Vortioxetine: Clinical Pharmacokinetics and Drug Interactions

Vortioxetine Can Be Used Safely to Treat Depression After Implantable Cardioverter Defibrillator Implantation for Congenital Long QT Syndrome: A Case Report

BACKGROUND

Vortioxetine, an antidepressant, acts on multiple 5-hydroxytryptamine receptors in addition to inhibiting the 5-hydroxytryptamine transporter. Currently, data on the effect of vortioxetine on the QT interval are limited. To the best of our knowledge, whether vortioxetine can safely be used for congenital long QT syndrome (LQTS) has not been reported.

CASE PRESENTATION

We here present the case of a 50-year-old Japanese woman who was rushed to our hospital because of a sudden cardiopulmonary arrest. Her corrected QT interval was prolonged to 535 ms. After a thorough examination in the cardiology department, she was diagnosed with congenital LQTS and an implantable cardioverter defibrillator (ICD) implanted. Thereafter, she gradually developed severe depression because of stress associated with ICD implantation. Mirtazapine induced daytime somnolence and duloxetine was relatively ineffective, prompting replacement with vortioxetine at 20 mg daily, which relieved her depression. During the treatment period, her corrected QT interval did not exceed 500 ms, beyond which the risk of cardiac events increases. To our knowledge, this is the first report of the safe use of vortioxetine in a patient with depression comorbid with congenital LQTS.

CONCLUSIONS

After ICD implantation, a patient's mental status should be monitored carefully. Our findings suggest that vortioxetine may be a safe treatment option for depression associated with congenital LQTS.

Vortioxetine: A Potential Drug for Repurposing for Glioblastoma Treatment via a Microsphere Local Delivery System

Drug repurposing is an attractive route for finding new therapeutics for brain cancers such as glioblastoma. Local administration of drugs to brain tumors or the postsurgical resection cavity holds promise to deliver a high dose to the target site with minimal off-target effects. Drug delivery systems aim to sustain the release of the drug at the target site but typically exhibit drawbacks such as a poor safety profile, uncontrolled/rapid drug release, or poor control over synthesis parameters/material dimensions. Herein, we analyzed the antidepressant vortioxetine and showed in vitro that it causes a greater loss of viability in glioblastoma cells than it does to normal primary human astrocytes. We developed a new droplet microfluidic-based emulsion method to reproducibly produce vortioxetine-loaded poly(lactic-co-glycolic) acid (PLGA) microspheres with tight size control (36.80 ± 1.96 μm). The drug loading efficiency was around 90% when 9.1% (w/w) drug was loaded into the microspheres, and drug release could be sustained for three to 4 weeks. The vortioxetine microspheres showed robust antiglioblastoma efficacy in both 2D monolayer and 3D spheroid patient-derived glioblastoma cells, highlighting the potential of combining an antidepressant with sustained local delivery as a new therapeutic strategy.

Safety and tolerability of vortioxetine versus serotonin reuptake inhibitors in late life depression: A systematic review and meta-analysis

INTRODUCTION

Late-life depression (LLD) is a significant yet often under-recognized health concern. While selective serotonin reuptake inhibitors (SSRIs) are widely used, their adverse effects remain a challenge. Vortioxetine, a multimodal antidepressant, has gained attention for its potentially better tolerability. However, data on its safety in older adults are limited. This meta-analysis assessed the safety and tolerability of Vortioxetine compared to serotonin reuptake inhibitors in LLD.

METHODS

A systematic search of PubMed, EMBASE, and Cochrane Central identified randomized controlled trials (RCTs) evaluating Vortioxetine's safety in ≥ 60-year-old patients. Primary outcomes included adverse events and withdrawal rates. Statistical analyses were conducted using Review Manager.

RESULTS

Three studies, involving 714 patients were included. There were no statistical differences between groups for nausea (RR 0.54; 95 % CI 0.22, 1.34; p = 0.18; I2 =75 %), diarrhea (RR 0.92; 95 % CI 0.20, 4.13; p = 0.91; I2 =59 %), constipation (RR 0.54; 95 % CI 0.28,1.02; p = 0.06; I2 =0 %) and loss of appetite (RR 1.00; 95 % CI 0.25, 4.05; p = 1.00; I2 =40 %). The total number of dropouts after randomization did not show a statistical significance with Vortioxetine use (RR 1.10; CI 95 % 0.82, 1.48; p = 0.52; I2 = 0 %), nor did the number of withdrawals (RR 1.09, CI 95 % 0.77, 1.55; p = 0.64; I2 = 0 %).

CONCLUSION

This meta-analysis suggests Vortioxetine is safe for LLD, with no significant increase in adverse effects. While reassuring, these findings emphasize the need for careful evaluation, as Vortioxetine showed no clear tolerability advantage over other serotonin reuptake inhibitors.

Mechanisms of NMDA receptor inhibition by vortioxetine - Comparison with fluoxetine

N-methyl-D-aspartate receptors (NMDARs) are involved in the pathophysiology of depression and are inhibited by many antidepressants. In this work, we studied the action of the vortioxetine, a relatively new multitarget antidepressant, on native NMDARs in rat hippocampal CA1 pyramidal neurons and compared it to the action of structurally similar antidepressant fluoxetine. Vortioxetine inhibited these receptors with IC50 value of 11 ± 1 μM at -80 mV holding voltage, being about three-fold more potent than fluoxetine in these conditions. The inhibition by both compounds was not competitive. Both vortioxetine and fluoxetine demonstrated complex voltage dependence with voltage-dependent and voltage-independent components. The voltage-dependent component corresponded to trapping channel block, while the voltage-independent component - to allosteric inhibition. Vortioxetine and fluoxetine were able to inhibit both open and closed NMDAR channels. Thus, NMDARs can be among important targets for vortioxetine or structurally related drugs. In addition, structural similarity of vortioxetine and fluoxetine allows to assume that these compounds may share other molecular targets besides serotonin transporter and NMDARs.

An Exploration of the Interplay Between Caffeine and Antidepressants Through the Lens of Pharmacokinetics and Pharmacodynamics

Caffeine consumption is regarded as a widespread phenomenon, and its usage has continued to increase. In addition, the growing usage of antidepressants worldwide and increase in mental health disorders were shown in recent statistical analyses conducted by the World Health Organisation. The coadministration of caffeine and antidepressants remains a concern due to potential interactions that can alter a patient's response to therapy. This review investigates the pharmacokinetic and pharmacodynamic interactions between caffeine and the five main classes of antidepressants: selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), serotonin and norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), and other antidepressants not categorised by class, which we have categorised as 'miscellaneous'. The interaction between fluvoxamine and caffeine resulted in increased concentrations of caffeine in the body and lowered the renal clearance of fluvoxamine. Other SSRIs such as fluoxetine and escitalopram had augmented antidepressant effects by decreasing their renal clearance and prolonging their effects in the body when coadministered with caffeine. Caffeine may also increase the concentration of paroxetine, potentially affecting its pharmacodynamic effects. TCAs such as clomipramine, imipramine, desipramine, and sertraline, were found to reduce the metabolism of caffeine. However, studies suggest caffeine had no significant effect on the concentration of these medications in blood or brain tissue. The inhibition of caffeine at high doses when used with MAOIs such as tranylcypromine and phenelzine was found to lead to a higher likelihood of experiencing hypertension. Coadministration of caffeine with venlafaxine (SNRIs) suggests minimal interactions between the two substances and the pharmacodynamic effects of venlafaxine were unlikely to be impacted by caffeine consumption. Miscellaneous antidepressants (reboxetine, mianserin, agomelatine, maprotiline, and mirtazapine) displayed varying pharmacodynamic interactions with caffeine, resulting in increased antidepressant effects where vortioxetine, maprotiline, and mirtazapine failed to demonstrate any interactions. In conclusion, caffeine demonstrated varying effects on the pharmacokinetic and pharmacodynamic properties of each class of antidepressants, with several classes of antidepressants demonstrating a similar effect on caffeine.

