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Barnes KN, Vogl CM, Nelson LA. Zuranolone: The First FDA-Approved Oral Treatment Option for Postpartum Depression. Ann Pharmacother 2024; 58:728-734. [PMID: 37876133 DOI: 10.1177/10600280231204953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023] Open
Abstract
OBJECTIVE The objective of this study was to review the characteristics, efficacy, and safety of zuranolone in the management of postpartum depression (PPD). DATA SOURCES Literature was identified using PubMed (1966-August 2023) and EMBASE (1973-August 2023) and clinicaltrials.gov. Search terms included zuranolone, SAGE-217, and PPD with further limitation of those published in English. STUDY SELECTION AND DATA EXTRACTION Articles selected for inclusion included trials evaluating zuranolone for the treatment of PPD. DATA SYNTHESIS Zuranolone was evaluated for the treatment of moderate to severe PPD in 2 phase III trials. Both studies resulted in statistically significant improvement in depressive symptoms at day 15 (P = 0.003 and P < 0.001). Sustained differences in remission rates favoring zuranolone were found in both studies at day 45 compared with placebo (P = 0.01 and P < 0.05). Zuranolone was well tolerated, with somnolence, dizziness, headache, and sedation reported as the most common side effects. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON TO EXISTING DRUGS Zuranolone is only the second medication approved by the Food and Drug Administration (FDA) for PPD and offers an advantage over brexanolone in that it can administered orally in the outpatient setting. The rapid onset of effect of zuranolone is advantageous to traditional antidepressant therapy which can be weeks to months; however, limited information is available on safety during lactation. CONCLUSIONS The recent FDA approval of oral zuranolone for PPD offers a second rapid-acting treatment for PPD, extending the opportunity for treatment to patients in the outpatient setting.
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Affiliation(s)
- Kylie N Barnes
- Division of Pharmacy Practice and Administration, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Claire M Vogl
- School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Leigh Anne Nelson
- Division of Pharmacy Practice and Administration, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
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Lian J, Lin Z, Li X, Chen G, Wu D. Different dosage regimens of zuranolone in the treatment of major depressive disorder: A meta-analysis of randomized controlled trials. J Affect Disord 2024; 354:206-215. [PMID: 38479510 DOI: 10.1016/j.jad.2024.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/06/2024] [Accepted: 03/09/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE To investigate the efficacy and safety of different dosage regimens of zuranolone in the treatment of patients with major depressive disorder (MDD). METHODS PubMed, Embase, The Cochrane Library and other databases were searched from inception until July 2019. Randomized controlled trials (RCTs) related to the efficacy and safety of zuranolone in the treatment of MDD were included. The data were extracted independently by 2 investigators and assessed the study quality by the Cochrane risk-of-bias tool. The primary outcome includes the 17-item HAMILTON total score (HAMD-17) and the incidence of adverse events (AEs). RESULTS Six high-quality RCTs with 1593 patients were finally included in our analysis. Zuranolone group achieve a notable treatment effect at day15 in HAMD-17 compared with placebo group (MD = -2.69, 95 % CI: -4.45 to -0.94, P < 0.05). For safety, no significant differences existed in the proportion of patients with AEs between zuranolone with placebo (RR = 1.25, 95 % CI: 0.99 to 1.58, P = 0.06). CONCLUSION Zuranolone has a significant efficacy in improving depressive symptoms in the short term and is positively correlated with the dosage administered. However, the efficacy of zuranolone decreased significantly when the time of administration was extended. Zuranolone demonstrated a controllable safety issue. But adverse effects increased as the dose of zuranolone was gradually increased to 50 mg.
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Affiliation(s)
- Jinrong Lian
- Department of Clinical Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Zhimin Lin
- Department of Clinical Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xiang Li
- Department of Clinical Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Gang Chen
- Department of Clinical Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
| | - Depei Wu
- Department of Clinical Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
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Fayoud AM, Orebi HA, Elshnoudy IA, Elsebaie MAT, Elewid MMM, Sabra HK. The efficacy and safety of Zuranolone for treatment of depression: A systematic review and meta-analysis. Psychopharmacology (Berl) 2024:10.1007/s00213-024-06611-y. [PMID: 38802705 DOI: 10.1007/s00213-024-06611-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
RATIONALE Zuranolone, a newly FDA-approved synthetic neurosteroid, shows promise in treating depression. OBJECTIVES Our aim is to evaluate Zuranolone's efficacy and safety in treating depression. METHODS Five databases were searched until September 2023 for relevant randomized clinical trials evaluating the efficacy and safety of zuranolone. The potential risk of bias in the included trials was evaluated by the Cochrane Risk of Bias II guideline Data were extracted and pooled using Review Manager Software (RevMan 5.3). RESULTS An analysis of eight studies highlights Zuranolone's efficacy in treating depression compared to placebo across most of the outcomes. Notably, the 30mg and 50mg doses demonstrated significant improvements in reducing HAM-D scores by over 50% within a 15-day follow-up (RR) of 1.46 (95% CI [1.27, 1.68], p < 0.0001) and 1.14 (95% CI [1.01, 1.3], p = 0.04). Additionally, the HAM-D ≤ 7% score analysis revealed significant enhancements with the 30mg dose over both 15-day (RR = 1.82, 95% CI [1.44, 2.31], p < 0.0001) and 45-day (RR = 1.43, 95% CI [1.16, 1.77], p = 0.0008) durations. Adverse Events Drug Discontinuation demonstrated no overall significant difference (OR = 1.33, 95% CI: [0.79, 2.23], p = 0.282). Further, specific adverse events, such as headache, showed no significant overall difference between Zuranolone and placebo (OR = 1.11, 95% CI: [0.84, 1.47], p = 0.47), with dose-dependent analysis revealing less headache in the 30 mg group. CONCLUSION Zuranolone demonstrates favorable tolerability and safety, particularly at 30mg and 50mg doses after 15 days, suggesting its potential and effective treatment for depression.
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Affiliation(s)
- Aya M Fayoud
- Faculty of Pharmacy, Kafr El-Sheikh University, Kafr El-Sheikh, Egypt.
- Medical Research Platform (MRP), Cairo, Egypt.
| | - Hisham Ahmed Orebi
- Medical Research Platform (MRP), Cairo, Egypt
- Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Iman Abdelhady Elshnoudy
- Medical Research Platform (MRP), Cairo, Egypt
- Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | | | - Hamdy Khaled Sabra
- Medical Research Platform (MRP), Cairo, Egypt
- Faculty of Medicine, Tanta University, Tanta, Egypt
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Deligiannidis KM, Bullock A, Nandy I, Dunbar J, Lasser R, Witte M, Leclair B, Wald J. Zuranolone Concentrations in the Breast Milk of Healthy, Lactating Individuals: Results From a Phase 1 Open-Label Study. J Clin Psychopharmacol 2024:00004714-990000000-00252. [PMID: 38739007 DOI: 10.1097/jcp.0000000000001873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
PURPOSE/BACKGROUND Zuranolone is a positive allosteric modulator of both synaptic and extrasynaptic γ-aminobutyric acid type A receptors and a neuroactive steroid approved as an oral, once-daily, 14-day treatment course for adults with postpartum depression in the United States. This study assessed zuranolone transfer into breast milk. METHODS/PROCEDURES Healthy, nonpregnant, lactating adult female participants received once-daily 30 mg zuranolone from day (D)1 through D5 in this phase 1 open-label study. The relative infant dose (RID; weight-adjusted proportion of the maternal dose in breast milk over 24 hours) for 30 mg zuranolone was assessed at D5. An RID for 50 mg zuranolone was estimated using a simulation approach across a range of infant ages and weights. FINDINGS/RESULTS Of 15 enrolled participants (mean age, 30.1 years), 14 completed the study. The mean RID for 30 mg zuranolone at D5 was 0.357%; the mean steady-state milk volume over D3 to D5 decreased from baseline by 8.3%. Overall unbound zuranolone in plasma was low (≤0.49%). Plasma concentrations peaked at D5 before decreasing in a biexponential manner. There was strong concordance between the temporal evolution of zuranolone concentrations in plasma and breast milk. The estimated mean RID for 50 mg zuranolone based on a milk intake of 200 mL/kg per day was 0.984%. All treatment-emergent adverse events reported by participants were mild, the most common being dizziness (n = 3). IMPLICATIONS/CONCLUSIONS Zuranolone transfer into the breast milk of healthy, nonpregnant, lactating adult female participants was low; the estimated RID for 50 mg zuranolone was <1%, well below the <10% threshold generally considered compatible with breastfeeding.
