fully Substituted Indoles via HDDA Coupling. Org Lett 2020; 22:956-959. [PMID: 31989829 DOI: 10.1021/acs.orglett.9b04499] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The HDDA-derived benzyne intermediate was captured by oxazolines based on the addition reaction of benzyne to the C═N double bond. Benzoxazepine derivatives, fused benzoxazepine derivatives, and fully substituted indoles are synthesized in one step. The reaction does not require any catalyst or additives. Possible reaction mechanisms are presented.
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Affiliation(s)
- Xiaojie Zheng
- Key Laboratory of Functional Molecular Solids, Ministry of Education, Anhui Laboratory of Molecule-Based Materials, State Laboratory Cultivation Base, College of Chemistry and Materials Science , Anhui Normal University , Wuhu , Anhui 241002 , China
| | - Baohua Liu
- Key Laboratory of Functional Molecular Solids, Ministry of Education, Anhui Laboratory of Molecule-Based Materials, State Laboratory Cultivation Base, College of Chemistry and Materials Science , Anhui Normal University , Wuhu , Anhui 241002 , China
| | - Feihu Yang
- Key Laboratory of Functional Molecular Solids, Ministry of Education, Anhui Laboratory of Molecule-Based Materials, State Laboratory Cultivation Base, College of Chemistry and Materials Science , Anhui Normal University , Wuhu , Anhui 241002 , China
| | - Qiong Hu
- Key Laboratory of Functional Molecular Solids, Ministry of Education, Anhui Laboratory of Molecule-Based Materials, State Laboratory Cultivation Base, College of Chemistry and Materials Science , Anhui Normal University , Wuhu , Anhui 241002 , China
| | - Liangliang Yao
- Key Laboratory of Functional Molecular Solids, Ministry of Education, Anhui Laboratory of Molecule-Based Materials, State Laboratory Cultivation Base, College of Chemistry and Materials Science , Anhui Normal University , Wuhu , Anhui 241002 , China
| | - Yimin Hu
- Key Laboratory of Functional Molecular Solids, Ministry of Education, Anhui Laboratory of Molecule-Based Materials, State Laboratory Cultivation Base, College of Chemistry and Materials Science , Anhui Normal University , Wuhu , Anhui 241002 , China
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21
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Ma H, Obeng S, Wang H, Zheng Y, Li M, Jali AM, Stevens DL, Dewey WL, Selley DE, Zhang Y. Application of Bivalent Bioisostere Concept on Design and Discovery of Potent Opioid Receptor Modulators. J Med Chem 2019; 62:11399-11415. [PMID: 31782922 DOI: 10.1021/acs.jmedchem.9b01767] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Here, we described the structural modification of previously identified μ opioid receptor (MOR) antagonist NAN, a 6α-N-7'-indolyl substituted naltrexamine derivative, and its 6β-N-2'-indolyl substituted analogue INTA by adopting the concept of "bivalent bioisostere". Three newly prepared opioid ligands, 25 (NBF), 31, and 38, were identified as potent MOR antagonists both in vitro and in vivo. Moreover, these three compounds significantly antagonized DAMGO-induced intracellular calcium flux and displayed varying degrees of inhibition on cAMP production. Furthermore, NBF produced much less significant withdrawal effects than naloxone in morphine-pelleted mice. Molecular modeling studies revealed that these bivalent bioisosteres may adopt similar binding modes in the MOR and the "address" portions of them may have negative or positive allosteric modulation effects on the function of their "message" portions compared with NAN and INTA. Collectively, our successful application of the "bivalent bioisostere concept" identified a promising lead to develop novel therapeutic agents toward opioid use disorder treatments.