Targeting 5-HT Is a Potential Therapeutic Strategy for Neurodegenerative Diseases

There is increasing interest in the potential therapeutic role of 5-HT (serotonin) in the treatment of neurodegenerative diseases, which are characterized by the progressive degeneration and death of nerve cells. 5-HT is a vital neurotransmitter that plays a central role in regulating mood, cognition, and various physiological processes in the body. Disruptions in the 5-HT system have been linked to several neurological and psychiatric disorders, making it an attractive target for therapeutic intervention. Although the exact causes of neurodegenerative diseases such as Alzheimer's disease (AD), Parkinson's disease (PD), and amyotrophic lateral sclerosis (ALS) are not fully understood, researchers believe that regulating the 5-HT system could help alleviate symptoms and potentially slow the progression of these diseases. Here, we delve into the potential of harnessing 5-HT as a therapeutic target for the treatment of neurodegenerative diseases. It is important to note that the current clinical drugs targeting 5-HT are still limited in the treatment of these complex diseases. Therefore, further research and clinical trials are needed to evaluate the feasibility and effectiveness of its clinical application.

Vortioxetine versus reuptake inhibitors in adults with major depressive disorder: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Although vortioxetine demonstrates superior efficacy relative to placebo, there is still a lack of robust evidence to determine whether it offers advantages over commonly prescribed antidepressants for treating major depressive disorder (MDD). Thus, we aimed to perform a systematic review and meta-analysis comparing vortioxetine vs reuptake inhibitors in adults with MDD, analyzing two classes separately: (i) vortioxetine vs SSRIs and (ii) vortioxetine vs SNRIs.

METHODS

We searched MEDLINE, Embase, and Cochrane Library databases for randomized controlled trials comparing vortioxetine with SSRIs or SNRIs in adults with a primary diagnosis of MDD following standardized diagnostic criteria. Independent examiners conducted the literature search, study selection, data extraction, and risk of bias assessment. Data were pooled in random-effects analyses. Statistical significance was considered at p<0.05.

RESULTS

We included 6 trials (n=478) in the vortioxetine vs SSRIs analysis and 11 (n=4230) in the vortioxetine vs SNRIs analysis. There were no significant differences between vortioxetine and SSRIs/SNRIs in the probability of response, remission, overall dropouts, and dropout due to lack of efficacy. Vortioxetine provided a significantly lower risk of dropout due to adverse events compared with SNRIs, while not significant compared with SSRIs. Vortioxetine did not differ significantly from SNRIs regarding variation in MADRS score post-treatment. In general, vortioxetine exhibited a statistically lower risk of individual adverse events compared with SNRIs, while not significant compared with SSRIs.

CONCLUSIONS

Our study reveals that vortioxetine is as effective as SSRIs and SNRIs for treating MDD, with safety equivalent to SSRIs and superior to SNRIs.

Antidepressant-induced membrane trafficking regulates blood-brain barrier permeability

As the most prescribed psychotropic drugs in current medical practice, antidepressant drugs (ADs) of the selective serotonin reuptake inhibitor (SSRI) class represent prime candidates for drug repurposing. The mechanisms underlying their mode of action, however, remain unclear. Here, we show that common SSRIs and selected representatives of other AD classes bidirectionally regulate fluid-phase uptake at therapeutic concentrations and below. We further characterize membrane trafficking induced by a canonical SSRI fluvoxamine to show that it involves enhancement of clathrin-mediated endocytosis, endosomal system, and exocytosis. RNA sequencing analysis showed few fluvoxamine-associated differences, consistent with the effect being independent of gene expression. Fluvoxamine-induced increase in membrane trafficking boosted transcytosis in cell-based blood-brain barrier models, while a single injection of fluvoxamine was sufficient to enable brain accumulation of a fluid-phase fluorescent tracer in vivo. These findings reveal modulation of membrane trafficking by ADs as a possible cellular mechanism of action and indicate their clinical repositioning potential for regulating drug delivery to the brain.

Vortioxetine Exposure During Pregnancy and Lactation: A Japanese Case Study of Neonatal Implications and Quantitative Milk and Plasma Analyses

Background: Information about influences of vortioxetine on pregnant women and neonates during perinatal period is almost unknown. Case Presentation: The case was a 28-year-old Japanese woman in her first pregnancy, treated for depression with vortioxetine (20 mg daily) among other medications. At 36 weeks of gestation, she was admitted for premature rupture of the membranes and delivered a girl with no apparent congenital anomalies. Immediately after birth, the neonate required brief respiratory support due to her dyspnea and poor muscle tone. Her respiratory condition improved in 6 days after delivery, and she demonstrated normal developmental progress afterward. Maternal plasma and breast milk samples, collected 4 days postpartum, revealed vortioxetine concentrations of 11.4 ng/mL and 9.3 ng/mL, respectively. The calculated relative infant dose (RID) was estimated at 0.32%. After discharge from hospital, the infant presented no detectable drug-related adverse effects, with over 50% of nutrition derived from breastfeeding. Conclusion: This case showed minimal transfer of vortioxetine into breast milk, reflected in a low RID. The findings suggest limited neonatal exposure to the drug, with no adverse developmental effects observed in the infant. However, the case also indicated the potential for vortioxetine use during pregnancy to contribute to the onset of severe neonatal asphyxia. Further research is needed for a comprehensive understanding of its impact on neonatal health.

Interactions of antidepressants with concomitant medications-safety of complex therapies in multimorbidities

Depression is the fourth most serious disease in the world. Left untreated, it is a cause of suicide attempts, emergence or exacerbation worsening of serious diseases, bodily and mental disorders, as well as increased risk of cardiovascular diseases, stroke, diabetes, and obesity, as well as endocrine and neurological diseases. Frequent coexistence of depression and other diseases requires the simultaneous use of several drugs from different therapeutic groups, which very often interact and intensify comorbidities, sometimes unrelated mechanisms. Sufficient awareness of potential drug interactions is critical in clinical practice, as it allows both to avoid disruption of proper pharmacotherapy and achieve substantive results. Therefore, this review aims to analyze the interactions of antidepressants with other concomitant medications. Against the backdrop of experimental research and a thorough analysis of the up-to-date literature, the authors discuss in detail the mechanisms and effects of action of individual drug interactions and adaptogens, including the latest antidepressants.

Effectiveness of vortioxetine in elderly patients with major depressive disorder in real-world clinical practice: Results from the RELIEVE study

BACKGROUND

Data demonstrating the real-world, long-term effectiveness of vortioxetine in elderly patients with major depressive disorder (MDD) are clinically useful to confirm findings from randomized trials.

METHODS

RELIEVE was a multinational, 24-week, observational, prospective study in outpatients with MDD initiating vortioxetine treatment in routine care settings (NCT03555136). Here, we report data from a subgroup of 130 patients aged ⩾ 65 years. The primary study outcome was changed from baseline in patient functioning assessed using the Sheehan Disability Scale (SDS). Other clinical outcomes included depression severity (Patient Health Questionnaire-9 [PHQ-9] and Clinical Global Impressions-Severity [CGI-S]), cognitive performance (Digit Symbol Substitution Test [DSST]) and symptoms (Perceived Deficits Questionnaire - Depression-5 item [PDQ-D-5]), and health-related quality of life (HRQoL) (EuroQoL 5 Dimensions 5 Levels [EQ-5D-5L]).

RESULTS

Clinically meaningful and statistically significant improvements in patient functioning, depressive symptoms, cognitive function, and HRQoL were observed at week 24. Least squares mean SDS, PHQ-9, CGI-S, PDQ-D-5, DSST, and EQ-5D-5L scores improved from baseline by 6.5, 5.7, 1.2, 3.2, 4.4, and 0.11 points, respectively (p < 0.01 for all). Adverse events were observed in 23.1% of patients.

CONCLUSIONS

Consistent with previous clinical studies of vortioxetine, this study supports the effectiveness and safety of vortioxetine in treating elderly patients with MDD in a real-world setting over a 6-month period. Patients showed clinically relevant and sustained improvements in psychosocial functioning, depressive symptoms, and cognitive function after receiving vortioxetine, which was generally well tolerated. Main study limitations include the open-label study design and lack of a placebo or comparator group.

Overview of Psychiatric Medications in the Pipeline in Phase III Trials as of June 1, 2024: A Systematic Review

Objective

This systematic review provides an overview of psychiatric medications in the late stages of development (Phase III clinical trials) as of June 1, 2024. It details the mechanisms of action, efficacy, dosing, and adverse effects of these medications.