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Li J, Haj Ebrahimi A, Ali AB. Advances in Therapeutics to Alleviate Cognitive Decline and Neuropsychiatric Symptoms of Alzheimer's Disease. Int J Mol Sci 2024; 25:5169. [PMID: 38791206 PMCID: PMC11121252 DOI: 10.3390/ijms25105169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
Dementia exists as a 'progressive clinical syndrome of deteriorating mental function significant enough to interfere with activities of daily living', with the most prevalent type of dementia being Alzheimer's disease (AD), accounting for about 80% of diagnosed cases. AD is associated with an increased risk of comorbidity with other clinical conditions such as hypertension, diabetes, and neuropsychiatric symptoms (NPS) including, agitation, anxiety, and depression as well as increased mortality in late life. For example, up to 70% of patients diagnosed with AD are affected by anxiety. As aging is the major risk factor for AD, this represents a huge global burden in ageing populations. Over the last 10 years, significant efforts have been made to recognize the complexity of AD and understand the aetiology and pathophysiology of the disease as well as biomarkers for early detection. Yet, earlier treatment options, including acetylcholinesterase inhibitors and glutamate receptor regulators, have been limited as they work by targeting the symptoms, with only the more recent FDA-approved drugs being designed to target amyloid-β protein with the aim of slowing down the progression of the disease. However, these drugs may only help temporarily, cannot stop or reverse the disease, and do not act by reducing NPS associated with AD. The first-line treatment options for the management of NPS are selective serotonin reuptake inhibitors/selective noradrenaline reuptake inhibitors (SSRIs/SNRIs) targeting the monoaminergic system; however, they are not rational drug choices for the management of anxiety disorders since the GABAergic system has a prominent role in their development. Considering the overall treatment failures and side effects of currently available medication, there is an unmet clinical need for rationally designed therapies for anxiety disorders associated with AD. In this review, we summarize the current status of the therapy of AD and aim to highlight novel angles for future drug therapy in our ongoing efforts to alleviate the cognitive deficits and NPS associated with this devastating disease.
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Affiliation(s)
| | | | - Afia B. Ali
- UCL School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK; (J.L.); (A.H.E.)
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Hitt EM. Zuranolone: A Narrative Review of a New Oral Treatment for Postpartum Depression. Clin Ther 2024; 46:433-438. [PMID: 38697873 DOI: 10.1016/j.clinthera.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 03/05/2024] [Accepted: 04/04/2024] [Indexed: 05/05/2024]
Abstract
PURPOSE Postpartum depression is a prevalent and overlooked mental disorder. Pathophysiology is thought to originate from a combination of biological and social factors, including hormones, and genetics. The consequences of untreated postpartum depression can be severe and negatively impact maternal and infant health. Zuranolone was approved as an oral agent in August 2023 for the treatment of postpartum depression in adults. The purpose of this article is evaluating the clinical aspects of zuranolone, including safety and efficacy pertaining to the drug and the clinical data that led to its approval. METHODS A literature search was conducted using PubMed, Web of Science, and EMBASE with the terms postpartum depression, postpartum depression management, and zuranolone to locate relevant data for this narrative review. The prescribing information of zuranolone and clinicaltrials.gov were also utilized. FINDINGS Two Phase III trials (Study 1-NCT04442503 and Study 2-NCT02978326) led to the approval of zuranolone by the Food and Drug Administration (FDA) based on clinically meaningful improvement in depressive symptoms. The trials met their primary endpoint, a change from baseline in HAM-D total score at day 15 (Study 1; 95% CI -6.3 to -1.7, P = 0.001: Study 2; 95% CI (-6.9 to -1.5, P = 0.003). IMPLICATIONS Zuranolone, an oral and rapidly acting antidepressant, represents a promising new oral treatment option for individuals with postpartum depression.
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Affiliation(s)
- Emily M Hitt
- Washington State University College of Pharmacy and Pharmaceutical Sciences, Spokane, WA.
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Sharma R, Bansal P, Saini L, Sharma N, Dhingra R. Zuranolone, a neuroactive drug, used in the treatment of postpartum depression by modulation of GABA A receptors. Pharmacol Biochem Behav 2024; 238:173734. [PMID: 38387651 DOI: 10.1016/j.pbb.2024.173734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Postpartum depression [PPD] is a prevalent and debilitating mood disorder that affects mothers in the weeks to months after childbirth. Zuranolone (Zurzuvae) is a novel pharmaceutical agent that was approved by the US FDA on 4 August 2023 for the management of PPD. This review article provides a comprehensive overview of zuranolone, focusing on its dosing, chemistry, mechanism of action, clinical trials, adverse drug reaction, and overall conclusion regarding its utility in the management of PPD. It also discusses the recommended dosing strategies to achieve optimal efficacy while minimizing adverse effects as the dosage regimen of zuranolone is critical for its therapeutic application. Moreover, it gives insights into neurobiological pathways involved in PPD. METHODOLOGY Data from randomized controlled trials and observational studies was collected to provide a comprehensive understanding of zuranolone in the management and treatment of PPD. CONCLUSION Zuranolone represents a promising therapeutic option for women suffering from postpartum depression. However, ongoing research and post-marketing surveillance are essential to further elucidate its long-term safety and efficacy. The integration of zuranolone into clinical practice may significantly improve the quality of life for mothers facing the challenges of postpartum depression.
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Affiliation(s)
- Renu Sharma
- Department of Pharmacy, GD Goenka University, Gurugram, Haryana 122103, India
| | - Pranjal Bansal
- Department of Pharmacy, GD Goenka University, Gurugram, Haryana 122103, India
| | - Lokesh Saini
- Department of Pharmacy, GD Goenka University, Gurugram, Haryana 122103, India
| | - Nidhi Sharma
- Department of Pharmacy, GD Goenka University, Gurugram, Haryana 122103, India
| | - Richa Dhingra
- Department of Pharmacy, GD Goenka University, Gurugram, Haryana 122103, India; Amity Institute of Pharmacy, Amity University, Sector - 125, Noida, Uttar Pradesh-201301, India.
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Niwa M, Lockhart S, Wood DJ, Yang K, Francis-Oliveira J, Kin K, Ahmed A, Wand GS, Kano SI, Payne JL, Sawa A. Prolonged HPA axis dysregulation in postpartum depression associated with adverse early life experiences: A cross-species translational study. NATURE. MENTAL HEALTH 2024; 2:593-604. [PMID: 38736646 PMCID: PMC11087073 DOI: 10.1038/s44220-024-00217-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 02/21/2024] [Indexed: 05/14/2024]
Abstract
Childhood and adolescent stress increase the risk of postpartum depression (PPD), often providing an increased probability of treatment refractoriness. Nevertheless, the mechanisms linking childhood/adolescent stress to PPD remain unclear. Our study investigated the longitudinal effects of adolescent stress on the hypothalamic-pituitary-adrenal (HPA) axis and postpartum behaviors in mice and humans. Adolescent social isolation prolonged glucocorticoid elevation, leading to long-lasting postpartum behavioral changes in female mice. These changes were unresponsive to current PPD treatments but improved with post-delivery glucocorticoid receptor antagonist treatment. Childhood/adolescent stress significantly impacted HPA axis dysregulation and PPD in human females. Repurposing glucocorticoid receptor antagonists for some cases of treatment-resistant PPD may be considered.
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Affiliation(s)
- Minae Niwa
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
- Department of Neurobiology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
- Department of Biomedical Engineering, University of Alabama at Birmingham School of Engineering, Birmingham, AL, USA
| | - Sedona Lockhart
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel J. Wood
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kun Yang
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jose Francis-Oliveira
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Kyohei Kin
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Adeel Ahmed
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Gary S. Wand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shin-ichi Kano
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
- Department of Neurobiology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Jennifer L. Payne
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlotte, VA, USA
| | - Akira Sawa
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Ahmad A, Awan AR, Nadeem N, Javed AS, Farooqi M, Daniyal M, Mumtaz H. Zuranolone for treatment of major depressive disorder: a systematic review and meta-analysis. Front Neurosci 2024; 18:1361692. [PMID: 38726035 PMCID: PMC11079210 DOI: 10.3389/fnins.2024.1361692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/01/2024] [Indexed: 05/12/2024] Open
Abstract
Background Current treatment modalities for Major Depressive Disorder have variable efficacies and a variety of side effects. To amend this, many trials for short term, well tolerated monotherapies are underway. One such option is Zuranolone (SAGE-217), which is a recent FDA approved antidepressant for Post Partum depression (PPD) and is undergoing clinical trials for PPD, major depressive disorder (MDD) and essential tremors (ET). Objectives Pool currently available data that compare Zuranolone to Placebo for the treatment of Major Depressive Disorder and evaluate its efficacy and safety profile. Methods We retrieved data from PUBMED and SCOPUS from inception to July 2023. We included articles comparing Zuranolone or SAGE 217 with placebo in patients suffering from Major Depressive Disorder. Review Manager 5.4 was used to analyze the outcomes including changes in the Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A) and Montgomery-Åsberg Depression Rating Scale (MADRS) scores from baseline as well as any treatment emergent adverse events (TEAEs) and severe adverse events. Results Our review analyzed 4 trials and the data of 1,357 patients. Patients treated with Zuranolone indicated a statistically significant effect in the change from baseline in HAM-D score (p = 0.0009; MD [95% CI]: -2.03 [-3.23, -0.84]) as well as in MADRS score (p = 0.02; MD [95% CI]: -2.30[-4.31, -0.30]) and HAM-A score (p = 0.03; MD [95% CI]: -1.41[-2.70, -0.11]) on 15th day when compared to the Placebo group. Zuranolone was also significantly associated with a higher response rate (p = 0.0008; OR [95% CI]: 1.63[1.14, 2.35]) and higher remission rate (p = 0.03; OR [95% CI]: 1.65[1.05, 2.59]) when compared with the placebo. As for safety, Zuranolone was significantly associated with 1 or more TEAE (p = 0.006; RR [95% CI]: 1.14[1.04, 1.24]) but an insignificant association with side effects that lead to drug discontinuation (p = 0.70; RR [95% CI]: 1.18[0.51, 2.76]) and serious adverse events (p = 0.48; RR [95% CI]: 1.46 [0.52, 4.10]) when compared with placebo. Conclusion Zuranolone is an effective and safe drug for short course major depressive disorder monotherapy. It shows results in 14 days (compared to 2-4 weeks that SSRI's take) and has anti-anxiolytic effects as well. However, only 4 trials have been used for the analysis and the sample size was small. The trials reviewed also cannot determine the long-term effects of the drug. More trials are needed to determine long term effects.
