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Giliberto S, Shishodia R, Nastruz M, Brar C, Bulathsinhala S, Terry J, Pemminati S, Shenoy SK. A Comprehensive Review of Novel FDA-Approved Psychiatric Medications (2018-2022). Cureus 2024; 16:e56561. [PMID: 38646400 PMCID: PMC11028406 DOI: 10.7759/cureus.56561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/23/2024] Open
Abstract
Mental health disorders are among the top leading causes of disease burden worldwide and many patients have high levels of treatment resistance. Even though medications offer improvement to some patients, antidepressants are only effective in about half of those treated, and schizophrenia is treatment-refractory in about one-third of patients. One way to combat this disparity is to improve medication development and discovery for psychiatric disorders through evidence-based research. Recently, most psychiatric medications approved by the United States Food and Drug Administration (FDA) are for increased tolerability or extended release. Because of the slow, incremental progress, there is a pressing need to explore novel medications with new indications or mechanisms of action to treat the expanding population with mental disorders, especially in those who are fully or partially recalcitrant to first-line medication options. This review aims to present the newest FDA medications with new indications, establish the clinical need for each, and discuss future directions in drug development. We searched and reviewed novel psychiatric medications approved by the FDA from 2018 to 2022. We then analyzed each medication in the United States Clinical Trials Registry and gathered updated results for efficacy and safety information. We also searched PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online), Scopus, Web of Science, Elsevier, and Google Scholar to understand how these new indications met current clinical needs. Finally, we inquired about related technological implications that will lead the field of psychopharmacology now and in the years to come. We found 12 novel psychiatric medications approved by the FDA from 2018 to 2022, representing a very small percentage of the total FDA approvals during that period. These psychiatric medications with novel mechanisms or improved efficacy and safety are expected to provide further options for treating mental health disorders; promising results will lead to new patterns of research.
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Affiliation(s)
- Shannon Giliberto
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Rhea Shishodia
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Meredith Nastruz
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Chamandeep Brar
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Sadeepa Bulathsinhala
- Department of Biomedical Education, St. George's University School of Medicine, True Blue, GRD
| | - Jonathan Terry
- Department of Specialty Medicine, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Sudhakar Pemminati
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
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Mitchell BG, Lee J. Case Report: Concurrent Clonidine Abuse and Opioid Use Disorder. J Psychoactive Drugs 2021; 53:373-377. [PMID: 33814003 DOI: 10.1080/02791072.2021.1908644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Clonidine is a centrally acting alpha-2 selective adrenergic receptor agonist used to treat hypertension and to control or prevent withdrawal in patients with opioid and alcohol use disorders. Case reports describe abuse of clonidine alone or in combination with benzodiazepines, methadone, codeine, or heroin. Clonidine reportedly boosts and extends the opioid-related euphoria and reduces the amount of psychoactive drug needed. In this case report, we describe clonidine abuse and withdrawal management in an elderly patient with concurrent opioid use disorder. The usage of clonidine in the treatment of opioid detoxification remains controversial. Clonidine abuse is underestimated and requires more attention among health-care providers who concurrently prescribe clonidine and opioids. With the opioid epidemic becoming increasingly prevalent, physicians and other health-care providers must be vigilant in their opioid prescribing as well as concurrent prescribing of other psychoactive pharmacologic agents.
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Affiliation(s)
- Brian G Mitchell
- Department of Pharmacy Services, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Jaekyu Lee
- Department of Pharmacy Services, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
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3
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Abstract
Introduction Maintaining abstinence through the opioid withdrawal period is a substantial barrier to treatment for patients with opioid use disorder. The alpha-2 agonist lofexidine has demonstrated efficacy and safety in clinical trials, but pragmatic studies describing its use in clinical practice are lacking. This case series describes the use of lofexidine for opioid withdrawal symptoms in an inpatient addiction treatment facility. Methods Seventeen patients receiving at least 1 dose of lofexidine during inpatient treatment for opioid withdrawal were included in this study. A retrospective chart review was conducted for clinical, subjective, and objective data. Adverse events, total daily dose, clinical opioid withdrawal scale (COWS) scores, vital signs, and reasons for early discontinuation of lofexidine are reported. Results Patients treated with lofexidine experienced mild withdrawal symptoms throughout treatment. Most patients (65%) experienced a decrease in their average daily COWS scores from intake to discharge. Two patients (12%) left treatment against medical advice, and 5 patients (29%) discontinued treatment prior to day 7 due to resolution of symptoms. Average daily blood pressure readings remained stable, and daily average heart rate decreased over time. Discussion Lofexidine can be successfully incorporated into a conventional withdrawal management protocol. The cost of lofexidine and its recent introduction to the market remain barriers to accessibility in the United States. Studies evaluating patient-reported outcomes as well as direct comparisons with other alpha-2 agonists are needed to inform optimal clinical use of lofexidine.