Methods

We searched the PubMed database for Phase III studies of psychiatric medications published until June 1, 2024, using the keywords "psychiatric" OR "psychopharm*" AND "medic*" OR "pharm*". Our review encompassed medications currently undergoing Phase III clinical trials and those that have completed Phase III but are awaiting approval from the United States Food and Drug Administration (FDA). We independently analyzed the identified studies and reached a consensus on the medications to be included in this systematic review.

Results

As of June 1, 2024, a total of 89 pipeline drug trials were identified, including nine for schizophrenia, five for bipolar disorders, 25 for depressive disorders, 11 for anxiety disorders, five for post-traumatic stress disorder (PTSD), one for obsessive compulsive disorder (OCD), two for eating disorders, two for sleep-wake disorders, three for sexual dysfunctions, one for substance-related and addictive disorders, 22 for neurocognitive disorders, and three for neurodevelopmental disorders, specifically attention deficit hyperactivity disorder (ADHD).

Conclusion

The psychiatric medications in the pipeline as of June 1, 2024, demonstrate significant promise in treating psychiatric disorders.

Reducing overconfident errors in molecular property classification using Posterior Network

Deep-learning-based classification models are increasingly used for predicting molecular properties in drug development. However, traditional classification models using the Softmax function often give overconfident mispredictions for out-of-distribution samples, highlighting a critical lack of accurate uncertainty estimation. Such limitations can result in substantial costs and should be avoided during drug development. Inspired by advances in evidential deep learning and Posterior Network, we replaced the Softmax function with a normalizing flow to enhance the uncertainty estimation ability of the model in molecular property classification. The proposed strategy was evaluated across diverse scenarios, including simulated experiments based on a synthetic dataset, ADMET predictions, and ligand-based virtual screening. The results demonstrate that compared with the vanilla model, the proposed strategy effectively alleviates the problem of giving overconfident but incorrect predictions. Our findings support the promising application of evidential deep learning in drug development and offer a valuable framework for further research.

Individualized strategies for depression: narrative review of clinical profiles responsive to vortioxetine

BACKGROUND

Depression is a highly heterogeneous disorder, often resulting in suboptimal response and remission rates. This underscores the need for more nuanced clinical characterization of patients to tailor individualized treatment plans. Emerging evidence highlights the critical role of cognitive and emotional dysfunction in major depression, prompting the exploration of novel therapeutic interventions that target these specific symptom domains.

MAIN TEXT

Vortioxetine, a multimodal antidepressant, enhances serotonergic activity while also modulating several other neurotransmitter systems involved in depressive symptoms such as emotional blunting, anhedonia, and cognitive dysfunction. Numerous randomized, placebo-controlled trials have demonstrated vortioxetine's efficacy and safety in treating depression, particularly in specific subgroups of depressed patients, including those with cognitive deficits and comorbid anxiety symptoms or disorders. Although not randomized or placebo-controlled, studies have also shown vortioxetine's efficacy in depressed patients with emotional blunting or anhedonia. Vortioxetine's ability to effectively treat a range of depressive symptoms, including anhedonia, emotional blunting, anxiety, and cognitive dysfunction, provides an individualized treatment solution for depressed individuals suffering from these symptoms. The purpose of this paper is to identify clinical profiles of patients who may benefit from vortioxetine, with the goal of optimizing therapeutic outcomes.

CONCLUSION

Vortioxetine has been shown to be effective for patients with depression and symptoms such as anhedonia, emotional blunting, anxiety, and cognitive dysfunction. Tailoring treatment plans to individual needs and personalizing treatment choices based on the specific symptoms presented by depressed patients improve treatment outcomes.

Perspectives on the impact of vortioxetine on the treatment armamentarium of major depressive disorder

INTRODUCTION

Major Depressive Disorder (MDD) is a mental health issue that significantly affects patients' quality of life and functioning. Despite available treatments, many patients continue to suffer due to incomplete symptom resolution and side effects.

AREAS COVERED

This manuscript examines Vortioxetine's role in Major Depressive Disorder (MDD) treatment, highlighting its potential to reshape therapeutic strategies due to its unique Multimodal action and proven broad-spectrum efficacy in multiple depressive domains. A detailed examination of Vortioxetine's pharmacological aspects, including indications, dosage, pharmacodynamics, and pharmacokinetics, is provided, emphasizing its safety and effectiveness. The discussion extends to Vortioxetine's role in acute-phase treatment and maintenance of MDD and its profound impact on specialized depression domains.

EXPERT OPINION

Vortioxetine is distinguished for its novel multimodal serotonin modulation mechanism, showcasing significant promise as an innovative treatment for MDD. Its efficacy, which is dose-dependent, along with a commendable tolerability profile, positions it as a potential leading option for initial treatment strategies. The discourse on dosage titration, particularly the strategy of initiating treatment at lower doses followed by gradual escalation, underscores the approach toward minimizing initial adverse effects while optimizing therapeutic outcomes, aligning with the principles of personalized medicine in psychiatric care.

The effectiveness of vortioxetine on neurobiochemical metabolites and cognitive of major depressive disorders patients: A 8-week follow-up study

OBJECTIVE

Vortioxetine has been shown to improve cognitive performance in people with depression. This study will look at the changes in neurobiochemical metabolites that occur when vortioxetine improves cognitive performance in MDD patients, with the goal of determining the neuroimaging mechanism through which vortioxetine improves cognitive function.

METHODS

30 depressed patients and 30 demographically matched healthy controls (HC) underwent MCCB cognitive assessment and 1H-MRS. After 8 weeks of vortioxetine medication, MCCB and 1H-MRS tests were retested in the MDD group. Before and after therapy, changes in cognitive performance, NAA/Cr, and Cho/Cr were examined in the MDD group.

RESULTS

Compared with the HC group, the MDD group had significant reduced in verbal learning, social cognition, and total cognition (all p < 0.05). And the MDD group had lower NAA/Cr in Right thalamus and Left PFC; the Cho/Cr in Right thalamus was lower than HC; the Cho/Cr in Left ACC had significantly increase (all p < 0.05). The MDD group showed significant improvements in the areas of verbal learning, attention/alertness, and total cognitive function before and after Vortioxetine treatment (all p < 0.05). The NAA/Cr ratio of the right PFC before and after treatment (t = 2.338, p = 0.026) showed significant changes.

CONCLUSIONS

Vortioxetine can enhance not just the depression symptoms of MDD patients in the initial period, but also their verbal learning, social cognition, and general cognitive capacities after 8 weeks of treatment. Furthermore, vortioxetine has been shown to enhance cognitive function in MDD patients by altering NAA/Cr and Cho/Cr levels in the frontal-thalamic-ACC.

An anti-depressant drug vortioxetine suppresses malignant glioblastoma cell growth

Glioblastoma (GBM) stands as the predominant primary malignant brain tumor in adults, characterized by an exceedingly grim prognosis. Urgent efforts are essential to pioneer effective therapeutics capable of addressing both the intrinsic and acquired resistance exhibited by GBM towards existing treatments. This study employs a drug repurposing strategy to explore the anti-cancer potential of vortioxetine in malignant U251 and T98G glioblastoma cells. Findings from the WST-8 cell counting assay and clonogenic assays indicated that vortioxetine effectively suppressed the short-term viability and long-term survival of glioblastoma cells. We also showed that vortioxetine inhibited the migration of glioblastoma cells as compared to the control. Our findings encourage further exploration and validation of the use of vortioxetine in the treatment of glioblastoma.

Carbon-Based Nanomaterials 4.0

Research on carbon-based nanomaterials, such as carbon nanotubes and graphene and its derivatives, has experienced exponential development in recent years [...].

The effect of vortioxetine on anhedonia in patients with schizophrenia

OBJECTIVE

Anhedonia is a common symptom of depression, but is also a negative symptom of schizophrenia. The purpose of this study was to examine the effects of vortioxetine on anhedonia in patients with schizophrenia.

METHODS

A total of 120 patients with schizophrenia in remission who met inclusion criteria were randomized 1:1 by the envelope method into intervention and control groups. All participants in both groups were divided into three subgroups based on the antipsychotic therapy they were receiving (olanzapine, risperidone, or aripiprazole). Vortioxetine was administered to those in the intervention group at a fixed dose of 10 mg per day. The Positive and Negative Syndrome Scale (PANSS), Calgary Depression Scale for Schizophrenia (CDSS), and Chapman Scale for Social and Physical Anhedonia (CSPA) were administered. The study lasted 12 weeks. Participants were assessed twice: At baseline and at the end of the study. Six participants dropped out, with 114 completing the trial.