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Affiliation(s)
- Abdullah Ahmad
- CMH Lahore Medical College, National University of Medical Sciences, Lahore, Pakistan
| | - Abdul Rafeh Awan
- Department of Medicine, Nishtar Medical University, Multan, Pakistan
| | - Natasha Nadeem
- CMH Lahore Medical College, National University of Medical Sciences, Lahore, Pakistan
| | - Aamir Shahid Javed
- CMH Lahore Medical College, National University of Medical Sciences, Lahore, Pakistan
| | - Mobeen Farooqi
- CMH Lahore Medical College, National University of Medical Sciences, Lahore, Pakistan
| | - Muhammed Daniyal
- CMH Lahore Medical College, National University of Medical Sciences, Lahore, Pakistan
| | - Hassan Mumtaz
- Department of Data Analytics, BPP University, London, United Kingdom
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Clayton AH, Suthoff E, Jain R, Kosinski M, Fridman M, Deligiannidis KM, Meltzer-Brody S, Chen SY, Gervitz L, Huang MY, Trivedi M, Bonthapally V. The magnitude and sustainability of treatment benefit of zuranolone on function and well-being as assessed by the SF-36 in adult patients with MDD and PPD: An integrated analysis of 4 randomized clinical trials. J Affect Disord 2024; 351:904-914. [PMID: 38325605 DOI: 10.1016/j.jad.2024.01.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 01/23/2024] [Accepted: 01/31/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Major depressive disorder (MDD) and postpartum depression (PPD) are disabling conditions. This integrated analysis of MDD and PPD clinical trials investigated the impact of zuranolone-a positive allosteric modulator of synaptic and extrasynaptic GABAA receptors and neuroactive steroid under investigation for adults with MDD and approved as an oral, once-daily, 14-day treatment course for adults with PPD in the US-on health-related quality of life, including functioning and well-being, as assessed using the 36-item Short Form Health Survey V2 (SF-36). METHODS Integrated data from 3 MDD (201B, MOUNTAIN, WATERFALL) and 1 PPD trial (ROBIN) for individual SF-36 domains were compared for zuranolone (30- and 50-mg) vs placebo at Day (D)15 and D42. Comparisons between zuranolone responders (≥50 % reduction from baseline in 17-item Hamilton Depression Rating Scale total score) and nonresponders were assessed. RESULTS Overall, 1003 patients were included (zuranolone, n = 504; placebo, n = 499). Significant differences in change from baseline (CFB) to D15 for patients in zuranolone vs placebo groups were observed in 6/8 domains; changes were sustained or improved at D42, with significant CFB differences for all 8 domains. Zuranolone responders had significantly higher CFB scores vs nonresponders for all domains at D15 and D42 (p < 0.001). LIMITATIONS Two zuranolone doses were integrated across populations of 2 disease states with potential differences in functioning, comorbidities, and patient demographics. All p-values presented are nominal. CONCLUSIONS Integrated data across 4 zuranolone clinical trials showed improvements in functioning and well-being across all SF-36 domains. Benefits persisted after completion of treatment course at D42.
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Affiliation(s)
- Anita H Clayton
- University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Ellison Suthoff
- Sage Therapeutics, Inc., Cambridge, MA, United States of America.
| | - Rakesh Jain
- Texas Tech University School of Medicine, Midland, TX, United States of America
| | - Mark Kosinski
- QualityMetric Incorporated, LLC, Johnston, RI, United States of America
| | - Moshe Fridman
- AMF Consulting, Los Angeles, CA, United States of America
| | - Kristina M Deligiannidis
- AMF Consulting, Los Angeles, CA, United States of America; Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, New York, NY, United States of America; Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States of America; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States of America
| | - Samantha Meltzer-Brody
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | | | | | - Ming-Yi Huang
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Madhukar Trivedi
- Center for Depression Research and Clinical Care, Department of Psychiatry and Peter O'Donnell Jr. Brain Institute, The University of Texas Southwestern Medical Center, Dallas, TX, United States of America
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Mitchell SJ, Phillips GD, Tench B, Li Y, Belelli D, Martin SJ, Swinny JD, Kelly L, Atack JR, Paradowski M, Lambert JJ. Neurosteroid Modulation of Synaptic and Extrasynaptic GABA A Receptors of the Mouse Nucleus Accumbens. Biomolecules 2024; 14:460. [PMID: 38672476 PMCID: PMC11048561 DOI: 10.3390/biom14040460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/29/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
The recent approval of formulations of the endogenous neurosteroid allopregnanolone (brexanolone) and the synthetic neuroactive steroid SAGE-217 (zuranolone) to treat postpartum depression (PPD) has encouraged further research to elucidate why these potent enhancers of GABAAR function are clinically effective in this condition. Dopaminergic projections from the ventral tegmental area (VTA) to the nucleus accumbens are associated with reward/motivation and brain imaging studies report that individuals with PPD show reduced activity of this pathway in response to reward and infant engagement. However, the influence of neurosteroids on GABA-ergic transmission in the nucleus accumbens has received limited attention. Here, we investigate, in the medium spiny neurons (MSNs) of the mouse nucleus accumbens core, the effect of allopregnanolone, SAGE-217 and other endogenous and synthetic steroids of interest on fast phasic and tonic inhibition mediated by synaptic (α1/2βγ2) and extrasynaptic (α4βδ) GABAARs, respectively. We present evidence suggesting the resident tonic current results from the spontaneous opening of δ-GABAARs, where the steroid-enhanced tonic current is GABA-dependent. Furthermore, we demonstrate local neurosteroid synthesis in the accumbal slice preparation and reveal that GABA-ergic neurotransmission of MSNs is influenced by an endogenous neurosteroid tone. Given the dramatic fluctuations in allopregnanolone levels during pregnancy and postpartum, this neurosteroid-mediated local fine-tuning of GABAergic transmission in the MSNs will probably be perturbed.
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Affiliation(s)
- Scott J. Mitchell
- Division of Cellular & Systems Medicine, School of Medicine, Medical Sciences Institute, Dundee University, Dow Street, Dundee DD1 5HL, UK; (S.J.M.); (G.D.P.); (B.T.); (Y.L.); (D.B.); (S.J.M.)
| | - Grant D. Phillips
- Division of Cellular & Systems Medicine, School of Medicine, Medical Sciences Institute, Dundee University, Dow Street, Dundee DD1 5HL, UK; (S.J.M.); (G.D.P.); (B.T.); (Y.L.); (D.B.); (S.J.M.)
| | - Becks Tench
- Division of Cellular & Systems Medicine, School of Medicine, Medical Sciences Institute, Dundee University, Dow Street, Dundee DD1 5HL, UK; (S.J.M.); (G.D.P.); (B.T.); (Y.L.); (D.B.); (S.J.M.)
| | - Yunkai Li
- Division of Cellular & Systems Medicine, School of Medicine, Medical Sciences Institute, Dundee University, Dow Street, Dundee DD1 5HL, UK; (S.J.M.); (G.D.P.); (B.T.); (Y.L.); (D.B.); (S.J.M.)
| | - Delia Belelli
- Division of Cellular & Systems Medicine, School of Medicine, Medical Sciences Institute, Dundee University, Dow Street, Dundee DD1 5HL, UK; (S.J.M.); (G.D.P.); (B.T.); (Y.L.); (D.B.); (S.J.M.)
| | - Stephen J. Martin
- Division of Cellular & Systems Medicine, School of Medicine, Medical Sciences Institute, Dundee University, Dow Street, Dundee DD1 5HL, UK; (S.J.M.); (G.D.P.); (B.T.); (Y.L.); (D.B.); (S.J.M.)
| | - Jerome D. Swinny
- School of Pharmacy & Biomedical Sciences, St. Michael’s Building, University of Portsmouth, White Swan Road, Portsmouth PO1 2DT, UK; (J.D.S.); (L.K.)
| | - Louise Kelly
- School of Pharmacy & Biomedical Sciences, St. Michael’s Building, University of Portsmouth, White Swan Road, Portsmouth PO1 2DT, UK; (J.D.S.); (L.K.)
| | - John R. Atack
- Main Building, Medicines Discovery Institute, Park Place, Cardiff University, Cardiff, CF10 3AT, UK; (J.R.A.); (M.P.)
| | - Michael Paradowski
- Main Building, Medicines Discovery Institute, Park Place, Cardiff University, Cardiff, CF10 3AT, UK; (J.R.A.); (M.P.)
| | - Jeremy J. Lambert
- Division of Cellular & Systems Medicine, School of Medicine, Medical Sciences Institute, Dundee University, Dow Street, Dundee DD1 5HL, UK; (S.J.M.); (G.D.P.); (B.T.); (Y.L.); (D.B.); (S.J.M.)