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Affiliation(s)
- Mandy L Renfro
- Post-Doctoral Fellow, Pharmacyclics, An AbbVie Company, Sunnyvale, California,
| | - Lindsey J Loera
- Postdoctoral Pharm Fellow, The University of Texas at Austin College of Pharmacy, Austin, Texas
| | | | - Lucas G Hill
- Clinical Assistant Professor, The University of Texas at Austin College of Pharmacy, Austin, Texas
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Alam D, Tirado C, Pirner M, Clinch T. Efficacy of lofexidine for mitigating opioid withdrawal symptoms: results from two randomized, placebo-controlled trials. J Drug Assess 2020; 9:13-19. [PMID: 32002194 PMCID: PMC6968526 DOI: 10.1080/21556660.2019.1704416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/11/2019] [Indexed: 11/27/2022] Open
Abstract
Objectives Fear of opioid withdrawal syndrome (OWS) often dissuades opioid discontinuation. Lofexidine is an FDA-approved, alpha2-adrenergic receptor agonist for treatment of OWS. Pivotal trial results from the per-protocol statistical analyses have been published. However, the FDA prescribing information presents these efficacy results using a different, standardized statistical approach that does not transform data or impute missing values. This analysis is easier to interpret and allows comparison across studies. This reanalysis is presented here. Methods Studies were double-blind, placebo-controlled for 7 days in Study 1 and 5 days in Study 2. Opioid-dependent adults received placebo or lofexidine; efficacy was assessed using the Short Opioid Withdrawal Scale of Gossop (SOWS-G) daily. Results Study 1 (N = 602) mean SOWS-G scores were 6.1 (SE: 0.35), 6.5 (SE: 0.34), and 8.8 (SE: 0.47) over Days 1–7 for lofexidine 2.88 mg/day, 2.16 mg/day, and placebo, respectively (for 2.88, p < .0001; for 2.16 mg, p < .0001). Study 2 (N = 264) mean SOWS-G scores were 7.0 (SE: 0.44) and 8.9 (SE: 0.48) over Days 1–5 for lofexidine 2.16 mg/day and placebo, respectively (p = .0037). Median time to treatment discontinuation was approximately 2 days later with lofexidine treatment than with placebo and significantly more lofexidine-treated subjects completed the studies. Hypotension and bradycardia were more common with lofexidine. More placebo subjects withdrew prematurely for lack of efficacy. Conclusion This simplified analysis confirmed previous per-protocol results, that lofexidine better reduces OWS severity and increases retention compared with placebo in opioid-dependent adults. These results are robust and comparable across studies using various methods of analysis. ClinicalTrials.gov identifier Study 1, NCT01863186; Study 2 NCT00235729. URL: https://clinicaltrials.gov/
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Affiliation(s)
- Danesh Alam
- Northwestern Medicine Central DuPage Hospital, Winfield, IL, USA
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Haney M, Cooper ZD, Bedi G, Herrmann E, Comer SD, Reed SC, Foltin RW, Levin FR. Guanfacine decreases symptoms of cannabis withdrawal in daily cannabis smokers. Addict Biol 2019; 24:707-716. [PMID: 29659126 DOI: 10.1111/adb.12621] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 12/22/2017] [Accepted: 02/12/2018] [Indexed: 01/27/2023]
Abstract
The α2a-adrenergic agonist, lofexidine, reduced cannabis withdrawal-related sleep disruption in the laboratory, but side effects (e.g. fatigue, hypotension) limit its utility as a treatment for cannabis use disorder. This study tested the potential efficacy and tolerability of a daily bedtime administration of the FDA-approved α2a-adrenergic agonist, guanfacine, in a human laboratory model of cannabis use disorder. Daily, nontreatment-seeking cannabis smokers (13M, 2F) completed a within-subject study comprising two 9-day inpatient study phases. Each phase tested the effects of daily placebo or immediate-release guanfacine (2 mg) on cannabis intoxication (5.6 percent THC; 2 days), withdrawal (4 days of abstinence) and subsequent 'relapse' (3 days of cannabis self-administration). Ratings of mood, sleep, cardiovascular