FINDINGS

Vortioxetine treatment had a significant effect on level of physical anhedonia. The treatment interaction was also statistically significant, but with a relatively small effect (F = 3.17, P < .05; η2 = .061). Vortioxetine treatment had a particularly strong effect on the level of social anhedonia. The interaction between the treatment and the type of antipsychotics was also statistically significant with a small effect (F = 5.04, P < 0. 01; η2 = .091).

CONCLUSION

The combination of olanzapine and vortioxetine was found to be the best option to reduce symptoms of social and physical anhedonia in these patients with remitted schizophrenia.

Clinical benefits and bioequivalence of vortioxetine oral drop solution versus oral tablets

BACKGROUND

Vortioxetine is efficacious and well tolerated in patients with major depressive disorder (MDD) and is available as an immediate-release tablet and oral drop solution. The oral drop solution may offer clinical benefits versus a tablet, such as the reduced risk of nausea, personalised dosing and ease of administration.

AIMS

To investigate the bioequivalence of vortioxetine 20 mg/mL oral drop solution versus a 20 mg immediate-release tablet.

METHODS

Healthy adults were randomised 1:1 to receive vortioxetine 20 mg oral drop solution or immediate-release 20 mg tablet after fasting on days 1 and 29 in an open-label, single-centre, single-dose crossover study. The area under the plasma concentration-time curve from 0 to 72 h (AUC0-72h) and maximum plasma concentration (Cmax) were analysed. Bioequivalence was concluded if the 90% CI for the oral drop solution-to-immediate-release tablet ratio for AUC0-72h and Cmax were contained within a range of 0.80-1.25.

RESULTS

Vortioxetine oral drop solution was bioequivalent to the tablet (n = 26; estimated AUC0-72h ratio 1.06 (90% CI: 1.03-1.10); Cmax ratio 1.01 (90% CI: 0.97-1.05)). A similar proportion of participants reported adverse events in each study arm but more headache events (7 vs 1) were reported with the oral drop solution versus tablet. The most common adverse event was nausea (16-23% of participants; all mild intensity).

CONCLUSIONS

Vortioxetine oral drop solution is bioequivalent to immediate-release tablets. Oral drop solution provides an alternative to tablets and facilitates clinical benefit through individualised treatment, including gradual dose up-titration, for patients with MDD.

The Role of Vortioxetine in the Treatment of Depressive Symptoms in General Hospital Psychiatry: A Case-Series and PRISMA-Compliant Systematic Review of the Literature

Depressive symptoms are a customary finding in hospitalized patients, particularly those who are undergoing long hospitalizations, underwent major surgical procedures or suffer from high levels of multimorbidity and frailty. The patients included in this case series shared high degrees of frailty-complexity and were evaluated within the ordinary consultation and liaison psychiatry service of the University Hospital in Pisa, Italy, from September 2021 to June 2023. Patients were administered at least one follow-up evaluation after a week and before discharge. To relate this case series to the extant literature, a comprehensive systematic review of vortioxetine safety and efficacy was performed. None of the six patients included developed serious safety issues, but one patient complained of mild-to-moderate nausea for some days after the vortioxetine introduction. Five out of six patients exhibited at least a slight clinical benefit as measured by the clinical global impression scale. Of the 858 entries screened via Scopus and Medline/PubMed, a total of 134 papers were included in our review. The present case series provides preliminary evidence for vortioxetine's safety in this healthcare domain. The literature reviewed in this paper seems to endorse a promising safety profile and a very peculiar efficacy niche for vortioxetine in consultation and liaison psychiatry.

Establishment of a 3D multicellular placental microtissues for investigating the effect of antidepressant vortioxetine

The placenta is a unique organ with an active metabolism and dynamically changing physiology throughout pregnancy. It is difficult to elucidate the structure of cell-cell and cell-extracellular matrix interactions of the placenta in in vivo studies due to interspecies differences and ethical constraints. In this study, human umbilical cord vein cells (HUVEC) and human placental choriocarcinoma cells (BeWo) were co-cultured for the first time to form spheroids (microtissues) on a three-dimensional (3D) Petri Dish® mold and compared with a traditional two-dimensional (2D) system. Vortioxetine is an antidepressant with a lack of literature on its use in pregnancy in established cultures, the toxicity of vortioxetine was studied to investigate the response of spheroids representing placental tissue. Spheroids were characterised by morphology and exposed to vortioxetine. Cell viability and barrier integrity were then measured. Intercellular junctions and the localisation of serotonin transporter (SERT) proteins were demonstrated by immunofluorescence (IF) staining in BeWo cells. Human chorionic gonadotropin (beta-hCG) hormone levels were also measured. In the 3D system, cell viability and hormone production were higher than in the 2D system. It was observed that the barrier structure was impaired, the structure of intracellular skeletal elements was altered and SERT expression decreased depending on vortioxetine exposure. These results demonstrate that the multicellular microtissue placenta model can be used to obtain results that more closely resemble in vivo toxicity studies of various xenobiotics than other 2D and mono-culture spheroid models in the literature. It also describes the use of 3D models for soft tissues other than the placenta.

Neuroproteomics: Unveiling the Molecular Insights of Psychiatric Disorders with a Focus on Anxiety Disorder and Depression

Anxiety and depression are two of the most common mental disorders worldwide, with a lifetime prevalence of up to 30%. These disorders are complex and have a variety of overlapping factors, including genetic, environmental, and behavioral factors. Current pharmacological treatments for anxiety and depression are not perfect. Many patients do not respond to treatment, and those who do often experience side effects. Animal models are crucial for understanding the complex pathophysiology of both disorders. These models have been used to identify potential targets for new treatments, and they have also been used to study the effects of environmental factors on these disorders. Recent proteomic methods and technologies are providing new insights into the molecular mechanisms of anxiety disorder and depression. These methods have been used to identify proteins that are altered in these disorders, and they have also been used to study the effects of pharmacological treatments on protein expression. Together, behavioral and proteomic research will help elucidate the factors involved in anxiety disorder and depression. This knowledge will improve preventive strategies and lead to the development of novel treatments.

Vortioxetine usage in an elderly patient with major depressive disorder and accompanied by multiple physical conditions: A case report

Elderly patients with depressive disorder always have complex and diverse symptoms, and are mostly combined with chronic physical conditions. This case report presents a case of vortioxetine usage in a 67-year-old male patient with major depressive disorder and accompanied by multiple physical conditions.

Clinical Consequences of Altered Drug Disposition in Obesity: Call for Change

Obesity is a serious condition with many known comorbid conditions and other health risks. Despite the rising global rates of obesity, drug disposition in this population is typically understudied, which results in limited information guiding the use of drugs in patients with obesity. Presently, dosing adjustments for patients with obesity typically focus on addressing altered drug clearance with body size and are therefore limited to chronic dosing recommendations. These instructions are variable and rarely based on dedicated studies in people with obesity. This review briefly discusses the current clinical use of body measurements to guide chronic dosing instructions and highlights the need for obesity-specific dosing instructions when the half-life of a drug is prolonged (typically through increased volume of distribution) in people with obesity. Examples of drugs with apparent opportunities for either ramp-up, loading, or washout instructions for patients based on body mass index are identified, specifically for vortioxetine, posaconazole, and brexpiprazole. We call for inclusion of people with obesity in clinical studies as a special subpopulation during drug development and propose the use of body mass index to guide dosing decisions among these patients.

Lethal vortioxetine poisoning? A forensic investigation

Vortioxetine is an antidepressant recently licensed in the US and EU for the treatment of major depressive disorder. No fatalities from vortioxetine overdose have been reported, yet. Two cases of attempted suicide are described in the literature, although no toxicological analyzes were conducted. Vortioxetine concentrations found in blood and organs in a case of a probable acute lethal intoxication are reported here. A 65-year-old woman was found on the floor behind her bed with no vital signs. The woman was recently on vortioxetine 10 mg/day for major depression, anxiety, and psychotic attacks. Vortioxetine was quantified in blood, brain, liver, kidney, and lung samples by LC-MS/MS. Vortioxetine concentrations were: 1.197 ng/ml in the blood, 804 ng/g in the brain, 8.992 ng/g in the lung, 1.389 ng/g in the liver, 292 in the kidney. No other substance was found. In the case reported here, the blood concentration was approximately 35-135 times higher than the antemortem therapeutic value. Histological examination showed signs of a probable sudden cardiac death following to arrhythmia, with no evidence of myocardial infarction. The present case indicate that blood concentrations close to 1,000 ng/mL could lead to death, involving probably to a cardiac toxicity.