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12
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Beckley JT, Aman TK, Ackley MA, Kazdoba TM, Lewis MC, Smith AC, Farley BJ, Dai J, Deats W, Hoffmann E, Robichaud AJ, Doherty JJ, Quirk MC. Pharmacological characterization of SAGE-718, a novel positive allosteric modulator of N-methyl-d-aspartate receptors. Br J Pharmacol 2024; 181:1028-1050. [PMID: 37698384 DOI: 10.1111/bph.16235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 07/25/2023] [Accepted: 08/22/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND AND PURPOSE Select neuroactive steroids tune neural activity by modulating excitatory and inhibitory neurotransmission, including the endogenous cholesterol metabolite 24(S)-hydroxycholesterol (24(S)-HC), which is an N-methyl-d-aspartate (NMDA) receptor positive allosteric modulator (PAM). NMDA receptor PAMs are potentially an effective pharmacotherapeutic strategy to treat conditions associated with NMDA receptor hypofunction. EXPERIMENTAL APPROACH Using in vitro and in vivo electrophysiological recording experiments and behavioural approaches, we evaluated the effect of SAGE-718, a novel neuroactive steroid NMDA receptor PAM currently in clinical development for the treatment of cognitive impairment, on NMDA receptor function and endpoints that are altered by NMDA receptor hypoactivity and assessed its safety profile. KEY RESULTS SAGE-718 potentiated GluN1/GluN2A-D NMDA receptors with equipotency and increased NMDA receptor excitatory postsynaptic potential (EPSP) amplitude without affecting decay kinetics in striatal medium spiny neurons. SAGE-718 increased the rate of unblock of the NMDA receptor open channel blocker ketamine on GluN1/GluN2A in vitro and accelerated the rate of return on the ketamine-evoked increase in gamma frequency band power, as measured with electroencephalogram (EEG), suggesting that PAM activity is driven by increased channel open probability. SAGE-718 ameliorated deficits due to NMDA receptor hypofunction, including social deficits induced by subchronic administration of phencyclidine, and behavioural and electrophysiological deficits from cholesterol and 24(S)-HC depletion caused by 7-dehydrocholesterol reductase inhibition. Finally, SAGE-718 did not produce epileptiform activity in a seizure model or neurodegeneration following chronic dosing. CONCLUSIONS AND IMPLICATIONS These findings provide strong evidence that SAGE-718 is a neuroactive steroid NMDA receptor PAM with a mechanism that is well suited as a treatment for conditions associated with NMDA receptor hypofunction.
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Affiliation(s)
| | - Teresa K Aman
- Sage Therapeutics Inc, Cambridge, Massachusetts, USA
| | | | | | | | - Anne C Smith
- Sage Therapeutics Inc, Cambridge, Massachusetts, USA
| | | | - Jing Dai
- Sage Therapeutics Inc, Cambridge, Massachusetts, USA
| | - Wayne Deats
- Sage Therapeutics Inc, Cambridge, Massachusetts, USA
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13
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Petersen N. Spotlighting SHAPERS: sex hormones associated with psychological and endocrine roles. Neuropsychopharmacology 2024; 49:772-773. [PMID: 38366139 PMCID: PMC10948803 DOI: 10.1038/s41386-024-01819-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 02/18/2024]
Affiliation(s)
- Nicole Petersen
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
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14
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Elble RJ, Ondo WG, Lyons KE, Qin M, Garafola S, Hersh B, Lieu T, Arkilo D, Chuang R, Bankole K, Pahwa R. A Randomized Phase 2 KINETIC Trial Evaluating SAGE-324/BIIB124 in Individuals with Essential Tremor. Mov Disord 2024; 39:733-738. [PMID: 38357797 DOI: 10.1002/mds.29731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 12/18/2023] [Accepted: 01/10/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND SAGE-324/BIIB124 is an investigational positive allosteric modulator of GABAA receptors. OBJECTIVE KINETIC (NCT04305275), a double-blind, randomized, placebo-controlled, phase 2 study, evaluated SAGE-324/BIIB124 in individuals with essential tremor (ET). METHODS Individuals aged 18 to 80 years were randomly assigned 1:1 to orally receive 60 mg of SAGE-324/BIIB124 or placebo once daily for 28 days. The primary endpoint was change from baseline in The Essential Tremor Rating Assessment Scale-Performance Subscale (TETRAS-PS) Item 4 (upper-limb tremor) at day 29 with SAGE-324/BIIB124 versus placebo. RESULTS Between May 2020 and February 2021, 69 U.S. participants were randomly assigned to receive SAGE-324/BIIB124 (n = 34) or placebo (n = 35). There was a significant reduction from baseline in TETRAS-PS Item 4 at day 29 with SAGE-324/BIIB124 versus placebo (least squares mean [standard error]: -2.31 [0.401] vs. -1.24 [0.349], P = 0.0491). The most common treatment-emergent adverse events included somnolence, dizziness, fatigue, and balance disorder. CONCLUSION These results support further development of SAGE-324/BIIB124 for potential ET treatment. © 2024 Sage Therapeutics, Inc and The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Rodger J Elble
- Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - William G Ondo
- Department of Neurology, Houston Methodist Hospital, Houston, Texas, USA
| | - Kelly E Lyons
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Min Qin
- Sage Therapeutics, Inc, Cambridge, Massachusetts, USA
| | | | | | | | | | | | - Kemi Bankole
- Sage Therapeutics, Inc, Cambridge, Massachusetts, USA
| | - Rajesh Pahwa
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
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15
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Uusi-Oukari M, Korpi ER. GABAergic mechanisms in alcohol dependence. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 175:75-123. [PMID: 38555121 DOI: 10.1016/bs.irn.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The target of alcohol's effect on the central nervous system has been sought for more than 50 years in the brain's GABA system. The behavioral and emotional effects of alcohol in humans and rodents are very similar to those of barbiturates and benzodiazepines, and GABAA receptors have been shown to be one of the sites of alcohol action. The mechanisms of GABAergic inhibition have been a hotspot of research but have turned out to be complex and controversial. Genetics support the involvement of some GABAA receptor subunits in the development of alcohol dependence and in alcohol use disorders (AUD). Since the effect of alcohol on the GABAA system resembles that of a GABAergic positive modulator, it may be possible to develop GABAergic drug treatments that could substitute for alcohol. The adaptation mechanisms of the GABA system and the plasticity of the brain are a big challenge for drug development: the drugs that act on GABAA receptors developed so far also may cause adaptation and development of additional addiction. Human polymorphisms should be studied further to get insight about how they affect receptor function, expression or other factors to make reasonable predictions/hypotheses about what non-addictive interventions would help in alcohol dependence and AUD.
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Affiliation(s)
- Mikko Uusi-Oukari
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Esa R Korpi
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
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16
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Reddy DS. Neurosteroids as Novel Anticonvulsants for Refractory Status Epilepticus and Medical Countermeasures for Nerve Agents: A 15-Year Journey to Bring Ganaxolone from Bench to Clinic. J Pharmacol Exp Ther 2024; 388:273-300. [PMID: 37977814 PMCID: PMC10801762 DOI: 10.1124/jpet.123.001816] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 10/05/2023] [Accepted: 10/23/2023] [Indexed: 11/19/2023] Open
Abstract
This article describes recent advances in the use of neurosteroids as novel anticonvulsants for refractory status epilepticus (RSE) and as medical countermeasures (MCs) for organophosphates and chemical nerve agents (OPNAs). We highlight a comprehensive 15-year journey to bring the synthetic neurosteroid ganaxolone (GX) from bench to clinic. RSE, including when caused by nerve agents, is associated with devastating morbidity and permanent long-term neurologic dysfunction. Although recent approval of benzodiazepines such as intranasal midazolam and intranasal midazolam offers improved control of acute seizures, novel anticonvulsants are needed to suppress RSE and improve neurologic function outcomes. Currently, few anticonvulsant MCs exist for victims of OPNA exposure and RSE. Standard-of-care MCs for postexposure treatment include benzodiazepines, which do not effectively prevent or mitigate seizures resulting from nerve agent intoxication, leaving an urgent unmet medical need for new anticonvulsants for RSE. Recently, we pioneered neurosteroids as next-generation anticonvulsants that are superior to benzodiazepines for treatment of OPNA intoxication and RSE. Because GX and related neurosteroids that activate extrasynaptic GABA-A receptors rapidly control seizures and offer robust neuroprotection by reducing neuronal damage and neuroinflammation, they effectively improve neurologic outcomes after acute OPNA exposure and RSE. GX has been selected for advanced, Biomedical Advanced Research and Development Authority-supported phase 3 trials of RSE and nerve agent seizures. In addition, in mechanistic studies of neurosteroids at extrasynaptic receptors, we identified novel synthetic analogs with features that are superior to GX for current medical needs. Development of new MCs for RSE is complex, tedious, and uncertain due to scientific and regulatory challenges. Thus, further research will be critical to fill key gaps in evaluating RSE and anticonvulsants in vulnerable (pediatric and geriatric) populations and military persons. SIGNIFICANCE STATEMENT: Following organophosphate and nerve agent intoxication, refractory status epilepticus (RSE) occurs despite benzodiazepine treatment. RSE occurs in 40% of status epilepticus patients, with a 35% mortality rate and significant neurological morbidity in survivors. To treat RSE, neurosteroids are better anticonvulsants than benzodiazepines. Our pioneering use of neurosteroids for RSE and nerve agents led us to develop ganaxolone as a novel anticonvulsant and neuroprotectant with significantly improved neurological outcomes. This article describes the bench-to-bedside journey of bringing neurosteroid therapy to patients, with ganaxolone leading the way.