effects, food intake, psychomotor performance and cannabis self-administration were assessed. An outpatient phase preceded each inpatient phase for medication clearance or dose induction. Under placebo medication conditions, cannabis abstinence produced significant withdrawal, including irritability, sleep disruption and anorexia. Guanfacine reduced ratings of irritability and improved objective measures of sleep during cannabis withdrawal relative to placebo but did not reduce cannabis self-administration. Guanfacine was well tolerated with little evidence of fatigue and only small decreases in blood pressure: no dose was held due to hypotension. Thus, a single daily administration of guanfacine at bedtime improved sleep and mood during cannabis withdrawal relative to placebo. This positive signal supports further studies varying the guanfacine dose, formulation or frequency of administration, or combining it with other medications to increase the likelihood of having an impact on cannabis use.
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Affiliation(s)
- Margaret Haney
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of PsychiatryColumbia University Medical Center New York NY USA
| | - Ziva D. Cooper
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of PsychiatryColumbia University Medical Center New York NY USA
| | - Gillinder Bedi
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of PsychiatryColumbia University Medical Center New York NY USA
| | - Evan Herrmann
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of PsychiatryColumbia University Medical Center New York NY USA
| | - Sandra D. Comer
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of PsychiatryColumbia University Medical Center New York NY USA
| | - Stephanie Collins Reed
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of PsychiatryColumbia University Medical Center New York NY USA
| | - Richard W. Foltin
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of PsychiatryColumbia University Medical Center New York NY USA
| | - Frances R. Levin
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of PsychiatryColumbia University Medical Center New York NY USA
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Rehman SU, Maqsood MH, Bajwa H, Tameez Ud Din A, Malik MN. Clinical Efficacy and Safety Profile of Lofexidine Hydrochloride in Treating Opioid Withdrawal Symptoms: A Review of Literature. Cureus 2019; 11:e4827. [PMID: 31403015 PMCID: PMC6682385 DOI: 10.7759/cureus.4827] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Opioid use disorder (OUD) is a rapidly growing challenge worldwide and is characterized by an increase in dependence on opioids up to a point that a person loses control over the drug use. Multiple drugs are approved for its treatment, including methadone, buprenorphine, and diazepam. Although not approved, clonidine is also used for the treatment of OUD. On May 16, 2018, the United States Food and Drug Administration (FDA) approved a new drug lofexidine hydrochloride for the treatment of opioid withdrawal symptoms. Lofexidine is a centrally acting alpha two receptor agonist. It reduces the neurochemical surge by inhibiting the conversion of adenosine triphosphate (ATP) into cyclic adenosine monophosphate (cAMP) which in turn decrease the sympathetic outflow. This results in the improvement of withdrawal symptoms. When compared with methadone and buprenorphine, it is equally effective in controlling withdrawal symptoms. Its efficacy is also similar to clonidine with a better side effects profile. The adverse effects of lofexidine include bradycardia, hypotension, orthostasis, somnolence, sedation, dry mouth, and rebound elevations in blood pressure and prolongation of QT interval. Lofexidine is contraindicated in patients who are on beta-blockers and angiotensin converting enzyme inhibitors (ACE inhibitors). In our review, we have discussed the clinical efficacy and safety profile of lofexidine in treating opioid withdrawal symptoms and its comparison to other available treatment options.