Effects of Vortioxetine on Sleep Architecture of Adolescents with Major Depressive Disorder

The relationship between depression and insomnia is bidirectional and both conditions need to be treated adequately, especially in a vulnerable neurodevelopmental stage of adolescence. This study aimed to evaluate the effects of antidepressant treatment using vortioxetine (VOR) on the sleep architecture of depressed adolescents by using video-polysomnography (v-PSG), which has not been researched before. The v-PSG was performed on 30 adolescent in-patients (mean age of 15.0 years ± 1.5 SD, 21 girls) treated with VOR (dosage of 10/15/20 mg/day) administered orally once a day, before and after VOR treatment. The evaluated parameters were conventional sleep parameters, sleep fragmentation parameters, and selected spectral power indices. Symptoms of depression and insomnia before and after the treatment period were evaluated using valid and reliable questionnaires (the Children´s Depression Inventory and the Athens Insomnia Scale). Depressed adolescents showed higher REM latency and decreased REM sleep percentage after treatment than before the treatment period (p = 0.005, p = 0.009, respectively). Our study revealed REM suppression (increased REM latency and reduced REM sleep percentage), indicating altered sleep architecture as a potential result of VOR treatment, which seems to be dose-dependent.

Inhibitory mechanism of vortioxetine on CYP450 enzymes in human and rat liver microsomes

Vortioxetine is a novel anti-major depression disorder drug with a high safety profile compared with other similar drugs. However, little research has been done on drug-drug interactions (DDI) about vortioxetine. In this paper, the inhibitory effect of vortioxetine on cytochrome P450 (CYP450) and the type of inhibitory mechanism were investigated in human and rat liver microsomes. We set up an in vitro incubation system of 200 μL to measure the metabolism of probe substrates at the present of vortioxetine at 37°C. The concentrations of the metabolites of probe substrates were all measured by ultra-performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) method. It was found no time-dependent inhibition (TDI) of vortioxetine through determination of half-maximal inhibitory concentration (IC50) shift values. The enzymes and metabolites involved in this experiment in human and rats were as follows: CYP3A4/CYP3A (midazolam); CYP2B6/CYP2B (bupropion); CYP2D6/CYP2D (dextromethorphan); CYP2C8/CYP2C-1 (amodiaquine); CYP2C9/CYP2C-2 (losartan); and CYP2C19/CYP2C-3 (mephenytoin). We found that vortioxetine competitively inhibited CYP2C19 and CYP2D6 in human liver microsomes (HLMs) with inhibition constant (Ki) values of 2.17 μM and 9.37 μM, respectively. It was noncompetitive inhibition for CYP3A4 and CYP2C8, and its Ki values were 7.26 μM and 6.96 μM, respectively. For CYP2B6 and CYP2C9, vortioxetine exhibited the mixed inhibition with Ki values were 8.55 μM and 4.17 μM, respectively. In RLMs, the type of vortioxetine inhibition was uncompetitive for CYP3A and CYP2D (Ki = 4.41 and 100.9 μM). The inhibition type was competitive inhibition, including CYP2B and CYP2C-2 (Ki = 2.87 and 0.12 μM). The inhibition types of CYP2C-1 and CYP2C-3 (Ki = 39.91 and 4.23 μM) were mixed inhibition and noncompetitive inhibition, respectively. The study of the above mechanism will provide guidance for the safe clinical use of vortioxetine so that the occurrence of DDI can be avoided.

One-Pot, Three-Component Assembly of Sulfides Using a Sulfoxide Reagent as a Sulfur Dication Equivalent

We report a one-pot, three-component synthesis of sulfides by exploiting a sulfoxide reagent as a formal sulfur dication equivalent. Our protocol consists of three simple chemical operations involving two Grignard reagents and trimethylsilyl chloride (TMSCl) to sequentially form sulfenate anions, sulfenate esters, and sulfides. We demonstrate a wide range of Grignard reagents to be coupled, thereby allowing the modular, thiol-free synthesis of sulfides including dialkenyl and alkenyl-alkynyl sulfides.

The prescriber's guide to classic MAO inhibitors (phenelzine, tranylcypromine, isocarboxazid) for treatment-resistant depression

This article is a clinical guide which discusses the "state-of-the-art" usage of the classic monoamine oxidase inhibitor (MAOI) antidepressants (phenelzine, tranylcypromine, and isocarboxazid) in modern psychiatric practice. The guide is for all clinicians, including those who may not be experienced MAOI prescribers. It discusses indications, drug-drug interactions, side-effect management, and the safety of various augmentation strategies. There is a clear and broad consensus (more than 70 international expert endorsers), based on 6 decades of experience, for the recommendations herein exposited. They are based on empirical evidence and expert opinion-this guide is presented as a new specialist-consensus standard. The guide provides practical clinical advice, and is the basis for the rational use of these drugs, particularly because it improves and updates knowledge, and corrects the various misconceptions that have hitherto been prominent in the literature, partly due to insufficient knowledge of pharmacology. The guide suggests that MAOIs should always be considered in cases of treatment-resistant depression (including those melancholic in nature), and prior to electroconvulsive therapy-while taking into account of patient preference. In selected cases, they may be considered earlier in the treatment algorithm than has previously been customary, and should not be regarded as drugs of last resort; they may prove decisively effective when many other treatments have failed. The guide clarifies key points on the concomitant use of incorrectly proscribed drugs such as methylphenidate and some tricyclic antidepressants. It also illustrates the straightforward "bridging" methods that may be used to transition simply and safely from other antidepressants to MAOIs.

Pharmacotherapy for post-stroke aphasia: what are the options?

INTRODUCTION

Aphasia is a common, long-lasting aftermath of stroke lesions. There is an increased integration of pharmacotherapy as an adjunctive strategy to speech and language therapy (SLT) for post-stroke aphasia (PSA). Nevertheless, more research in pharmacotherapy for acute and chronic PSA is necessary, including the election of drugs that target different neurotransmitter systems and deficits in specific language domains.

AREAS COVERED

This article updates the role of pharmacotherapy for PSA, focusing the spotlight on some already investigated drugs and candidate agents deserving of future research. Refining the precision of drug election would require using multimodal biomarkers to develop personalized treatment approaches. There is a solid need to devise feasible randomized controlled trials adapted to the particularities of the PSA population. The emergent role of multimodal interventions combining one or two drugs with noninvasive brain stimulation to augment SLT is emphasized.

EXPERT OPINION

Pharmacotherapy can improve language deficits not fully alleviated by SLT. In addition, the 'drug-only' approach can also be adopted when administering SLT is not possible. The primary goal of pharmacotherapy is reducing the overall aphasia severity, although targeting language-specific deficits (i.e. naming, spoken output) also contributes to improving functional communication. Unfortunately, there is still little information for recommending a drug for specific language deficits.

Broad Serotonergic Actions of Vortioxetine as a Promising Avenue for the Treatment of L-DOPA-Induced Dyskinesia

Parkinson's Disease (PD) is a neurodegenerative disorder characterized by motor symptoms that result from loss of nigrostriatal dopamine (DA) cells. While L-DOPA provides symptom alleviation, its chronic use often results in the development of L-DOPA-induced dyskinesia (LID). Evidence suggests that neuroplasticity within the serotonin (5-HT) system contributes to LID onset, persistence, and severity. This has been supported by research showing 5-HT compounds targeting 5-HT1A/1B receptors and/or the 5-HT transporter (SERT) can reduce LID. Recently, vortioxetine, a multimodal 5-HT compound developed for depression, demonstrated acute anti-dyskinetic effects. However, the durability and underlying pharmacology of vortioxetine's anti-dyskinetic actions have yet to be delineated. To address these gaps, we used hemiparkinsonian rats in Experiment 1, examining the effects of sub-chronic vortioxetine on established LID and motor performance. In Experiment 2, we applied the 5-HT1A antagonist WAY-100635 or 5-HT1B antagonist SB-224289 in conjunction with L-DOPA and vortioxetine to determine the contributions of each receptor to vortioxetine's effects. The results revealed that vortioxetine consistently and dose-dependently attenuated LID while independently, 5-HT1A and 5-HT1B receptors each partially reversed vortioxetine's effects. Such findings further support the promise of pharmacological strategies, such as vortioxetine, and indicate that broad 5-HT actions may provide durable responses without significant side effects.