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Affiliation(s)
- Hongguang Ma
- Department of Medicinal Chemistry, School of Pharmacy , Virginia Commonwealth University , 800 E Leigh Street , Richmond , Virginia 23298 , United States
| | - Samuel Obeng
- Department of Medicinal Chemistry, School of Pharmacy , Virginia Commonwealth University , 800 E Leigh Street , Richmond , Virginia 23298 , United States
| | - Huiqun Wang
- Department of Medicinal Chemistry, School of Pharmacy , Virginia Commonwealth University , 800 E Leigh Street , Richmond , Virginia 23298 , United States
| | - Yi Zheng
- Department of Medicinal Chemistry, School of Pharmacy , Virginia Commonwealth University , 800 E Leigh Street , Richmond , Virginia 23298 , United States
| | - Mengchu Li
- Department of Medicinal Chemistry, School of Pharmacy , Virginia Commonwealth University , 800 E Leigh Street , Richmond , Virginia 23298 , United States
| | - Abdulmajeed M Jali
- Department of Pharmacology and Toxicology , Virginia Commonwealth University , 410 North 12th Street , Richmond , Virginia 23298 , United States
| | - David L Stevens
- Department of Pharmacology and Toxicology , Virginia Commonwealth University , 410 North 12th Street , Richmond , Virginia 23298 , United States
| | - William L Dewey
- Department of Pharmacology and Toxicology , Virginia Commonwealth University , 410 North 12th Street , Richmond , Virginia 23298 , United States
| | - Dana E Selley
- Department of Pharmacology and Toxicology , Virginia Commonwealth University , 410 North 12th Street , Richmond , Virginia 23298 , United States
| | - Yan Zhang
- Department of Medicinal Chemistry, School of Pharmacy , Virginia Commonwealth University , 800 E Leigh Street , Richmond , Virginia 23298 , United States
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22
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Schmiedl S, Peters D, Schmalz O, Mielke A, Rossmanith T, Diop S, Piefke M, Thürmann P, Schmidtko A. Loxapine for Treatment of Patients With Refractory, Chemotherapy-Induced Neuropathic Pain: A Prematurely Terminated Pilot Study Showing Efficacy But Limited Tolerability. Front Pharmacol 2019; 10:838. [PMID: 31402867 PMCID: PMC6669235 DOI: 10.3389/fphar.2019.00838] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 07/01/2019] [Indexed: 12/25/2022] Open
Abstract
Neuropathic pain is a debilitating and commonly treatment-refractory condition requiring novel therapeutic options. Accumulating preclinical studies indicate that the potassium channel Slack (KNa1.1) contributes to the processing of neuropathic pain, and that Slack activators, when injected into mice, ameliorate pain-related hypersensitivity. However, whether Slack activation might reduce neuropathic pain in humans remains elusive. Here, we evaluated the tolerability and analgesic efficacy of loxapine, a first-generation antipsychotic drug and Slack activator, in neuropathic pain patients. We aimed to treat 12 patients with chronic chemotherapy-induced, treatment-refractory neuropathic pain (pain severity ≥ 4 units on an 11-point numerical rating scale) in a monocentric, open label, proof-of-principle study. Patients received loxapine orally as add-on analgesic in a dose-escalating manner (four treatment episodes for 14 days, daily dose: 20, 30, 40, or 60 mg loxapine) depending on tolerability and analgesic efficacy. Patient-reported outcomes of pain intensity and/or relief were recorded daily. After enrolling four patients, this study was prematurely terminated due to adverse events typically occurring with first-generation antipsychotic drugs that were reported by all patients. In two patients receiving loxapine for at least two treatment episodes, a clinically relevant analgesic effect was found at a daily dose of 20-30 mg of loxapine. Another two patients tolerated loxapine only for a few days. Together, our data further support the hypothesis that Slack activation might be a novel strategy for neuropathic pain therapy. However, loxapine is no valid treatment option for painful polyneuropathy due to profound dopamine and histamine receptor-related side effects. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02820519.
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Affiliation(s)
- Sven Schmiedl
- Philipp Klee-Institute for Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany.,Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - David Peters
- Philipp Klee-Institute for Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany.,Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Oliver Schmalz
- Clinic of Internal Medicine I, Division of Oncology and Palliative Care, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Anke Mielke
- Clinic for Anesthesiology, Pain Management Unit, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Tanja Rossmanith
- Fraunhofer Institute for Molecular Biology and Applied Ecology (IME), branch for Translational Medicine and Pharmacology of the Fraunhofer IME, Frankfurt, Germany
| | - Shirin Diop
- Neurobiology and Genetics of Behavior, Department of Psychology and Psychotherapy, Centre for Biomedical Education and Research (ZBAF), Witten/Herdecke University, Witten, Germany
| | - Martina Piefke
- Neurobiology and Genetics of Behavior, Department of Psychology and Psychotherapy, Centre for Biomedical Education and Research (ZBAF), Witten/Herdecke University, Witten, Germany
| | - Petra Thürmann
- Philipp Klee-Institute for Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany.,Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Achim Schmidtko
- Institute of Pharmacology and Toxicology, Centre for Biomedical Education and Research (ZBAF), School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany.,Institute of Pharmacology and Clinical Pharmacy, College of Pharmacy, Goethe University, Frankfurt, Germany
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Paul P, Ramachandran S, Xia S, Unruh JR, Conkright-Fincham J, Li R. Dopamine receptor antagonists as potential therapeutic agents for ADPKD. PLoS One 2019; 14:e0216220. [PMID: 31059522 PMCID: PMC6502331 DOI: 10.1371/journal.pone.0216220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 04/16/2019] [Indexed: 12/24/2022] Open
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is caused mostly by mutations in polycystin-1 or polycystin-2. Fluid flow leads to polycystin-dependent calcium influx and nuclear export of histone deacetylase 5 (HDAC5), which facilitates the maintenance of renal epithelial architecture by de-repression of MEF2C target genes. Here, we screened a small-molecule library to find drugs that promotes nuclear export of HDAC5. We found that dopamine receptor antagonists, domperidone and loxapine succinate, stimulate export of HDAC5, even in Pkd1–/–cells. Domperidone targets Drd3 receptor to modulate the phosphorylation of HDAC5. Domperidone treatment increases HDAC5 phosphorylation likely by reducing protein phosphatase 2A (PP2A) activity, thus shifting the equilibrium towards HDAC5-P and export from the nucleus. Treating Pkd1–/–mice with domperidone showed significantly reduced cystic growth and cell proliferation. Further, treated mice displayed a reduction in glomerular cyst and increased body weight and activity. These results suggest that HDAC5 nucleocytoplasmic shuttling may be modulated to impede disease progression in ADPKD and uncovers an unexpected role for a class of dopamine receptors in renal epithelial morphogenesis.