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Affiliation(s)
- Saif Ur Rehman
- Internal Medicine, King Edward Medical University / Mayo Hospital, Lahore, PAK
| | | | - Hamza Bajwa
- Internal Medicine, King Edward Medical University / Mayo Hospital, Lahore, PAK
| | | | - Mustafa N Malik
- Internal Medicine, District Headquarter Hospital, Rawalpindi, PAK
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Abstract
OBJECTIVE To review the pharmacology, efficacy, and safety of lofexidine for the treatment of opioid withdrawal secondary to the recent Food and Drug Administration (FDA) approval. DATA SOURCES A literature search using PubMed was conducted (inception to December 2018) using the terms lofexidine, opioid, opiate, and withdrawal. References from retrieved articles and the prescribing information were reviewed for any additional material. STUDY SELECTION/DATA EXTRACTION The literature search was limited to human studies published in English that pertained to human pharmacology, pharmacokinetics, pharmacodynamics, dosing, efficacy, and safety regarding opioid withdrawal. Phase I, II, and III studies of lofexidine for opioid withdrawal were reviewed for inclusion. DATA SYNTHESIS Lofexidine is newly FDA approved in the United States for the treatment of opioid withdrawal symptoms in adults. Several randomized controlled trials and a Cochrane review noted the effectiveness of lofexidine versus placebo for this indication. The efficacy of lofexidine has also been shown to be comparable to that of other indicated first- and second-line pharmacological agents. Relevance to Patient Care and Clinical Practice: This article examines the trials that led to lofexidine's new FDA-approved indication as well as other recent literature published since its last major review, seeking to guide providers in the appropriate use of lofexidine for its new indication. CONCLUSIONS Lofexidine is an effective and safe agent in treating symptoms related to opioid withdrawal in adults when compared with placebo; although it is more widely accessible than other first-line therapies, its use in practice may be limited by cost.
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Affiliation(s)
- Bennett Doughty
- 1 Binghamton University School of Pharmacy and Pharmaceutical Sciences, NY, USA
| | | | - Tracy Brooks
- 1 Binghamton University School of Pharmacy and Pharmaceutical Sciences, NY, USA
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8
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Management of opioid withdrawal symptoms. Med Lett Drugs Ther 2018; 60:137-41. [PMID: 30133420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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9
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Expanded table: Some drugs for management of opioid withdrawal symptoms. Med Lett Drugs Ther 2018; 60:e144-6. [PMID: 30133422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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10
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Lofexidine (Lucemyra) for opioid withdrawal. Med Lett Drugs Ther 2018; 60:115-7. [PMID: 30036346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Law FD, Diaper AM, Melichar JK, Coulton S, Nutt DJ, Myles JS. Buprenorphine/naloxone versus methadone and lofexidine in community stabilisation and detoxification: A randomised controlled trial of low dose short-term opiate-dependent individuals. J Psychopharmacol 2017. [PMID: 28631527 DOI: 10.1177/0269881117711710] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Buprenorphine/naloxone, methadone and lofexidine are medications with utility in the treatment of opiate withdrawal. We report the first randomised controlled trial to compare the effects of these two medications on withdrawal symptoms and outcome during opiate induction/stabilisation and detoxification. A double-blind randomised controlled trial was conducted in an outpatient satellite clinic of a specialist drug service. Eighty opiate dependent individuals meeting DSM-IV criteria for opiate dependence, using ⩽ ½ g heroin smoked/chased or ¼ g heroin injected or ⩽ 30mg methadone, with ⩽ 3 years of opioid dependency, underwent a short-term opiate treatment programme involving induction/stabilisation on methadone 30mg or buprenorphine/naloxone 4mg/1mg, followed by detoxification (where the methadone group was assisted by lofexidine). The main outcome measures were urine drug screens for opiates and withdrawal and craving questionnaires. There were no overall differences in positive urine drug screens and drop-outs during any phase of the study. During induction/stabilisation, withdrawal symptoms subsided more slowly for buprenorphine/naloxone than for methadone, and craving was significantly higher in the buprenorphine/naloxone group ( p<0.05, 95% confidence interval -3.5, -0.38). During detoxification, withdrawal symptoms were significantly greater and the peak of withdrawal was earlier for the methadone/lofexidine group than the buprenorphine/naloxone group ( p<0.01, 95% confidence interval 3.0, 8.3). Methadone/lofexidine and buprenorphine/naloxone had comparable outcomes during rapid outpatient stabilisation and detoxification in low dose opiate users.