Vortioxetine 20 mg/day in patients with major depressive disorder: updated analysis of efficacy, safety, and optimal timing of dose adjustment

BACKGROUND

Analysis of efficacy and tolerability of vortioxetine 20 mg/day, and optimal timing of dose adjustment, in patients with major depressive disorder (MDD).

METHODS

Pooled analysis of six randomized, fixed-dose studies of vortioxetine 5 to 20 mg/day. Mean change from baseline in Montgomery-Åsberg Depression Rating Scale (MADRS) total score was analyzed by vortioxetine dose using a mixed model for repeated measures. Tolerability was assessed over the 8-week treatment period and from day 8 (ie, following dose increase to 20 mg/day). Data from three randomized, flexible-dose studies were examined for frequency and timing of dose adjustment.

RESULTS

A clear dose-response relationship for vortioxetine was confirmed in terms of improvement in MADRS total score. Significant differences vs placebo were seen for vortioxetine 20 mg/day from week 2 onwards; vortioxetine 10 mg did not separate from placebo until week 4. At week 8, mean change in MADRS total score from baseline was significantly greater for vortioxetine 20 mg/day vs 10 mg/day (difference, -1.03 points; P < .05). Incidence of adverse events was not increased in patients who received vortioxetine 20 mg/day vs 10 mg/day. In flexible-dose studies, dosage was increased to 20 mg/day after 1 week in 48.0% of patients; final dosage was 20 mg/day in 64.3% of patients.

CONCLUSIONS

Vortioxetine 20 mg is significantly more effective than vortioxetine 10 mg in patients with MDD, with a similar tolerability profile. In flexible-dose studies, almost half of all patients received 20 mg/day after 1 week and two-thirds received 20 mg/day as their final dosage.

Deciphering Nonbioavailable Substructures Improves the Bioavailability of Antidepressants by Serotonin Transporter

Inadequate bioavailability is one of the most critical reasons for the failure of oral drug development. However, the way that substructures affect bioavailability remains largely unknown. Serotonin transporter (SERT) inhibitors are first-line drugs for major depression disorder, and improving their bioavailability may be able to decrease side-effects by reducing daily dose. Thus, it is an excellent model to probe the relationship between substructures and bioavailability. Here, we proposed the concept of "nonbioavailable substructures", referring to substructures that are unfavorable to bioavailability. A machine learning model was developed to identify nonbioavailable substructures based on their molecular properties and shows the accuracy of 83.5%. A more potent SERT inhibitor DH4 was discovered with a bioavailability of 83.28% in rats by replacing the nonbioavailable substructure of approved drug vilazodone. DH4 exhibits promising anti-depression efficacy in animal experiments. The concept of nonbioavailable substructures may open up a new venue for the improvement of drug bioavailability.

Safety and effectiveness of vortioxetine for major depressive disorder: Real-world evidence from a population-based study in South Korea

Background

A post-marketing surveillance study was conducted to assess the real-world safety and effectiveness of vortioxetine for the treatment of major depressive disorder (MDD) in South Korea.

Methods

Adult patients aged 19-94 years receiving vortioxetine for MDD at 72 hospitals and clinics in South Korea between 19^th August 2014 and 18^th August 2020 were included. Patients were followed for up to 24±2 weeks, at up to three visits. Adverse events (AEs) and effectiveness, assessed by both clinician and patient-reported measures, were analyzed.

Results

A total of 3,263 patients (mean age: 51.28 years) were included in the safety set; 1,095 were aged ≥65 years. The majority of the safety set (61.97%) were female. The overall rate of any AEs and serious AEs were 17.13 and 1.56%, respectively. The majority of AEs were mild (88.32%). The rates of AEs did not differ statistically by age (≥65 years: 16.89% [185/1,095] versus <65 years: 17.25% [374/2,168)], p=0.7989), sex (male: 15.95% [198/1,241] versus female: 17.85% [361/2,022], p=0.1623), or liver impairment (with liver impairment: 20.90% [14/67] versus without liver impairment: 17.05% [545/3,196], p=0.4087). Effectiveness was assessed in 1,918 patients. By 24±2 weeks, there were significant clinical improvements from baseline, assessed by change in Montgomery-Asberg Depression Rating Scale total score (mean±standard deviation [SD]: -10.49±9.42 points, p <0.0001), the proportion of patients with improved symptoms using the Clinical Global Impression - Improvement scores (79.29%), and in both patient-reported measures, with a significant improvement in the Korean Version of the Perceived Deficits Questionnaire-Depression (mean±SD: -6.06±13.23, p <0.0001) and Digit Symbol Substitution Test (mean±SD: 4.83±9.81, p <0.0001) total scores from baseline. Similar to the safety profiles, the proportions of patients with improved symptoms compared with baseline using the Clinical Global Impression - Improvement scores did not differ by age (≥65 years: 82.09% versus <65 years: 78.32%, p=0.0511), sex (male: 77.45% versus female: 81.01%, p=0.0587), or liver impairment (with liver impairment: 67.57% versus without liver impairment: 79.85%, p=0.0663).

Conclusion

Vortioxetine appears to be well-tolerated and effective for treating MDD patients in the real-world setting in South Korea, irrespective of age, sex, and liver impairment, reflecting the known profile of vortioxetine based on studies worldwide.

Pharmacokinetic Interactions Between Antiseizure and Psychiatric Medications

Antiseizure medications and drugs for psychiatric diseases are frequently used in combination. In this context, pharmacokinetic interactions between these drugs may occur. The vast majority of these interactions are primarily observed at a metabolic level and result from changes in the activity of the cytochrome P450 (CYP). Carbamazepine, phenytoin, and barbiturates induce the oxidative biotransformation and can consequently reduce the plasma concentrations of tricyclic antidepressants, many typical and atypical antipsychotics and some benzodiazepines. Newer antiseizure medications show a lower potential for clinically relevant interactions with drugs for psychiatric disease. The pharmacokinetics of many antiseizure medications is not influenced by antipsychotics and anxiolytics, while some newer antidepressants, namely fluoxetine, fluvoxamine and viloxazine, may inhibit CYP enzymes leading to increased serum concentrations of some antiseizure medications, including phenytoin and carbamazepine. Clinically relevant pharmacokinetic interactions may be anticipated by knowledge of CYP enzymes involved in the biotransformation of individual medications and of the influence of the specific comedication on the activity of these CYP enzymes. As a general rule, these interactions can be managed by careful evaluation of clinical response and, when indicated, individualized dosage adjustments guided by measurement of drugs serum concentrations, especially if pharmacokinetic interactions may cause any change in seizure control or signs of toxicity. Further studies are required to improve predictions of pharmacokinetic interactions between antiseizure medications and drugs for psychiatric diseases providing practical helps for clinicians in the clinical setting.

[The relationship of cytochrome P450 isoforms with the efficacy and safety of antipsychotic and antidepressant therapy]

Cytochrome P450 (CYP450) is the leading enzyme in the biotransformation of most psychotropic drugs. CYP450 gene polymorphisms determine a patient's endophenotype with respect to the activity of enzymes of the family and affect the metabolism of prescribed antipsychotics and antidepressants. Categorizing patients by endophenotype during genotyping is likely to help simplify the selection of therapy in clinical practice. Co-prescribing drugs that may be inhibitors or inducers of CYP450 isoforms, in turn, may lead to adverse reactions or no effect of therapy. The article presents a compilation of known pharmacogenetic recommendations regarding the four major endophenotypes of metabolizers.