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Affiliation(s)
- Parama Paul
- Center for Cell Dynamics, Department of Cell Biology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Stowers Institute for Medical Research, Kansas City, MO, United States
| | - Sreekumar Ramachandran
- Center for Cell Dynamics, Department of Cell Biology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sheng Xia
- Center for Cell Dynamics, Department of Cell Biology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Stowers Institute for Medical Research, Kansas City, MO, United States
- Division of Neonatology, Children’s Mercy Hospital, Kansas City, MO, United States
| | - Jay R. Unruh
- Stowers Institute for Medical Research, Kansas City, MO, United States
| | | | - Rong Li
- Center for Cell Dynamics, Department of Cell Biology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Stowers Institute for Medical Research, Kansas City, MO, United States
- Department of Chemical and Biomolecular Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
- * E-mail:
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24
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Moon H, Jung Y, Kim Y, Kim BW, Choi JG, Kim NH, Oh MS, Park S, Kim BM, Kim D. High Stability of a Donor–Acceptor Type Oxazepine-Containing Fluorophore and Its Applications in Cellular Imaging and Two-Photon Deep Tissue Imaging. Org Lett 2019; 21:3891-3894. [DOI: 10.1021/acs.orglett.9b00784] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Heejo Moon
- Department of Chemistry, College of Natural Sciences, Seoul National University, Seoul 08826, Republic of Korea
| | | | - Youngseo Kim
- Department of Chemistry, Korea University, Seoul 02841, Republic of Korea
| | - Byeong Wook Kim
- Department of Chemistry, College of Natural Sciences, Seoul National University, Seoul 08826, Republic of Korea
| | | | | | | | - Sungnam Park
- Department of Chemistry, Korea University, Seoul 02841, Republic of Korea
| | - B. Moon Kim
- Department of Chemistry, College of Natural Sciences, Seoul National University, Seoul 08826, Republic of Korea
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Pacciardi B, Calcedo A, Messer T. Inhaled Loxapine for the Management of Acute Agitation in Bipolar Disorder and Schizophrenia: Expert Review and Commentary in an Era of Change. Drugs R D 2019; 19:15-25. [PMID: 30721526 PMCID: PMC6380965 DOI: 10.1007/s40268-019-0262-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Agitation is a common and costly phenomenon associated with a number of psychiatric conditions including schizophrenia and bipolar disorder. Early identification and prompt intervention to relieve the symptoms of agitation are essential to avoid symptomatic escalation and emergence of aggressive behaviour. Recent consensus guidelines emphasise the need for non-coercive management strategies to protect the therapeutic alliance between patients and their healthcare providers—an alliance that is critical for the effective management of chronic psychiatric conditions. Rapid symptom relief and de-escalation of agitation are necessary to avoid the costly and traumatic use of coercive techniques of physical restraint and seclusion, which require admission and prolonged hospitalisation. Inhaled loxapine is approved for the treatment of acute agitation in patients with schizophrenia or bipolar disorder. Clinical studies have confirmed the efficacy, rapid onset of action, and safety and tolerability of this agent in the psychiatric emergency and hospital settings. Emerging data have indicated the potential for inhaled loxapine as a self-administered agent for use in the community setting without the direct supervision of a healthcare professional. We discuss the evolving treatment paradigm and the place of inhaled medications for acutely agitated patients both within and outside the emergency and hospital setting.
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Affiliation(s)
| | - Alfredo Calcedo
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Thomas Messer
- Danuvius Klinik GmbH, Pfaffenhofen an Der Ilm, Germany
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26
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Faden J, Citrome L. Examining the safety, efficacy, and patient acceptability of inhaled loxapine for the acute treatment of agitation associated with schizophrenia or bipolar I disorder in adults. Neuropsychiatr Dis Treat 2019; 15:2273-2283. [PMID: 31496709 PMCID: PMC6689540 DOI: 10.2147/ndt.s173567] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/24/2019] [Indexed: 12/19/2022] Open
Abstract
Agitation is a common and serious symptom of bipolar mania and schizophrenia, and can be defined as excessive motor and verbal activity. If left unrecognized and untreated, agitation can evolve into aggression, resulting in potential patient and staff injury. An ideal treatment for agitation would have a rapid onset, cause calmness without sedation, and be tolerable, efficacious, and non-coercive, while managing the underlying condition. A novel approach for the treatment of agitation is inhaled loxapine. Inhaled loxapine is rapidly absorbed into the systemic circulation through the alveoli, resulting in a near immediate onset of action. The efficacy of inhaled loxapine was established in an extensive clinical development program that included persons with schizophrenia and bipolar mania. Additionally, inhaled loxapine has comparable efficacy to intramuscular ziprasidone, olanzapine, haloperidol, aripiprazole, and lorazepam, with the added benefit of being non-painful and non-traumatizing. Inhaled loxapine carries a bolded black box warning for bronchospasm, and as a result, in the US, requires enrollment in a Risk Evaluation and Mitigation Strategy program, and is contraindicated in those with pulmonary disease. Additionally, the use of inhaled loxapine can be associated with dysgeusia and throat irritation. Inhaled loxapine requires some degree of patient cooperation, and therefore may not be appropriate for all agitated patients.