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Affiliation(s)
- Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, Texas and Institute of Pharmacology and Neurotherapeutics, Texas A&M University Health Science Center, Bryan, Texas
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17
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Takasu K, Yawata Y, Tashima R, Aritomi H, Shimada S, Onodera T, Taishi T, Ogawa K. Distinct mechanisms of allopregnanolone and diazepam underlie neuronal oscillations and differential antidepressant effect. Front Cell Neurosci 2024; 17:1274459. [PMID: 38259500 PMCID: PMC10800935 DOI: 10.3389/fncel.2023.1274459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/29/2023] [Indexed: 01/24/2024] Open
Abstract
The rapid relief of depressive symptoms is a major medical requirement for effective treatments for major depressive disorder (MDD). A decrease in neuroactive steroids contributes to the pathophysiological mechanisms associated with the neurological symptoms of MDD. Zuranolone (SAGE-217), a neuroactive steroid that acts as a positive allosteric modulator of synaptic and extrasynaptic δ-subunit-containing GABAA receptors, has shown rapid-onset, clinically effective antidepressant action in patients with MDD or postpartum depression (PPD). Benzodiazepines, on the other hand, act as positive allosteric modulators of synaptic GABAA receptors but are not approved for the treatment of patients with MDD. It remains unclear how differences in molecular mechanisms contribute to the alleviation of depressive symptoms and the regulation of associated neuronal activity. Focusing on the antidepressant-like effects and neuronal activity of the basolateral amygdala (BLA) and medial prefrontal cortex (mPFC), we conducted a head-to-head comparison study of the neuroactive steroid allopregnanolone and the benzodiazepine diazepam using a mouse social defeat stress (SDS) model. Allopregnanolone but not diazepam exhibited antidepressant-like effects in a social interaction test in SDS mice. This antidepressant-like effect of allopregnanolone was abolished in extrasynaptic GABAA receptor δ-subunit knockout mice (δko mice) subjected to the same SDS protocol. Regarding the neurophysiological mechanism associated with these antidepressant-like effects, allopregnanolone but not diazepam increased theta oscillation in the BLA of SDS mice. This increase did not occur in δko mice. Consistent with this, allopregnanolone potentiated tonic inhibition in BLA interneurons via δ-subunit-containing extrasynaptic GABAA receptors. Theta oscillation in the mPFC of SDS mice was also increased by allopregnanolone but not by diazepam. Finally, allopregnanolone but not diazepam increased frontal theta activity in electroencephalography recordings in naïve and SDS mice. Neuronal network alterations associated with MDD showed decreased frontal theta and beta activity in depressed SDS mice. These results demonstrated that, unlike benzodiazepines, neuroactive steroids increased theta oscillation in the BLA and mPFC through the activation of δ-subunit-containing GABAA receptors, and this change was associated with antidepressant-like effects in the SDS model. Our findings support the notion that the distinctive mechanism of neuroactive steroids may contribute to the rapid antidepressant effects in MDD.
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Affiliation(s)
- Keiko Takasu
- Laboratory for Drug Discovery and Disease Research, Shionogi Pharmaceutical Research Center, Shionogi & Co., Ltd., Osaka, Japan
| | - Yosuke Yawata
- Laboratory for Drug Discovery and Disease Research, Shionogi Pharmaceutical Research Center, Shionogi & Co., Ltd., Osaka, Japan
| | - Ryoichi Tashima
- Laboratory for Drug Discovery and Disease Research, Shionogi Pharmaceutical Research Center, Shionogi & Co., Ltd., Osaka, Japan
| | | | | | - Tsukasa Onodera
- Laboratory for Drug Discovery and Disease Research, Shionogi Pharmaceutical Research Center, Shionogi & Co., Ltd., Osaka, Japan
| | - Teruhiko Taishi
- Laboratory for Drug Discovery and Disease Research, Shionogi Pharmaceutical Research Center, Shionogi & Co., Ltd., Osaka, Japan
| | - Koichi Ogawa
- Laboratory for Drug Discovery and Disease Research, Shionogi Pharmaceutical Research Center, Shionogi & Co., Ltd., Osaka, Japan
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18
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Thompson SM. Modulators of GABA A receptor-mediated inhibition in the treatment of neuropsychiatric disorders: past, present, and future. Neuropsychopharmacology 2024; 49:83-95. [PMID: 37709943 PMCID: PMC10700661 DOI: 10.1038/s41386-023-01728-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/14/2023] [Accepted: 08/08/2023] [Indexed: 09/16/2023]
Abstract
The predominant inhibitory neurotransmitter in the brain, γ-aminobutyric acid (GABA), acts at ionotropic GABAA receptors to counterbalance excitation and regulate neuronal firing. GABAA receptors are heteropentameric channels comprised from subunits derived from 19 different genes. GABAA receptors have one of the richest and well-developed pharmacologies of any therapeutic drug target, including agonists, antagonists, and positive and negative allosteric modulators (PAMs, NAMs). Currently used PAMs include benzodiazepine sedatives and anxiolytics, barbiturates, endogenous and synthetic neurosteroids, and general anesthetics. In this article, I will review evidence that these drugs act at several distinct binding sites and how they can be used to alter the balance between excitation and inhibition. I will also summarize existing literature regarding (1) evidence that changes in GABAergic inhibition play a causative role in major depression, anxiety, postpartum depression, premenstrual dysphoric disorder, and schizophrenia and (2) whether and how GABAergic drugs exert beneficial effects in these conditions, focusing on human studies where possible. Where these classical therapeutics have failed to exert benefits, I will describe recent advances in clinical and preclinical drug development. I will also highlight opportunities to advance a generation of GABAergic therapeutics, such as development of subunit-selective PAMs and NAMs, that are engendering hope for novel tools to treat these devastating conditions.
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Affiliation(s)
- Scott M Thompson
- Center for Novel Therapeutics, Department of Psychiatry, University of Colorado School of Medicine, 12700 E. 19th Ave., Aurora, CO, 80045, USA.
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19
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Cha DS, Kleine N, Teopiz KM, Di Vincenzo JD, Ho R, Galibert SL, Samra A, Zilm SPM, Cha RH, d'Andrea G, Gill H, Ceban F, Meshkat S, Wong S, Le GH, Kwan ATH, Rosenblat JD, Rhee TG, Mansur RB, McIntyre RS. The efficacy of zuranolone in postpartum depression and major depressive disorder: a review & number needed to treat (NNT) analysis. Expert Opin Pharmacother 2024; 25:5-14. [PMID: 38164653 DOI: 10.1080/14656566.2023.2298340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Major depressive disorder (MDD) is a common and debilitating mental illness. Postpartum depression (PPD) impacts women globally and is one of the most common complications of childbirth that is underdiagnosed and undertreated, adversely impacting the mental health of women, children, and partners.Available antidepressant medications require weeks to months before showing effect. In this setting, zuranolone, an oral neuroactive steroid and a positive allosteric modulator of GABAA receptors, is an attractive alternative as a rapid-acting antidepressant treatment. AREAS COVERED This article reviews zuranolone (SAGE217), focusing on available clinical studies in individuals with PPD and MDD. This paper adds to the extant literature by presenting the efficacy data as Number Needed to Treat (NNT) to facilitate indirect comparisons with other antidepressants. EXPERT OPINION Zuranolone is a novel rapid-acting (i.e. two week course) oral antidepressant for the treatment of adults with PPD with ongoing clinical trials evaluating its efficacy in adults with MDD. Zuranolone is well tolerated with no significant safety concerns in any clinical trials completed to date. Zuranolone will be scheduled by the Drug Enforcement Agency (DEA).