Use of Hierarchical Carbon Nanofibers Decorated with NiCo Nanoparticles for Highly Sensitive Vortioxetine Determination

A new voltammetry method for the highly sensitive antidepressant drug vortioxetine (VOR) is presented using glassy carbon electrodes modified with hierarchical carbon nanofibers with NiCo nanoparticles (eCNF/CNT/NiCo-GCE). The electrochemical behavior of VOR was investigated by cyclic voltammetry, which indicates that its oxidation is an adsorption-controlled process with the exchange of two electrons and one proton. The effects of various factors on the VOR peak, such as supporting electrolyte type, preconcentration time, and potential, or influence of interferents, were tested using the square wave voltammetry technique (SWV). The linear voltametric response for the analyte was obtained in the concentration range from 0.01·10-6 to 3.0·10-6 mol L-1 with the detection limit of 1.55·10-9 mol L-1 for a preconcentration time of 60 s. The proposed method was successfully applied for highly sensitive VOR determination in complex matrices such as tablets, urine, and plasma with good recovery parameter.

Agomelatine, Ketamine and Vortioxetine Attenuate Energy Cell Metabolism-In Vitro Study

This determination of the mitochondrial effect of pharmacologically different antidepressants (agomelatine, ketamine and vortioxetine) was evaluated and quantified in vitro in pig brain-isolated mitochondria. We measured the activity of mitochondrial complexes, citrate synthase, malate dehydrogenase and monoamine oxidase, and the mitochondrial respiratory rate. Total hydrogen peroxide production and ATP production were assayed. The most potent inhibitor of all mitochondrial complexes and complex I-linked respiration was vortioxetine. Agomelatine and ketamine inhibited only complex IV activity. None of the drugs affected complex II-linked respiration, citrate synthase or malate dehydrogenase activity. Hydrogen peroxide production was mildly increased by agomelatine, which might contribute to increased oxidative damage and adverse effects at high drug concentrations. Vortioxetine significantly reduced hydrogen peroxide concentrations, which might suggest antioxidant mechanism activation. All tested antidepressants were partial MAO-A inhibitors, which might contribute to their antidepressant effect. We observed vortioxetine-induced MAO-B inhibition, which might be linked to decreased hydrogen peroxide formation and contribute to its procognitive and neuroprotective effects. Mitochondrial dysfunction could be linked to the adverse effects of vortioxetine, as vortioxetine is the most potent inhibitor of mitochondrial complexes and complex I-linked respiration. Clarifying the molecular interaction between drugs and mitochondria is important to fully understand their mechanism of action and the connection between their mechanisms and their therapeutic and/or adverse effects.

The role of reelin in the pathological mechanism of depression from clinical to rodents

Major depressive disorder (MDD) is a devastating mental illness and the leading cause of disability worldwide. Previous studies have suggested that synaptic plasticity in the hippocampus plays an important role in depression pathogenesis. Reelin is expressed mainly in the frontal lobe and hippocampus, and is closely associated with neurodevelopment and synaptic plasticity. However, few studies have investigated its role in MDD combining clinical trials and animal experiments. We show that in a clinical trial, plasma reelin levels decreased in patients with first-episode drug-naïve MDD and increased after treatment; further, plasma reelin levels allowed to distinguish drug-naïve patients with first-episode MDD from healthy individuals. In rats, chronic mild and unpredictable stress led to a decrease in both reelin mRNA and protein levels in the hippocampus, which could be reversed by vortioxetine. Subsequent experiments confirmed that the reelin-ApoER2-NR2A /NR2B pathway regulates hippocampal synaptic plasticity and may be involved in depression or antidepressant responses. Our work contributes to a deeper understanding of MDD pathogenesis and provides new evidence that reelin should be considered a potential therapeutic target for MDD.

Magnesium Potentiates the Vortioxetine’s Effects on Physical Performances and Biological Changes in Exercise-Induced Stress in Rats

Background and objectives: Vortioxetine (VRT) is a relatively new selective serotonin reuptake inhibitor (SSRI) antidepressant and serotonin receptor modulator, approved for the treatment of major depression and generalized anxiety disorder. Depression has been linked with psychomotor disengagement, oxidative stress burden and decreased blood levels of brain-derived neurotrophic factor (BDNF). In our study we performed the experimental investigation of VRT, magnesium and of their association on the rats’ endurance capacity, motor behavior and blood biological disturbances in rats subjected to forced exercise in treadmill test. Materials and Methods: The substances were administered orally for 14 consecutive days, as follows: group 1 (control): distilled water 0.3 mL/100 g body; group 2 (Mg): magnesium chloride 200 mg/kg body; group 3 (VRT): VRT 20 mg/kg body; group 4 (VRT+Mg): VRT 20 mg/kg body + magnesium chloride 200 mg/kg body. Magnesium was used as positive control substance with known effects in treadmill test. The consequences of VRT treatment on glucose, cortisol, BDNF and oxidative stress biomarkers (superoxide-dismutase, malondialdehyde, glutathione-peroxidase, lactate dehydrogenase) were also assessed. Results and conclusions: The use of VRT resulted in an improvement in motor capacity and an increase of the rats’ endurance to physical effort. The administration of VRT increased the serum BDNF levels and reduced the oxidative stress in rats subjected to physical effort. The association of magnesium potentiated the effects of VRT on physical performances, the antioxidant activity and the decreasing in serum stress markers in treadmill test in rats.

Efficacy and safety of vortioxetine in treatment of patients with major depressive disorder and common co-morbid physical illness

BACKGROUND

The multimodal antidepressant vortioxetine is effective in reducing somatic symptoms in patients with major depressive disorder (MDD), but little is known about its effects in reducing depressive symptoms in patients with common comorbid physical illnesses.

METHODS

This was a pooled analysis of 13 randomized, placebo-controlled trials which evaluated the efficacy (using the Montgomery-Åsberg Depression Rating Scale [MADRS]) and safety of vortioxetine (5-20 mg/day) in adult patients with MDD. We evaluated stable somatic comorbid conditions that were verified by a diagnosis and had sufficient database representation.

RESULTS

Of the 5982 patients included in the database, 963 (16.1%) patients had a diagnosis of cardiovascular disease, 152 (2.5%) had diabetes mellitus and 26 (0.4%) had chronic obstructive pulmonary disorder (COPD). At Week 8, adjusted mean[95%CI] treatment differences (vortioxetine vs. placebo) on MADRS total scores were -2.7[-4.2, -1.3] (p = 0.0002) points for the cardiovascular disease, -4.0[-7.7, -0.4] (p = 0.03) for the diabetes, and -6.2[-21.3, 8.9] (p = 0.36) for the COPD groups. The rate and pattern of adverse events were similar across the sub-groups with comorbidities and was consistent with that expected for vortioxetine treatment.

LIMITATIONS

The primary studies were not designed to investigate the relationship between vortioxetine and comorbidities, nor were the post hoc analyses powered to detect group differences.

CONCLUSIONS

Patients with MDD and comorbid cardiovascular disease or diabetes respond to vortioxetine in a similar way to the broader MDD population. Vortioxetine was generally safe and well tolerated and without unexpected adverse events in these subpopulations, most of whom are taking multiple concomitant medications.

Real-world effectiveness of vortioxetine in outpatients with major depressive disorder: functioning and dose effects

BACKGROUND

Functional recovery is an important treatment goal in major depressive disorder (MDD). This study assessed the real-world effectiveness of vortioxetine in patients with MDD, with particular focus on functioning; dose-response was also assessed.

METHODS

This was a non-interventional, prospective, multicenter study conducted in Greece. Adult outpatients with MDD (n = 336) initiating vortioxetine (5-20 mg/day flexible dosing) as treatment for a current major depressive episode were followed for 3 months. Analyses were stratified according to vortioxetine dosage at 3 months: 5-10 mg/day versus 15-20 mg/day. Functioning was assessed using the Sheehan Disability Scale (SDS).

RESULTS

Mean ± standard error SDS total score decreased (improved) from 18.7 ± 0.3 at baseline to 12.9 ± 0.3 after 1 month of vortioxetine treatment and 7.8 ± 0.4 after 3 months (p < 0.001 vs. baseline for all comparisons). Functional recovery (SDS score ≤ 6) was achieved in 14.6% of patients after 1 month of treatment and 48.4% of patients after 3 months. Improvement from baseline in SDS total and domain scores at 3 months was more pronounced in patients receiving vortioxetine 15-20 mg/day than in those receiving vortioxetine 5-10 mg/day. The mean ± standard error change in SDS total score from baseline was 9.2 ± 0.8 in the 5-10 mg/day group and 12.1 ± 0.4 in the 15-20 mg/day group (p < 0.001). Limitations of this study include its non-interventional study design and lack of a control group or active comparator.