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Affiliation(s)
- Justin Faden
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19125, USA
| | - Leslie Citrome
- Psychiatry & Behavioral Sciences, New York Medical College, Valhalla, NY 10595, USA
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27
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Evely KM, Pryce KD, Bausch AE, Lukowski R, Ruth P, Haj-Dahmane S, Bhattacharjee A. Slack K Na Channels Influence Dorsal Horn Synapses and Nociceptive Behavior. Mol Pain 2018; 13:1744806917714342. [PMID: 28604221 PMCID: PMC5486487 DOI: 10.1177/1744806917714342] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The sodium-activated potassium channel Slack (Kcnt1, Slo2.2) is highly expressed in dorsal root ganglion neurons where it regulates neuronal firing. Several studies have implicated the Slack channel in pain processing, but the precise mechanism or the levels within the sensory pathway where channels are involved remain unclear. Here, we furthered the behavioral characterization of Slack channel knockout mice and for the first time examined the role of Slack channels in the superficial, pain-processing lamina of the dorsal horn. We performed whole-cell recordings from spinal cord slices to examine the intrinsic and synaptic properties of putative inhibitory and excitatory lamina II interneurons. Slack channel deletion altered intrinsic properties and synaptic drive to favor an overall enhanced excitatory tone. We measured the amplitudes and paired pulse ratio of paired excitatory post-synaptic currents at primary afferent synapses evoked by electrical stimulation of the dorsal root entry zone. We found a substantial decrease in the paired pulse ratio at synapses in Slack deleted neurons compared to wildtype, indicating increased presynaptic release from primary afferents. Corroborating these data, plantar test showed Slack knockout mice have an enhanced nociceptive responsiveness to localized thermal stimuli compared to wildtype mice. Our findings suggest that Slack channels regulate synaptic transmission within the spinal cord dorsal horn and by doing so establishes the threshold for thermal nociception.
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Affiliation(s)
- Katherine M Evely
- Program in Neuroscience, University at Buffalo, The State University of New York, NY, USA
| | - Kerri D Pryce
- Department of Pharmacology and Toxicology, University at Buffalo, The State University of New York, NY, USA
| | - Anne E Bausch
- Institut für Pharmazie, Pharmakologie, Toxikologie und Klinische Pharmazie der Universität Tübingen, Germany
| | - Robert Lukowski
- Institut für Pharmazie, Pharmakologie, Toxikologie und Klinische Pharmazie der Universität Tübingen, Germany
| | - Peter Ruth
- Institut für Pharmazie, Pharmakologie, Toxikologie und Klinische Pharmazie der Universität Tübingen, Germany
| | - Samir Haj-Dahmane
- Program in Neuroscience, University at Buffalo, The State University of New York, NY, USA
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28
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San L, Estrada G, Oudovenko N, Montañés F, Dobrovolskaya N, Bukhanovskaya O, Popov M, Vieta E. PLACID study: A randomized trial comparing the efficacy and safety of inhaled loxapine versus intramuscular aripiprazole in acutely agitated patients with schizophrenia or bipolar disorder. Eur Neuropsychopharmacol 2018; 28:710-718. [PMID: 29724638 DOI: 10.1016/j.euroneuro.2018.03.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 02/13/2018] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
Abstract
The aim of the study was to investigate the efficacy and safety of inhaled loxapine compared with the intramuscular (IM) antipsychotic aripiprazole in acutely agitated patients with schizophrenia or bipolar I disorder. PLACID was an assessor-blind, parallel-group trial conducted in 23 centres in the Czech Republic, Germany, Spain, and Russia. Patients (aged 18-65 years) diagnosed with schizophrenia or bipolar I disorder experiencing acute agitation (Clinical Global Impression [CGI]-Severity score ≥ 4) while hospitalized or attending an emergency room were randomized to receive up to two doses of inhaled loxapine 9.1 mg or IM aripiprazole 9.75 mg (≥ 2 h between doses) during the 24-h study period. The primary efficacy endpoint was time to response (CGI-Improvement score 1 [very much improved] or 2 [much improved]). The primary analysis included randomized patients who provided informed consent (full analysis set [FAS]); the safety analysis included all patients who received study medication. The FAS comprised 357 patients (enrolled December 2, 2014 - October 31, 2016). The between-treatment difference in median time to CGI-Improvement response was 10 min (95% CI 0.0-30.0); p = 0.0005) in favour of inhaled loxapine (median [95% CI]: 50 min [30.0-50.0] vs 60 min [50.0-90.0] with IM aripiprazole); the difference was significant at 10 min (responders: 14% [loxapine] vs 4% [aripiprazole]; p = 0.001). There were no safety issues. Inhaled loxapine reduced agitation faster than IM aripiprazole, supporting its use as a first-line option for managing acute agitation in patients with schizophrenia or bipolar disorder.