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Affiliation(s)
- Danielle S Cha
- Royal Brisbane & Women's Hospital, Mental Health Services, Brisbane, Queensland, Australia
- School of Clinical Medicine - Royal Brisbane Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
- Brain and Cognition Foundation, Toronto, ON, Canada
- Mood Disorders Psychopharmacology Department, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Royal Brisbane & Women's Hospital, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Nicholas Kleine
- Mood Disorders Psychopharmacology Department, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Department of Pharmacology, University of Toronto, Toronto, Canada
| | - Kayla M Teopiz
- Mood Disorders Psychopharmacology Department, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Department of Pharmacology, University of Toronto, Toronto, Canada
| | - Joshua D Di Vincenzo
- Brain and Cognition Foundation, Toronto, ON, Canada
- Mood Disorders Psychopharmacology Department, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Roger Ho
- Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy
| | - Stephanie L Galibert
- Department of Obstetrics and Gynaecology, Logan Hospital, Logan, Queensland, Australia
| | - Amrita Samra
- Royal Brisbane & Women's Hospital, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Samuel P M Zilm
- Royal Brisbane & Women's Hospital, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Rebekah H Cha
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Giacomo d'Andrea
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. D'Annunzio", Chieti, Italy
| | - Hartej Gill
- Brain and Cognition Foundation, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Felicia Ceban
- Brain and Cognition Foundation, Toronto, ON, Canada
- Mood Disorders Psychopharmacology Department, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Sabrina Wong
- Brain and Cognition Foundation, Toronto, ON, Canada
- Mood Disorders Psychopharmacology Department, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Gia Han Le
- Brain and Cognition Foundation, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Angela T H Kwan
- Brain and Cognition Foundation, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Joshua D Rosenblat
- Brain and Cognition Foundation, Toronto, ON, Canada
- Mood Disorders Psychopharmacology Department, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Rodrigo B Mansur
- Brain and Cognition Foundation, Toronto, ON, Canada
- Mood Disorders Psychopharmacology Department, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Roger S McIntyre
- Department of Psychiatry and Pharmacology, University of Toronto, Toronto, Canada
- Brain and Cognition Discovery Foundation (BCDF), Toronto, ON, Canada
- Board Chair, Depression and Bipolar Support Alliance (DBSA) Board of Directors, Chicago, IL, USA
- Guangzhou Medical University, Guangzhou, GD, China
- College of Medicine, Korea University, Seoul, Republic of Korea
- College of Medicine, University of the Philippines, Manila, Philippines
- State University of New York (SUNY) Upstate Medical University, Syracuse, NY, USA
- Department of Psychiatry and Neurosciences, University of California School of Medicine, Riverside, CA, USA
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20
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Li Z, Wu Q, Peng P, Wu M, Liu S, Liu T. Efficacy and safety of zuranolone for the treatment of depression: A systematic review and meta-analysis. Psychiatry Res 2024; 331:115640. [PMID: 38029628 DOI: 10.1016/j.psychres.2023.115640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/19/2023] [Accepted: 11/25/2023] [Indexed: 12/01/2023]
Abstract
Major depressive disorder (MDD) and postpartum depression (PPD) are common and burdensome conditions. This study aims to evaluate the efficacy and safety of zuranolone, a neuroactive steroid γ-aminobutyric acid type A receptors-positive allosteric modulator, in treating MDD and PPD. A comprehensive literature search was conducted until September 2023, identifying seven randomized controlled trials (RCTs). The results demonstrated that zuranolone significantly decreased Hamilton Rating Scale for Depression (HAM-D) scores in patients with PPD or MDD at day 15 (concluding the 14-day course) and day 42-45 (4 weeks after treatment cessation) compared with the placebo, albeit exhibiting a diminishing trend. Moreover, a higher percentage of patients with PPD or MDD achieved HAM-D response and remission with zuranolone treatment compared with placebo at day 15. However, zuranolone did not significantly increase the proportion of MDD patients achieving HAM-D remission at 42/43 days. Adverse events (AEs) such as somnolence, dizziness, and sedation were linked to zuranolone, with a higher but not statistically significant rate of discontinuation due to AEs in the zuranolone group. Overall, our findings support the rapid antidepressant effects of zuranolone in MDD and PPD, along with a relatively favorable safety and tolerability. Large-scale longitudinal RCTs are needed to evaluate the long-term efficacy of zuranolone.
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Affiliation(s)
- Zejun Li
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, 139 Middle Renmin Road, Changsha, Hunan 410011, China
| | - Qiuxia Wu
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, 139 Middle Renmin Road, Changsha, Hunan 410011, China
| | - Pu Peng
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, 139 Middle Renmin Road, Changsha, Hunan 410011, China
| | - Min Wu
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, 139 Middle Renmin Road, Changsha, Hunan 410011, China
| | - Shouhuan Liu
- Department of Psychiatry, First Affiliated Hospital of Kunming Medical University, 295 Xichang Road, Kunming, Yunnan 650032, China.
| | - Tieqiao Liu
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, 139 Middle Renmin Road, Changsha, Hunan 410011, China.
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21
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Parikh SV, Aaronson ST, Mathew SJ, Alva G, DeBattista C, Kanes S, Lasser R, Bullock A, Kotecha M, Jung J, Forrestal F, Jonas J, Vera T, Leclair B, Doherty J. Efficacy and safety of zuranolone co-initiated with an antidepressant in adults with major depressive disorder: results from the phase 3 CORAL study. Neuropsychopharmacology 2024; 49:467-475. [PMID: 37875578 PMCID: PMC10724299 DOI: 10.1038/s41386-023-01751-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 09/20/2023] [Accepted: 10/02/2023] [Indexed: 10/26/2023]
Abstract
Major depressive disorder (MDD) is a mental health disorder that can cause disability and functional impairment that standard-of-care (SOC) antidepressant therapies (ADTs) can take weeks to treat. Zuranolone is a neuroactive steroid and positive allosteric modulator of synaptic and extrasynaptic γ-aminobutyric acid (GABA) type A receptors approved as an oral, once-daily, 14-day treatment course in adults with postpartum depression and under investigation in adults with MDD. The phase 3 CORAL Study (NCT04476030) evaluated the efficacy and safety of zuranolone 50 mg co-initiated with SOC ADT (zuranolone+ADT) vs placebo co-initiated with SOC ADT (placebo+ADT) in adults with MDD. Patients were randomized 1:1 to once-daily, blinded zuranolone+ADT or placebo+ADT for 14 days, then continued open-label SOC ADT for 28 more days. The primary endpoint was change from baseline (CFB) in the 17-item Hamilton Rating Scale for Depression (HAMD-17) total score at Day 3. Among 425 patients in the full analysis set, CFB in HAMD-17 total score at Day 3 was significantly improved with zuranolone+ADT vs placebo+ADT (least squares mean [standard error], -8.9 [0.39] vs -7.0 [0.38]; p = 0.0004). The majority of patients receiving zuranolone+ADT that experienced treatment-emergent adverse events (TEAEs) reported mild or moderate events. The most common TEAEs present in ≥10% of patients in either zuranolone+ADT or placebo+ADT groups were somnolence, dizziness, headache, and nausea. These results demonstrate that zuranolone+ADT provided more rapid improvement in depressive symptoms compared with placebo+ADT in patients with MDD, with a safety profile consistent with previous studies. Clinical trial registration: ClinicalTrials.gov identifier: NCT04476030.
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Affiliation(s)
- Sagar V Parikh
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
| | - Scott T Aaronson
- Institute for Advanced Diagnostics and Therapeutics, Sheppard Pratt, Baltimore, MD, USA
| | - Sanjay J Mathew
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | | | - Charles DeBattista
- General Psychiatry and Psychology, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | | | | | - Jeff Jonas
- Sage Therapeutics, Inc., Cambridge, MA, USA
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22
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O'Malley PA. ZURZUVAE-The First Oral Treatment Approved for Postpartum Depression. CLIN NURSE SPEC 2024; 38:15-17. [PMID: 38079140 DOI: 10.1097/nur.0000000000000788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Patricia Anne O'Malley
- Author Affiliation: Nurse Scientist, Center of Nursing Excellence, Premier Health-Miami Valley Hospital is in Dayton, Ohio
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23
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Marecki R, Kałuska J, Kolanek A, Hakało D, Waszkiewicz N. Zuranolone - synthetic neurosteroid in treatment of mental disorders: narrative review. Front Psychiatry 2023; 14:1298359. [PMID: 38116383 PMCID: PMC10729607 DOI: 10.3389/fpsyt.2023.1298359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/13/2023] [Indexed: 12/21/2023] Open
Abstract
With each passing year, the number of people suffering from mental disorders grows at a disturbing speed. Neuroactive steroids are a new promising group of drugs with the potential for use in many diseases like postpartum depression, postnatal psychosis, major depression, insomnia, bipolar disorder, and Parkinson's tremor, due to their ability to modulate the activity of GABAA receptor. Neurosteroids are progesterone metabolites that are synthesized from cholesterol or steroid hormones in various brain regions. They regulate neuronal development, regeneration, and neurotransmission. They are implicated in mood disorders, anxiety disorders, schizophrenia, PTSD, and impulsive aggression. Neurosteroids have been studied for their potential to prevent or treat neurodegenerative diseases such as Alzheimer's disease and HIV-associated dementia. They can promote neurogenesis, neuronal survival, myelination, and memory function. They can also affect the growth and sensitivity of hormone-dependent brain tumors such as gliomas. Zuranolone, a newly registered neurosteroid drug has shown huge flexibility in both clinical and ambulatory treatment thanks to its pharmacokinetic traits, especially the possibility for oral administration, unlike its predecessor Brexanolone. Zuranolone is a synthetic positive allosteric modulator of the GABAA receptor that can be taken orally. The review aims to summarize the current knowledge on zuranolone as a novel neurosteroid drug for various mental disorders, especially for postpartum mental disorders for which this drug was meant originally. It covers studies indexed in the PubMed, Scopus, and Web of Science databases published since 2017. Keywords used in the search, as well as inclusion and exclusion criteria, are given in the aims and methodology section. The review explains the evidence for the role of neurosteroids, especially allopregnanolone, in the pathophysiology and treatment of postpartum depression. It discusses the mechanisms of neurosteroid action, the changes in neurosteroid levels during pregnancy and postpartum, and the clinical trials of brexanolone and zuranolone, two synthetic analogs of allopregnanolone, for postpartum depression. It provides an overview of the biosynthesis and metabolism of neurosteroids in the central and peripheral nervous system. Furthermore, it explains the different sources and pathways of neurosteroid production and the factors that influence their synthesis and regulation, such as stress, hormones, drugs, and genetic variations. The review also explores the potential relevance of neurosteroids for other psychiatric disorders, such as major depression, bipolar disorder, post-traumatic stress disorder (PTSD), schizophrenia, and premenstrual dysphoric disorder. Finally, it highlights the associations between neurosteroid levels and symptom severity and the effects of neurosteroid modulation on mood, cognition, and neuroplasticity.