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Affiliation(s)
- Fergus D Law
- 1 Avon & Wiltshire Specialist Drug & Alcohol Services, Chippenham, UK
| | - Alison M Diaper
- 2 Psychopharmacology Unit, Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jan K Melichar
- 2 Psychopharmacology Unit, Social and Community Medicine, University of Bristol, Bristol, UK
| | - Simon Coulton
- 3 Centre for Health Services Studies, Faculty of Social Sciences, Cornwallis North East, University of Kent, Canterbury, UK
| | - David J Nutt
- 4 Neuropsychopharmacology Unit, Imperial College London, London, UK
| | - Judy S Myles
- 5 St George's Hospital Medical School, London, UK
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Abstract
The need to treat withdrawal syndromes is a common occurrence in outpatient, inpatient ward, and intensive care unit (ICU) settings. A PubMed and Google Scholar search using alpha2-adrenoreceptor agonist (A2AA), specific A2AA agents, withdrawal syndrome and nicotine, and alcohol and opioid withdrawal terms was performed. A2AA agents appear to be able to modulate many of the signs and symptoms of significant withdrawal syndromes but are also capable of significant side effects, which can limit clinical use. Non-opioid oral A2AA agent use for opioid withdrawal has been well established. Pharmacologic combination therapy that utilizes A2AA agents for withdrawal syndromes appears promising but requires further formal testing to better define which other agents, under what condition(s), and at what A2AA doses are needed. The A2AA dexmedetomidine may be useful as an adjunctive agent in treating severe alcohol withdrawal syndromes in the ICU. In general, the current data does not support the routine use of A2AA as the primary or sole agent to treat ethanol/alcohol or nicotine withdrawal syndromes. Specific A2AA agents such as lofexidine has been shown to have a primary role in non-opioid-based treatment of opioid withdrawal syndrome and dexmedetomidine in combination with benzodiazepines has been shown to have potential in the treatment of severe ICU-based alcohol withdrawal syndrome.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, UC Davis, 4150 V Street, Suite 3100, Sacramento, 95817, CA, USA,
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Abstract
INTRODUCTION Lofexidine is one therapeutic option used for treating the onslaught of sympathetic outflow that typically commences upon induction of opiate withdrawal. It was approved for opiate detoxification in the UK, most of EU, and a select few countries worldwide during the 1980s and the 90s. Within the US and Canada, however, it remains an experimental drug. AREAS COVERED The following article highlights lacunae in extant knowledge about the molecular pharmacology of lofexidine. Furthermore, the article provides a brief discussion on the nature and shortcomings of clinical trials for this drug that have been conducted over the past 30 years across the world. It also provides a discussion of the market factors and regulatory considerations responsible for the rather limited use of lofexidine thus far. EXPERT OPINION Many lessons can be learned from the 40-year-long development of lofexidine. Indeed, unless there is an urgent need to address an unmet and/or immediate health threat, preclinical development is dictated by pharmacoeconomic considerations. Lofexidine would likely have been excluded for further development in this day and age given the existence and value of clonidine as well as the lack of insurance coverage for opiate addiction. It should be noted, however, that although there have been many oversights in the past, current experimentation and clinical trials are beginning to address the mistakes made through the exploration of single enantiomers and controlled-release preparations.