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Affiliation(s)
- Luis San
- Parc Sanitari Sant Joan de Deu, CIBERSAM, Barcelona, Spain.
| | | | | | | | | | - Olga Bukhanovskaya
- Treatment and Rehabilitology Scientific Center "Phoenix", Rostov on Don, Russia
| | - Mikhail Popov
- City Psychiatric Hospital No. 3, Bekhterev Psychoneurological Research Institute, Sankt Peterburg, Russia
| | - Eduard Vieta
- Hospital Clínic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
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29
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Patel MX, Sethi FN, Barnes TR, Dix R, Dratcu L, Fox B, Garriga M, Haste JC, Kahl KG, Lingford-Hughes A, McAllister-Williams H, O'Brien A, Parker C, Paterson B, Paton C, Posporelis S, Taylor DM, Vieta E, Völlm B, Wilson-Jones C, Woods L. Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation. J Psychopharmacol 2018; 32:601-640. [PMID: 29882463 DOI: 10.1177/0269881118776738] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder. There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine. Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included.
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Affiliation(s)
- Maxine X Patel
- 1 Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Faisil N Sethi
- 2 Maudsley Hospital, South London and Maudsley NHS Foundation Trust, London, UK
| | - Thomas Re Barnes
- 3 The Centre for Psychiatry, Imperial College London, London, UK
| | - Roland Dix
- 4 Wotton Lawn Hospital, together NHS Foundation Trust, Gloucester, UK
| | - Luiz Dratcu
- 5 Maudsley Hospital, South London and Maudsley NHS Foundation Trust, London, UK
| | - Bernard Fox
- 6 National Association of Psychiatric Intensive Care Units, East Kilbride, Glasgow, UK
| | - Marina Garriga
- 7 Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - Julie C Haste
- 8 Mill View Hospital, Sussex Partnership NHS Foundation Trust, Hove, East Sussex, UK
| | - Kai G Kahl
- 9 Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hanover, Germany
| | - Anne Lingford-Hughes
- 10 The Centre for Psychiatry, Imperial College London, London, UK and Central North West London NHS Foundation Trust, London, UK
| | - Hamish McAllister-Williams
- 11 Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,12 Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Aileen O'Brien
- 13 South West London and St Georges NHS Foundation Trust, London, UK and St George's University of London, London, UK
| | - Caroline Parker
- 14 Central & North West London NHS Foundation Trust, London, UK
| | | | - Carol Paton
- 16 Oxleas NHS Foundation Trust, Dartford, UK
| | - Sotiris Posporelis
- 17 South London and Maudsley NHS Foundation Trust, London, UK and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - David M Taylor
- 18 South London and Maudsley NHS Foundation Trust, London, UK
| | - Eduard Vieta
- 7 Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - Birgit Völlm
- 19 Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Laura Woods
- 21 The Hellingly Centre, Forensic Health Care Services, Sussex Partnership NHS Foundation Trust, East Sussex, UK
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30
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Tezenas du Montcel C, Kowal C, Leherle A, Kabbaj S, Frajerman A, Le Guen E, Hamdani N, Schürhoff F, Leboyer M, Pelissolo A, Pignon B. Isolement et contention mécanique dans les soins psychiatriques : modalités de prescription, prise en charge et surveillance. Presse Med 2018; 47:349-362. [DOI: 10.1016/j.lpm.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/22/2018] [Accepted: 03/06/2018] [Indexed: 12/19/2022] Open
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31
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Ferreri F, Drapier D, Baloche E, Ouzid M, Zimmer L, Llorca PM. The in Vitro Actions of Loxapine on Dopaminergic and Serotonergic Receptors. Time to Consider Atypical Classification of This Antipsychotic Drug? Int J Neuropsychopharmacol 2017; 21:355-360. [PMID: 29106549 PMCID: PMC5887516 DOI: 10.1093/ijnp/pyx102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 10/29/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The denomination of typical antipsychotic for loxapine has poor relation to current knowledge of the molecule's relevant modes of action. MATERIALS AND METHODS Competition binding experiments were performed on expressed human recombinant receptors in CHO cells and HEK-293 cells for D1 to D5, 5-HT1A, 5-HT2A, 5-HT2C, 5-HT4, 5-HT6, and 5-HT7. In vitro autoradiographies using [11C]-Raclopride [18F]-Altanserin [18F]-MPPF [11C]-SB207145, and [18F]-2FNQ1P were measured in brain tissue of a male primate followed by addition of increasing doses of loxapine succinate. RESULTS In cell cultures, the measured Kb confirmed high affinity of loxapine for the D2; intermediate affinity for the D1, D4, D5, 5-HT2C receptorsl and a lack of affinity toward D3, 5-HT1A, 5-HT4, 5-HT6, and 5-HT7 receptors. In brain tissue, PET autoradiographies showed a radiopharmaceutical displacement at low concentrations of loxapine on D2 and 5-HT2A receptors. CONCLUSION This preclinical study reveals that loxapine receptorial spectrum is close to an "atypical" profile (D2/5HT2A ratio, 1.14). Loxapine is rightly classified as a DS-RAn agent in the Neuroscience Based Nomenclature classification.