CONCLUSIONS

Statistically significant and clinically relevant improvements in functioning were seen in patients with MDD treated with vortioxetine in a real-world setting. Higher doses of vortioxetine were associated with significantly greater improvements in functioning.

The effects of Vilazodone, YL-0919 and Vortioxetine in hemiparkinsonian rats

Parkinson's disease is a neurodegenerative disease often characterized by motor deficits and most commonly treated with dopamine replacement therapy. Despite its benefits, chronic use of L-DOPA results in abnormal involuntary movements known as L-DOPA-induced dyskinesia. Growing evidence shows that with burgeoning dopamine cell loss, neuroplasticity in the serotonin system leads to the development of L-DOPA-induced dyskinesia through the unregulated uptake, conversion, and release of L-DOPA-derived dopamine into the striatum. Previous studies have shown that coincident 5-HT_1A agonism and serotonin transporter inhibition may have anti-dyskinetic potential. Despite this, few studies have explicitly focused on targeting both 5-HT_1A and the serotonin transporter. The present study compares the 5-HT compounds Vilazodone, YL-0919, and Vortioxetine which purportedly work as simultaneous 5-HT_1A receptor agonists and SERT blockers. To do so, adult female Sprague Dawley rats were rendered hemiparkinsonian and treated daily for two weeks with L-DOPA to produce stable dyskinesia. The abnormal involuntary movements and forehand adjusting step tests were utilized as measurements for L-DOPA-induced dyskinesia and motor performance in a within-subjects design. Lesion efficacy was determined by analysis of striatal monoamines via high-performance liquid chromatography. Compounds selective for 5-HT_1A/SERT target sites including Vilazodone and Vortioxetine significantly reduced L-DOPA-induced dyskinesia without compromising L-DOPA pro-motor efficacy. In contrast, YL-0919 failed to reduce L-DOPA-induced dyskinesia, with no effects on L-DOPA-related improvements. Collectively, this work supports pharmacological targeting of 5-HT_1A/SERT to reduce L-DOPA-induced dyskinesia. Additionally, this further provides evidence for Vilazodone and Vortioxetine, FDA-approved compounds, as potential adjunct therapeutics for L-DOPA-induced dyskinesia management in Parkinson's patients.

Association Between CYP2D6 Metabolizer Status and Vortioxetine Exposure and Treatment Switching: A Retrospective, Naturalistic Cohort Study Using Therapeutic Drug Monitoring Data From 640 Patients

PURPOSE

The antidepressant vortioxetine is mainly metabolized by the polymorphic enzyme CYP2D6. The aim of this study was to investigate the absolute serum concentrations of vortioxetine and frequency of switching to an alternative antidepressant in relation to CYP2D6 genotype in a naturalistic patient population.

METHODS

The analyses included data from 640 CYP2D6 -genotyped patients treated with vortioxetine from a Norwegian therapeutic drug monitoring database. Serum concentration of vortioxetine was determined using ultrahigh-performance liquid chromatography-high-resolution mass spectrometry, whereas longitudinal reviews of therapeutic drug monitoring profiles were performed to identify cases of patients switching from vortioxetine to an alternative antidepressant.

RESULTS

Compared with CYP2D6 normal metabolizers (n = 342), the median vortioxetine serum concentration (ng/mL) was 2.1-fold ( P < 0.001) increased in poor metabolizers (PMs) (n = 48), 1.5-fold ( P < 0.001) increased in intermediate metabolizers (n = 238), and not significantly changed in ultrarapid metabolizers (n = 12). Compared with CYP2D6 normal metabolizers, treatment switch from vortioxetine to alternative antidepressants was 5.1-fold (95% confidence interval, 1.6-15.4, P = 0.003) more frequent among PMs. The prescribed doses did not differ significantly between the subgroups ( P = 0.26). A possible explanation for the increased frequency of treatment switch among PMs is that concentration-dependent adverse events were more frequent in this group because of increased drug exposure.

CONCLUSIONS

This naturalistic study provides novel data on the association between CYP2D6 genotype and treatment switch of vortioxetine, which likely reflects the significant effect of CYP2D6 genotype on vortioxetine exposure.

Toxicity of waterborne vortioxetine, a new antidepressant, in non-target aquatic organisms: From wonder to concern drugs?

Vortioxetine is increasing in popularity as a treatment for major depressive disorder and has been detected in wastewater effluent. However, information on the toxicity and environmental risk of vortioxetine in non-target organisms is scarce. Here, embryonic and juvenile zebrafish (Danio rerio) were used to assess the toxicity of vortioxetine (0, 1, 10, 30, 100, 300, and 1000 μg/L) after 120 h and 7 d of exposure, respectively. Vortioxetine induced significant toxicity during embryonic development, including effects on survival, hatching, basal heart rate, spontaneous tail coiling and developmental abnormalities, and inhibited larval locomotor activity at concentrations higher than 30 μg/L. Additionally, vortioxetine evoked anxiolytic-like behavior and caused histopathological changes to multiple organs (gills, heart, liver and intestine) in juvenile zebrafish. Significant increase in 5-HT content was observed in whole zebrafish larvae and juvenile brain tissues from animals treated with 1 or 100 μg/L vortioxetine. Notably, the lowest effective concentrations of vortioxetine for zebrafish were mainly in the range of 10-30 μg/L, which were slightly lower than the vortioxetine therapeutic concentrations. Risk quotients assuming conservative exposure assessments were above one in European countries indicating moderate risk for the behavioral endpoints assessed. We believe that these results highlight the adverse effects of vortioxetine on non-target organisms and that further investigations will be required to provide a higher confidence.

Inhibitory Effectiveness in Delayed-Rectifier Potassium Current Caused by Vortioxetine, Known to Be a Novel Antidepressant

Vortioxetine (VOR) is recognized to exert antidepressant actions. However, whether this drug modifies ionic currents in excitable cells remains unclear. The aim of this study was to explore the electrophysiological effects of VOR and other related compounds in pituitary GH3 cells and in Neuro-2a cells. VOR suppressed the delayed-rectifier K+ current (IK(DR)) in a concentration-, time-, and state-dependent manner. Effective IC50 values needed to inhibit peak and sustained IK(DR) were computed to be 31.2 and 8.5 μM, respectively, while the KD value estimated from minimal binding scheme was 7.9 μM. Cell exposure to serotonin (10 μM) alone failed to alter IK(DR), while fluoxetine (10 μM), a compound structurally similar to VOR, mildly suppressed current amplitude. In continued presence of VOR, neither further addition of propranolol nor risperidone reversed VOR-mediated inhibition of IK(DR). Increasing VOR concentration not only depressed IK(DR) conductance but also shifted toward the hyperpolarized potential. As the VOR concentration was raised, the recovery of IK(DR) block became slowed. The IK(DR) activated by a downsloping ramp was suppressed by its presence. The inhibition of IK(DR) by a train pulse was enhanced during exposure to VOR. In Neuro-2a cells, this drug decreased IK(DR). Overall, inhibitory effects of VOR on ionic currents might constitute another underlying mechanism of its actions.

The role of cytochromes P450 in metabolism of selected antidepressants and anxiolytics under psychological stress

In today's modern society, it seems to be more and more challenging to cope with life stresses. The effect of psychological stress on emotional and physical health can be devastating, and increased stress is associated with increased rates of heart attack, hypertension, obesity, addiction, anxiety and depression. This review focuses on the possibility of an influence of psychological stress on the metabolism of selected antidepressants (TCAs, SSRIs, SNRIs, SARIs, NDRIs a MMAs) and anxiolytics (benzodiazepines and azapirone), as patients treated with antidepressants and/or anxiolytics can still suffer from psychological stress. Emphasis is placed on the drug metabolism mediated by the enzymes of Phase I, typically cytochromes P450 (CYPs), which are the major enzymes involved in drug metabolism, as the majority of psychoactive substances are metabolized by numerous CYPs (such as CYP1A2, CYP2B6, CYP2C19, CYP2C9, CYP2A6, CYP2D6, CYP3A4). As the data on the effect of stress on human enzymes are extremely rare, modulation of the efficacy and even regulation of the biotransformation pathways of drugs by psychological stress can be expected to play a significant role, as there is increasing evidence that stress can alter drug metabolism, hence there is a risk of less effective drug metabolism and increased side effects.