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Affiliation(s)
- Ashish P Vartak
- University of Minnesota, Center for Drug Design , 4-270 NHH 310 Church St. SE, Minneapolis, MN 55455 , USA +1 612 327 7630 ;
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Fitzgerald PJ. Elevated Norepinephrine may be a Unifying Etiological Factor in the Abuse of a Broad Range of Substances: Alcohol, Nicotine, Marijuana, Heroin, Cocaine, and Caffeine. Subst Abuse 2013; 7:171-83. [PMID: 24151426 PMCID: PMC3798293 DOI: 10.4137/sart.s13019] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A wide range of commonly abused drugs have effects on the noradrenergic neurotransmitter system, including alterations during acute intoxication and chronic use of these drugs. It is not established, however, that individual differences in noradrenergic signaling, which may be present prior to use of drugs, predispose certain persons to substance abuse. This paper puts forth the novel hypothesis that elevated noradrenergic signaling, which may be raised largely due to genetics but also due to environmental factors, is an etiological factor in the abuse of a wide range of substances, including alcohol, nicotine, marijuana, heroin, cocaine, and caffeine. Data are reviewed for each of these drugs comprising their interaction with norepinephrine during acute intoxication, long-term use, subsequent withdrawal, and stress-induced relapse. In general, the data suggest that these drugs acutely boost noradrenergic signaling, whereas long-term use also affects this neurotransmitter system, possibly suppressing it. During acute withdrawal after chronic drug use, noradrenergic signaling tends to be elevated, consistent with the observation that norepinephrine lowering drugs such as clonidine reduce withdrawal symptoms. Since psychological stress can promote relapse of drug seeking in susceptible individuals and stress produces elevated norepinephrine release, this suggests that these drugs may be suppressing noradrenergic signaling during chronic use or instead elevating it only in reward circuits of the brain. If elevated noradrenergic signaling is an etiological factor in the abuse of a broad range of substances, then chronic use of pharmacological agents that reduce noradrenergic signaling, such as clonidine, guanfacine, lofexidine, propranolol, or prazosin, may help prevent or treat drug abuse in general.
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Ling W, Mooney L, Zhao M, Nielsen S, Torrington M, Miotto K. Selective review and commentary on emerging pharmacotherapies for opioid addiction. Subst Abuse Rehabil 2011; 2:181-8. [PMID: 24474855 PMCID: PMC3846315 DOI: 10.2147/sar.s22782] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pharmacotherapies for opioid addiction under active development in the US include lofexidine (primarily for managing withdrawal symptoms) and Probuphine®, a distinctive mode of delivering buprenorphine for six months, thus relieving patients, clinicians, and regulatory personnel from most concerns about diversion, misuse, and unintended exposure in children. In addition, two recently approved formulations of previously proven medications are in early phases of implementation. The sublingual film form of buprenorphine + naloxone (Suboxone®) provides a less divertible, more quickly administered, more child-proof version than the buprenorphine + naloxone sublingual tablet. The injectable depot form of naltrexone (Vivitrol®) ensures consistent opioid receptor blockade for one month between administrations, removing concerns about medication compliance. The clinical implications of these developments have attracted increasing attention from clinicians and policymakers in the US and around the world, especially given that human immunodeficiency virus/acquired immunodeficiency syndrome and other infectious diseases are recognized as companions to opioid addiction, commanding more efforts to reduce opioid addiction. While research and practice improvement efforts continue, reluctance to adopt new medications and procedures can be expected, especially considerations in the regulatory process and in the course of implementation. Best practices and improved outcomes will ultimately emerge from continued development efforts that reflect input from many quarters.
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Affiliation(s)
- Walter Ling
- Integrated Substance Abuse Programs, University of California, Los Angeles, CA, USA
| | - Larissa Mooney
- Integrated Substance Abuse Programs, University of California, Los Angeles, CA, USA
| | - Min Zhao
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Suzanne Nielsen
- Integrated Substance Abuse Programs, University of California, Los Angeles, CA, USA
| | - Matthew Torrington
- Integrated Substance Abuse Programs, University of California, Los Angeles, CA, USA
| | - Karen Miotto
- Integrated Substance Abuse Programs, University of California, Los Angeles, CA, USA