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Affiliation(s)
- Florian Ferreri
- Sorbonne Universités, UPMC Paris, France,Department of Psychiatry, Hospital Saint-Antoine, Paris, France,Correspondence: Florian Ferreri, MD, PhD, UPMC Paris Univ-06, Paris, France; Department of Psychiatry, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine 75012 Paris, France (, )
| | - Dominique Drapier
- Université de Rennes 1, Rennes, France,Department of Psychiatry, Rennes University Hospital, Rennes, France
| | | | | | - Luc Zimmer
- Université Claude Bernard Lyon1, CNRS, INSERM, Lyon, France,CERMEP-Imaging Platform, Hospices Civils de Lyon, Lyon, France
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Extrapyramidal side effects of antipsychotics are linked to their association kinetics at dopamine D 2 receptors. Nat Commun 2017; 8:763. [PMID: 28970469 PMCID: PMC5624946 DOI: 10.1038/s41467-017-00716-z] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 07/20/2017] [Indexed: 12/20/2022] Open
Abstract
Atypical antipsychotic drugs (APDs) have been hypothesized to show reduced extrapyramidal side effects (EPS) due to their rapid dissociation from the dopamine D2 receptor. However, support for this hypothesis is limited to a relatively small number of observations made across several decades and under different experimental conditions. Here we show that association rates, but not dissociation rates, correlate with EPS. We measured the kinetic binding properties of a series of typical and atypical APDs in a novel time-resolved fluorescence resonance energy transfer assay, and correlated these properties with their EPS and prolactin-elevating liabilities at therapeutic doses. EPS are robustly predicted by a rebinding model that considers the microenvironment of postsynaptic D2 receptors and integrates association and dissociation rates to calculate the net rate of reversal of receptor blockade. Thus, optimizing binding kinetics at the D2 receptor may result in APDs with improved therapeutic profile. Atypical antipsychotics show reduced extrapyramidal side effects compared to first generation drugs. Here the authors use time-resolved FRET to measure binding kinetics, and show that side effects correlate with drug association rates to the D2 receptor, while dissociation rates correlate with prolactin elevation.
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Selim S, Riesenberg R, Cassella J, Kunta J, Hellriegel E, Smith MA, Vinks AA, Rabinovich-Guilatt L. Pharmacokinetics and Safety of Single-Dose Inhaled Loxapine in Children and Adolescents. J Clin Pharmacol 2017; 57:1244-1257. [PMID: 28510296 DOI: 10.1002/jcph.932] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 04/04/2017] [Indexed: 12/16/2022]
Abstract
This multisite open-label study sought to characterize the pharmacokinetics and safety of a single dose of inhaled loxapine in children and adolescents. Loxapine powder for oral inhalation was administered via a single-use handheld drug device to children and adolescents (aged 10-17 years) with any condition warranting chronic antipsychotic use. Patients were dosed according to body weight and cohort (<50 kg [n = 15], 2.5 or 5 mg; ≥50 kg [n = 15], 5 or 10 mg); the first 6 patients (cohort 1) enrolled in each weight group received the lower dose. Patients were enrolled in the higher-dose group (cohort 2) after an interim pharmacokinetic and safety analysis of data from cohort 1. Blood samples were collected for 48 hours after dosing to determine the pharmacokinetic profile of loxapine and its metabolites. Safety was assessed using adverse event (AE), laboratory value, physical/neurologic examination, vital sign, electrocardiogram, suicidality, and extrapyramidal symptom assessment. Thirty patients were enrolled and evaluable for pharmacokinetics. Loxapine plasma concentrations peaked by 2 to 5 minutes in most patients; systemic exposure increased with dose in both weight subgroups. Loxapine terminal elimination half-life was ∼13 to 17 hours. The most common AEs were sedation and dysgeusia. Sedation was severe in 1 patient in the <50-kg group (2.5-mg dose) and 1 patient in the ≥50-kg group (5-mg dose). No AEs indicative of bronchospasm or other serious AEs were reported. Inhaled loxapine was rapidly absorbed and generally well tolerated in pediatric patients; no new safety signals were observed.