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24
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Adams JAM, Chandra P, Mehta D. The First Large GWAS Meta-Analysis for Postpartum Depression. Am J Psychiatry 2023; 180:862-864. [PMID: 38037399 DOI: 10.1176/appi.ajp.20230794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Jessica Ann May Adams
- Queensland University of Technology, Centre for Genomics and Personalised Health, School of Biomedical Sciences, Faculty of Health, Kelvin Grove, Australia (Adams, Mehta); Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India (Chandra)
| | - Prabha Chandra
- Queensland University of Technology, Centre for Genomics and Personalised Health, School of Biomedical Sciences, Faculty of Health, Kelvin Grove, Australia (Adams, Mehta); Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India (Chandra)
| | - Divya Mehta
- Queensland University of Technology, Centre for Genomics and Personalised Health, School of Biomedical Sciences, Faculty of Health, Kelvin Grove, Australia (Adams, Mehta); Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India (Chandra)
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25
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Paolini M, Fortaner-Uyà L, Lorenzi C, Spadini S, Maccario M, Zanardi R, Colombo C, Poletti S, Benedetti F. Association between NTRK2 Polymorphisms, Hippocampal Volumes and Treatment Resistance in Major Depressive Disorder. Genes (Basel) 2023; 14:2037. [PMID: 38002980 PMCID: PMC10671548 DOI: 10.3390/genes14112037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 10/28/2023] [Accepted: 10/31/2023] [Indexed: 11/26/2023] Open
Abstract
Despite the increasing availability of antidepressant drugs, a high rate of patients with major depression (MDD) does not respond to pharmacological treatments. Brain-derived neurotrophic factor (BDNF)-tyrosine receptor kinase B (TrkB) signaling is thought to influence antidepressant efficacy and hippocampal volumes, robust predictors of treatment resistance. We therefore hypothesized the possible role of BDNF and neurotrophic receptor tyrosine kinase 2 (NTRK2)-related polymorphisms in affecting both hippocampal volumes and treatment resistance in MDD. A total of 121 MDD inpatients underwent 3T structural MRI scanning and blood sampling to obtain genotype information. General linear models and binary logistic regressions were employed to test the effect of genetic variations related to BDNF and NTRK2 on bilateral hippocampal volumes and treatment resistance, respectively. Finally, the possible mediating role of hippocampal volumes on the relationship between genetic markers and treatment response was investigated. A significant association between one NTRK2 polymorphism with hippocampal volumes and antidepressant response was found, with significant indirect effects. Our results highlight a possible mechanistic explanation of antidepressant action, possibly contributing to the understanding of MDD pathophysiology.
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Affiliation(s)
- Marco Paolini
- Psychiatry and Clinical Psychobiology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Lidia Fortaner-Uyà
- Psychiatry and Clinical Psychobiology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Cristina Lorenzi
- Psychiatry and Clinical Psychobiology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Sara Spadini
- Psychiatry and Clinical Psychobiology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Melania Maccario
- Mood Disorders Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Faculty of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Raffaella Zanardi
- Mood Disorders Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Cristina Colombo
- Mood Disorders Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Faculty of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Sara Poletti
- Psychiatry and Clinical Psychobiology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Faculty of Psychology, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Francesco Benedetti
- Psychiatry and Clinical Psychobiology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Faculty of Psychology, Vita-Salute San Raffaele University, 20132 Milan, Italy
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26
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Abstract
Major depressive disorder (MDD) is a leading contributor to disability worldwide and is associated with increased morbidity and mortality. Current pharmacologic treatment options may be ineffective for some patients and can pose several limitations and challenges, including suboptimal response and slow onset of action. Many of these therapies can take 6 to 8 weeks for patients to achieve response and 12 weeks or longer to demonstrate full clinical benefit. Delays in depressive symptom resolution are associated with poor symptomatic and functional outcomes, decreased quality of life, and increased burden on the healthcare system. Achieving response and remission of symptoms soon after diagnosis and treatment is associated with lower rates of relapse and a greater likelihood of functional recovery. An unmet need exists for innovative treatments that offer rapid and sustained effects. This editorial discusses the benefits of rapid improvement in depressive symptoms with available and investigational agents for patients with MDD.
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Zou J, Yang L, Yang G, Gao J. The efficacy and safety of some new GABAkines for treatment of depression: A systematic review and meta-analysis from randomized controlled trials. Psychiatry Res 2023; 328:115450. [PMID: 37683318 DOI: 10.1016/j.psychres.2023.115450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/25/2023] [Accepted: 08/27/2023] [Indexed: 09/10/2023]
Abstract
Positive allosteric modulators of γ-aminobutyric acid-A (GABAA) receptors, or GABAkines, play important roles in the treatment of depression, epilepsy, insomnia, and other disorders. Recently, some new GABAkines (zuranolone and brexanolone) have been administrated to patients with major depressive disorder (MDD) or postpartum depression (PPD) in randomized controlled trials (RCTs). This study aims to systematically review and examine the efficacy and safety of zuranolone or brexanolone for treatment of depression. A systematic literature retrieval was conducted through August 20, 2023. RCTs evaluating the efficacy and safety of zuranolone or brexanolone for treatment of depression were included. Eight studies (nine reports) were identified in the study. The percentages of patients with PPD achieving Hamilton Depression Rating Scale (HAM-D) response and remission were significantly higher after brexanolone or zuranolone administration compared with placebo at different points. The percentages of patients with MDD achieving HAM-D response and remission were significantly increased during the zuranolone treatment period compared with placebo. In addition, zuranolone caused more adverse events in patients with MDD compared with placebo. Our findings support the effects of brexanolone on improving the core symptoms of depression in patients with PPD, and the potential of zuranolone in treating patients with MDD or PPD.
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Affiliation(s)
- Jiao Zou
- Department of Military Cognitive Psychology, School of Psychology, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Ling Yang
- Department of Military Cognitive Psychology, School of Psychology, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Guoyu Yang
- School of Psychology, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Junwei Gao
- Department of Military Cognitive Psychology, School of Psychology, Third Military Medical University (Army Medical University), Chongqing 400038, China.
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28
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Rupprecht R, Pradhan AK, Kufner M, Brunner LM, Nothdurfter C, Wein S, Schwarzbach J, Puig X, Rupprecht C, Rammes G. Neurosteroids and translocator protein 18 kDa (TSPO) in depression: implications for synaptic plasticity, cognition, and treatment options. Eur Arch Psychiatry Clin Neurosci 2023; 273:1477-1487. [PMID: 36574032 DOI: 10.1007/s00406-022-01532-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/30/2022] [Indexed: 12/28/2022]
Abstract
There is need for novel fast acting treatment options in affective disorders. 3α-reduced neurosteroids such as allopregnanolone are powerful positive allosteric modulators of GABAA receptors and target also extrasynaptic receptors. Their synthesis is mediated by the translocator protein 18 kDa (TSPO). TSPO ligands not only promote endogenous neurosteroidogenesis, but also exert a broad spectrum of functions involving modulation of mitochondrial activity and acting as anti-inflammatory and neuroregenerative agents. Besides affective symptoms, in depression cognitive impairment can be frequently observed, which may be ameliorated through targeting of extrasynaptic GABAA receptors either via TSPO ligands or exogenously administered 3α-reduced neurosteroids. Interestingly, recent findings indicate an enhanced activation of the complement system, e.g., enhanced expression of C1q, both in depression and dementia. It is of note that benzodiazepines have been shown to reduce long-term potentiation and to cause cognitive decline. Intriguingly, TSPO may be crucial in mediating the effects of benzodiazepines on synaptic pruning. Here, we discuss how benzodiazepines and TSPO may interfere with synaptic pruning. Moreover, we highlight recent developments of TSPO ligands and 3α-reduced neurosteroids as therapeutic agents. Etifoxine is the only clinically available TSPO ligand so far and has been studied in anxiety disorders. Regarding 3α-reduced neurosteroids, brexanolone, an intravenous formulation of allopregnanolone, has been approved for the treatment of postpartum depression and zuranolone, an orally available 3α-reduced neurosteroid, is currently being studied in major depressive disorder and postpartum depression. As such, 3α-reduced neurosteroids and TSPO ligands may constitute promising treatment approaches for affective disorders.