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Schmittner J, Schroeder JR, Epstein DH, Krantz MJ, Eid NC, Preston KL. Electrocardiographic effects of lofexidine and methadone coadministration: secondary findings from a safety study. Pharmacotherapy 2009; 29:495-502. [PMID: 19397459 PMCID: PMC3150470 DOI: 10.1592/phco.29.5.495] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To determine the electrocardiographic effects of coadministration of lofexidine and methadone. DESIGN Prospective, double-blind study. SETTING Outpatient drug treatment research clinic. PARTICIPANTS Fourteen adults (mean +/- SD age 34.9 +/- 5.3 yrs) with physical dependence on opioids. INTERVENTION Participants were stabilized on methadone maintenance therapy, reaching a target dose of 80 mg/day. After 3 weeks of methadone stabilization, participants received lofexidine 0.4 mg or placebo once/day, each for 1 week, administered at the same time as methadone. From weeks 3-8, all subjects received lofexidine, with the dose escalated each week in 0.2-mg increments so that by week 8, participants were receiving lofexidine 1.6 mg/day. Electrocardiograms (ECGs) were obtained at baseline (before methadone), after stabilization with methadone, and after lofexidine coadministration during peak plasma lofexidine levels. MEASUREMENTS AND MAIN RESULTS Prespecified outcome measures of mean and maximal changes in heart rate, and PR, QRS, and QTc intervals were obtained after stabilization with methadone and after lofexidine 0.4 mg coadministration. Repeated-measures regression showed no significant changes in heart rate or PR, QRS, or QTc interval after methadone stabilization, but a significant decrease in heart rate (mean +/- SD -8.0 +/- 7.3 beats/min, p=0.0006) after starting lofexidine. When data were analyzed by using maximal ECG response, again, no significant changes were noted during methadone induction compared with baseline, but significant changes did occur in all four ECG parameters when lofexidine was coadministered: decreased heart rate (mean +/- SD -9.6 +/- 5.8 beats/min, p<0.0001) and increased PR interval (+11.1 +/- 19.8 msec, p=0.026), QRS interval (+3.7 +/- 4.3 msec, p=0.002), and QTc interval (+21.9 +/- 40.8 msec, p=0.018). In three female participants, the change in QTc interval from baseline was clinically significant (> 40 msec). CONCLUSION Our preliminary data suggest that coadministration of lofexidine and methadone induces QTc interval prolongation. This drug combination should be prescribed cautiously, with ECG monitoring. Furthermore, because the participants with the largest changes in QTc interval in our study were female, women may be at highest risk.
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Affiliation(s)
- John Schmittner
- Clinical Pharmacology and Therapeutics Research Branch, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, 251 Bayview Boulevard, Baltimore, MD 21224, USA
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Yu E, Miotto K, Akerele E, Montgomery A, Elkashef A, Walsh R, Montoya I, Fischman MW, Collins J, McSherry F, Boardman K, Davies DK, O'Brien CP, Ling W, Kleber H, Herman BH. A Phase 3 placebo-controlled, double-blind, multi-site trial of the alpha-2-adrenergic agonist, lofexidine, for opioid withdrawal. Drug Alcohol Depend 2008; 97:158-68. [PMID: 18508207 DOI: 10.1016/j.drugalcdep.2008.04.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Revised: 04/08/2008] [Accepted: 04/09/2008] [Indexed: 11/26/2022]
Abstract
CONTEXT Lofexidine is an alpha-2-adrenergic receptor agonist that is approved in the United Kingdom for the treatment of opioid withdrawal symptoms. Lofexidine has been reported to have more significant effects on decreasing opioid withdrawal symptoms with less hypotension than clonidine. OBJECTIVE To demonstrate that lofexidine is well tolerated and effective in the alleviation of observationally defined opioid withdrawal symptoms in opioid dependent individuals undergoing medically supervised opioid detoxification as compared to placebo. DESIGN An inpatient, Phase 3, placebo-controlled, double-blind, randomized multi-site trial with three phases: (1) opioid agonist stabilization phase (days 1-3), (2) detoxification/medication or placebo phase (days 4-8), and (3) post detoxification/medication phase (days 9-11). SUBJECTS Sixty-eight opioid dependent subjects were enrolled at three sites with 35 randomized to lofexidine and 33 to placebo. MAIN OUTCOME MEASURE Modified Himmelsbach Opiate Withdrawal Scale (MHOWS) on study day 5 (second opioid detoxification treatment day). RESULTS Due to significant findings, the study was terminated early. On the study day 5 MHOWS, subjects treated with lofexidine had significantly lower scores (equating to fewer/less severe withdrawal symptoms) than placebo subjects (least squares means 19.5+/-2.1 versus 30.9+/-2.7; p=0.0019). Lofexidine subjects had significantly better retention in treatment than placebo subjects (38.2% versus 15.2%; Log rank test p=0.01). CONCLUSIONS Lofexidine is well tolerated and more efficacious than placebo for reducing opioid withdrawal symptoms in inpatients undergoing medically supervised opioid detoxification.
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