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Affiliation(s)
- Sally Selim
- Clinical Development, Teva Pharmaceutical Industries, Frazer, PA, USA
| | | | | | - Jeevan Kunta
- R&D, Teva Pharmaceutical Industries, West Chester, PA, USA
| | | | - Mark A Smith
- Clinical Development, Teva Pharmaceutical Industries, Frazer, PA, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Hellings JA, Arnold LE, Han JC. Dopamine antagonists for treatment resistance in autism spectrum disorders: review and focus on BDNF stimulators loxapine and amitriptyline. Expert Opin Pharmacother 2017; 18:581-588. [PMID: 28335658 DOI: 10.1080/14656566.2017.1308483] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Drug development and repurposing are urgently needed for individuals with autism spectrum disorders (ASD) and psychiatric comorbidity, which often presents as aggression and self-injury. Areas covered: We review dopamine antagonists, including classical and atypical, as well as unconventional antipsychotics in ASD. The older antipsychotic loxapine is discussed in terms of preliminary albeit limited evidence in ASD. Emerging promise of amitriptyline in ASD is discussed, together with promising BDNF effects of loxapine and amitriptyline. Expert opinion: In ASD, pharmacotherapy and specifically dopamine antagonist drugs are often prescribed for challenging behaviors including aggression. The novel antipsychotics risperidone and aripiprazole have received most study in ASD and are FDA-approved for irritability in children with ASD over age 5 years; individuals with ASD are prone to weight gain, Type II diabetes and associated side effects. Low dose loxapine has properties of classical and novel antipsychotics but importantly appears more weight neutral, and with promising use in adolescents and adults with ASD. Amitriptyline appears effective in ASD for irritability, aggression, gastrointestinal problems, and insomnia, in children, adolescents and adults however our adult data on amitriptyline in ASD is still in preparation for publication. Both loxapine and amitriptyline may stimulate BDNF; further studies are warranted.
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Affiliation(s)
- Jessica A Hellings
- a Kansas City Regional Center of Missouri Department of Mental Health , University of Missouri-Kansas City , Kansas City , MO , USA
| | - L Eugene Arnold
- b Department of Psychiatry , The Ohio State University Nisonger Center , Columbus , OH , USA
| | - Joan C Han
- c 454R Le Bonheur Children's Foundation Research Center , University of Tennessee , Memphis , TN , USA
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35
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San L, Estrada G, Oudovenko N, Vieta E. Rationale and design of the PLACID study: a randomised trial comparing the efficacy and safety of inhaled loxapine versus IM aripiprazole in acutely agitated patients with schizophrenia or bipolar disorder. BMC Psychiatry 2017; 17:126. [PMID: 28376877 PMCID: PMC5379730 DOI: 10.1186/s12888-017-1291-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 03/29/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The management of acute agitation manifesting in patients with schizophrenia or bipolar disorder requires swift pharmacological intervention to provide rapid symptomatic relief and prevent escalation to aggression and violence. Antipsychotic medications are widely used in this setting and the availability of an inhaled formulation with deep lung absorption of the antipsychotic loxapine has the potential to deliver a faster onset of therapeutic effect than the available intramuscular formulations of antipsychotics. METHODS The efficacy of inhaled loxapine and the alternative antipsychotic aripiprazole delivered via intramuscular (IM) injection will be compared in the Phase IIIb PLACID study. Adults (18-65 years) with a confirmed diagnosis of schizophrenia or bipolar I disorder presenting with acute agitation will be randomly assigned to open-label treatment in a 1:1 ratio. Clinical evaluation will be conducted by raters blinded to treatment assignment. The primary efficacy endpoint is time to response (defined as a Clinical Global Impression of Improvement [CGI-I] score of 1 [very much improved] or 2 [much improved]). Secondary endpoints will include the percentage of responders at different time points after dosing; the proportion of patients who receive 1 or 2 doses of study drug; time to second dose; time to rescue medication; satisfaction with study drug (evaluated using Item 14 of the Treatment Satisfaction Questionnaire for Medication); and safety and tolerability. Approximately 360 patients will be recruited with an interim analysis conducted once 180 patients have completed the study to decide whether to stop for futility or continue with or without an increase in the sample size up to additional 288 patients. DISCUSSION The PLACID trial will assess the efficacy and safety of inhaled loxapine with deep lung absorption compared with the IM antipsychotic, aripiprazole, in acutely agitated patients with schizophrenia or bipolar disorder. In the event that the median time to response of inhaled loxapine is significantly shorter than that of the intramuscular aripiprazole, the PLACID study has the potential to support the inhaled antipsychotic therapy as the standard of care in this setting. TRIAL REGISTRATION The study protocol was registered with the European Clinical Trials Database on the 31 October 2014 (EudraCT number 2014-000456-29 ).
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Affiliation(s)
- L. San
- Mental Health Department, Parc Sanitari Sant Joan de Deu, CIBERSAM, Carrer Camí Vell de la Colonia, 25 Sant Boi de Llobregat, Barcelona, Spain
| | | | | | - E. Vieta
- Hospital Clínic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
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The Role of Inhaled Loxapine in the Treatment of Acute Agitation in Patients with Psychiatric Disorders: A Clinical Review. Int J Mol Sci 2017; 18:ijms18020349. [PMID: 28208695 PMCID: PMC5343884 DOI: 10.3390/ijms18020349] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 01/26/2017] [Accepted: 02/02/2017] [Indexed: 01/26/2023] Open
Abstract
Loxapine is a first generation antipsychotic, belonging to the dibenzoxazepine class. Recently, loxapine has been reformulated at a lower dose, producing an inhaled powder that can be directly administered to the lungs to treat the agitation associated with psychiatric disorders, such as schizophrenia and bipolar disorder. Thus, the aim of this narrative and clinical mini-review was to evaluate the efficacy and tolerability of inhaled loxapine in the treatment of acute agitation in patients with psychiatric disorders. The efficacy of inhaled loxapine has been evaluated in one Phase II trial on patients with schizophrenia, and in two Phase III trials in patients with schizophrenia and bipolar disorder. Moreover, there are two published case series on patients with borderline personality disorder and dual diagnosis patients. Inhaled loxapine has proven to be effective and generally well tolerated when administered to agitated patients with schizophrenia and bipolar disorder. Two case series have suggested that inhaled loxapine may also be useful to treat agitation in patients with borderline personality disorder and with dual diagnosis, but further studies are needed to clarify this point. However, the administration of inhaled loxapine requires at least some kind of patient collaboration, and is not recommended in the treatment of severe agitation in totally uncooperative patients. Moreover, the drug-related risk of bronchospasm must always be kept in mind when planning to use inhaled loxapine, leading to a careful patient assessment prior to, and after, administration. Also, the higher costs of inhaled loxapine, when compared to oral and intramuscular medications, should be taken into account when selecting it for the treatment of agitation.
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Fountoulakis KN, Yatham L, Grunze H, Vieta E, Young A, Blier P, Kasper S, Moeller HJ. The International College of Neuro-Psychopharmacology (CINP) Treatment Guidelines for Bipolar Disorder in Adults (CINP-BD-2017), Part 2: Review, Grading of the Evidence, and a Precise Algorithm. Int J Neuropsychopharmacol 2017; 20:121-179. [PMID: 27816941 PMCID: PMC5409012 DOI: 10.1093/ijnp/pyw100] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/29/2016] [Accepted: 11/03/2016] [Indexed: 02/05/2023] Open
Abstract
Background The current paper includes a systematic search of the literature, a detailed presentation of the results, and a grading of treatment options in terms of efficacy and tolerability/safety. Material and Methods The PRISMA method was used in the literature search with the combination of the words 'bipolar,' 'manic,' 'mania,' 'manic depression,' and 'manic depressive' with 'randomized,' and 'algorithms' with 'mania,' 'manic,' 'bipolar,' 'manic-depressive,' or 'manic depression.' Relevant web pages and review articles were also reviewed. Results The current report is based on the analysis of 57 guideline papers and 531 published papers related to RCTs, reviews, posthoc, or meta-analysis papers to March 25, 2016. The specific treatment options for acute mania, mixed episodes, acute bipolar depression, maintenance phase, psychotic and mixed features, anxiety, and rapid cycling were evaluated with regards to efficacy. Existing treatment guidelines were also reviewed. Finally, Tables reflecting efficacy and recommendation levels were created that led to the development of a precise algorithm that still has to prove its feasibility in everyday clinical practice. Conclusions A systematic literature search was conducted on the pharmacological treatment of bipolar disorder to identify all relevant random controlled trials pertaining to all aspects of bipolar disorder and graded the data according to a predetermined method to develop a precise treatment algorithm for management of various phases of bipolar disorder. It is important to note that the some of the recommendations in the treatment algorithm were based on the secondary outcome data from posthoc analyses.
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Affiliation(s)
- Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Lakshmi Yatham
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Heinz Grunze
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Eduard Vieta
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Allan Young
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Pierre Blier
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Siegfried Kasper
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Hans Jurgen Moeller
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
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Pollack CV. Inhaled loxapine for the urgent treatment of acute agitation associated with schizophrenia or bipolar disorder. Curr Med Res Opin 2016; 32:1253-60. [PMID: 27121764 DOI: 10.1185/03007995.2016.1170004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute agitation is a serious complication of schizophrenia and bipolar disorder, which may escalate quickly to aggressive behavior. Rapid treatment is therefore important to calm and stabilize the patient, reducing the potential for harm to the patient and others, and allowing further assessment. Current guidelines suggest that where pharmacologic intervention is indicated, medication should preferably be non-invasive, should have a rapid onset and should control aggressive behavior in the short term without compromising the physician-patient relationship in the long term. OBJECTIVES This article presents an overview of a new inhaled formulation of the established antipsychotic loxapine, which aims to provide a more rapidly acting agent for the treatment of acute agitation without the disadvantages of intramuscular or intravenous injection. DISCUSSION Inhaled loxapine is rapidly absorbed with intravenous-like pharmacokinetics, with a time to maximum plasma concentration of 2 minutes and a plasma half-life of approximately 6 hours. In phase III studies, loxapine reduced agitation within 10 minutes of inhalation; agitation was decreased at all subsequent assessments during a 24-hour evaluation period. Inhaled loxapine was generally well tolerated with no undue sedation. The most common adverse events were dysgeusia, mild sedation, and dizziness. Inhaled loxapine is contraindicated in patients with asthma, COPD or other pulmonary disease associated with bronchospasm. CONCLUSIONS Inhaled loxapine rapidly reduces acute agitation in patients with schizophrenia or bipolar disorder and is generally well tolerated. The non-invasive route of delivery respects the patient's autonomy, reducing the perception of coercion or forced medication. Inhaled loxapine is therefore an effective and appropriate option for use in the emergency setting in patients with acute agitation.
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Affiliation(s)
- Charles V Pollack
- a Sidney Kimmel Medical College of Thomas Jefferson University , Philadelphia , PA , USA
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