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Affiliation(s)
- Rainer Rupprecht
- Department of Psychiatry and Psychotherapy, University Regensburg, Universitätsstrasse 84, 93053, Regensburg, Germany.
| | - Arpit Kumar Pradhan
- Experimental Neuropharmacology, Department of Anesthesiology, Technical University Munich, Munich, Germany
| | - Marco Kufner
- Department of Psychiatry and Psychotherapy, University Regensburg, Universitätsstrasse 84, 93053, Regensburg, Germany
| | - Lisa Marie Brunner
- Department of Psychiatry and Psychotherapy, University Regensburg, Universitätsstrasse 84, 93053, Regensburg, Germany
| | - Caroline Nothdurfter
- Department of Psychiatry and Psychotherapy, University Regensburg, Universitätsstrasse 84, 93053, Regensburg, Germany
| | - Simon Wein
- Department of Psychiatry and Psychotherapy, University Regensburg, Universitätsstrasse 84, 93053, Regensburg, Germany
| | - Jens Schwarzbach
- Department of Psychiatry and Psychotherapy, University Regensburg, Universitätsstrasse 84, 93053, Regensburg, Germany
| | - Xenia Puig
- Experimental Neuropharmacology, Department of Anesthesiology, Technical University Munich, Munich, Germany
| | - Christian Rupprecht
- Experimental Neuropharmacology, Department of Anesthesiology, Technical University Munich, Munich, Germany
| | - Gerhard Rammes
- Experimental Neuropharmacology, Department of Anesthesiology, Technical University Munich, Munich, Germany
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29
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Scala M, Fanelli G, De Ronchi D, Serretti A, Fabbri C. Clinical specificity profile for novel rapid acting antidepressant drugs. Int Clin Psychopharmacol 2023; 38:297-328. [PMID: 37381161 PMCID: PMC10373854 DOI: 10.1097/yic.0000000000000488] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/13/2023] [Indexed: 06/30/2023]
Abstract
Mood disorders are recurrent/chronic diseases with variable clinical remission rates. Available antidepressants are not effective in all patients and often show a relevant response latency, with a range of adverse events, including weight gain and sexual dysfunction. Novel rapid agents were developed with the aim of overcoming at least in part these issues. Novel drugs target glutamate, gamma-aminobutyric acid, orexin, and other receptors, providing a broader range of pharmacodynamic mechanisms, that is, expected to increase the possibility of personalizing treatments on the individual clinical profile. These new drugs were developed with the aim of combining a rapid action, a tolerable profile, and higher effectiveness on specific symptoms, which were relatively poorly targeted by standard antidepressants, such as anhedonia and response to reward, suicidal ideation/behaviours, insomnia, cognitive deficits, and irritability. This review discusses the clinical specificity profile of new antidepressants, namely 4-chlorokynurenine (AV-101), dextromethorphan-bupropion, pregn-4-en-20-yn-3-one (PH-10), pimavanserin, PRAX-114, psilocybin, esmethadone (REL-1017/dextromethadone), seltorexant (JNJ-42847922/MIN-202), and zuranolone (SAGE-217). The main aim is to provide an overview of the efficacy/tolerability of these compounds in patients with mood disorders having different symptom/comorbidity patterns, to help clinicians in the optimization of the risk/benefit ratio when prescribing these drugs.
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Affiliation(s)
- Mauro Scala
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giuseppe Fanelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Department of Human Genetics, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Diana De Ronchi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Alessandro Serretti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Chiara Fabbri
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
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30
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Reddy DS, Mbilinyi RH, Estes E. Preclinical and clinical pharmacology of brexanolone (allopregnanolone) for postpartum depression: a landmark journey from concept to clinic in neurosteroid replacement therapy. Psychopharmacology (Berl) 2023; 240:1841-1863. [PMID: 37566239 PMCID: PMC10471722 DOI: 10.1007/s00213-023-06427-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 07/17/2023] [Indexed: 08/12/2023]
Abstract
This article describes the critical role of neurosteroids in postpartum depression (PPD) and outlines the landmark pharmacological journey of brexanolone as a first-in-class neurosteroid antidepressant with significant advantages over traditional antidepressants. PPD is a neuroendocrine disorder that affects about 20% of mothers after childbirth and is characterized by symptoms including persistent sadness, fatigue, dysphoria, as well as disturbances in cognition, emotion, appetite, and sleep. The main pathology behind PPD is the postpartum reduction of neurosteroids, referred to as neurosteroid withdrawal, a concept pioneered by our preclinical studies. We developed neurosteroid replacement therapy (NRT) as a rational approach for treating PPD and other conditions related to neurosteroid deficiency, unveiling the power of neurosteroids as novel anxiolytic-antidepressants. The neurosteroid, brexanolone (BX), is a progesterone-derived allopregnanolone that rapidly relieves anxiety and mood deficits by activating GABA-A receptors, making it a transformational treatment for PPD. In 2019, the FDA approved BX, an intravenous formulation of allopregnanolone, as an NRT to treat PPD. In clinical studies, BX significantly improved PPD symptoms within hours of administration, with tolerable side effects including headache, dizziness, and somnolence. We identified the molecular mechanism of BX in a neuronal PPD-like milieu. The mechanism of BX involves activation of both synaptic and extrasynaptic GABA-A receptors, which promote tonic inhibition and serve as a key target for PPD and related conditions. Neurosteroids offer several advantages over traditional antidepressants, including rapid onset, unique mechanism, and lack of tolerance upon repeated use. Some limitations of BX therapy include lack of aqueous solubility, limited accessibility, hospitalization for treatment, lack of oral product, and serious adverse events at high doses. However, the unmet need for synthetic neurosteroids to address this critical condition supersedes these limitations. Recently, we developed novel hydrophilic neurosteroids with a superior profile and improved drug delivery. Overall, approval of BX is a major milestone in the field of neurotherapeutics, paving the way for the development of novel synthetic neurosteroids to treat depression, epilepsy, and status epilepticus.
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Affiliation(s)
- Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, 77807, USA.
- Institute of Pharmacology and Neurotherapeutics, Texas A&M University Health Science Center, 8447 Riverside Pkwy, Bryan, TX, 77807, USA.
| | - Robert H Mbilinyi
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, 77807, USA
| | - Emily Estes
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, 77807, USA
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31
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Clayton AH, Lasser R, Parikh SV, Iosifescu DV, Jung J, Kotecha M, Forrestal F, Jonas J, Kanes SJ, Doherty J. Zuranolone for the Treatment of Adults With Major Depressive Disorder: A Randomized, Placebo-Controlled Phase 3 Trial. Am J Psychiatry 2023; 180:676-684. [PMID: 37132201 DOI: 10.1176/appi.ajp.20220459] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVE This study assessed the efficacy and safety of a 14-day treatment course of once-daily zuranolone 50 mg, an investigational oral positive allosteric modulator of the γ-aminobutyric acid type A (GABAA) receptor, for the treatment of major depressive disorder. METHODS Patients 18-64 years of age with severe major depressive disorder were enrolled in this randomized, double-blind, placebo-controlled trial. Patients self-administered zuranolone 50 mg or placebo once daily for 14 days. The primary endpoint was change from baseline in total score on the 17-item Hamilton Depression Rating Scale (HAM-D) at day 15. Safety and tolerability were assessed by incidence of adverse events. RESULTS Of 543 randomized patients, 534 (266 in the zuranolone group, 268 in the placebo group) constituted the full analysis set. Compared with patients in the placebo group, patients in the zuranolone group demonstrated a statistically significant improvement in depressive symptoms at day 15 (least squares mean change from baseline HAM-D score, -14.1 vs. -12.3). Numerically greater improvements in depressive symptoms for zuranolone versus placebo were observed by day 3 (least squares mean change from baseline HAM-D score, -9.8 vs. -6.8), which were sustained at all visits throughout the treatment and follow-up periods of the study (through day 42, with the difference remaining nominally significant through day 12). Two patients in each group experienced a serious adverse event; nine patients in the zuranolone group and four in the placebo group discontinued treatment due to adverse events. CONCLUSIONS Zuranolone at 50 mg/day elicited a significantly greater improvement in depressive symptoms at day 15, with a rapid time to effect (day 3). Zuranolone was generally well tolerated, with no new safety findings compared with previously studied lower dosages. These findings support the potential of zuranolone in treating adults with major depressive disorder.
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Affiliation(s)
- Anita H Clayton
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville (Clayton); Sage Therapeutics, Cambridge, Mass. (Lasser, Jung, Jonas, Kanes, Doherty); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh); Nathan Kline Institute for Psychiatric Research and Department of Psychiatry, New York University School of Medicine, New York (Iosifescu); Biogen, Cambridge, Mass. (Kotecha, Forrestal)
| | - Robert Lasser
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville (Clayton); Sage Therapeutics, Cambridge, Mass. (Lasser, Jung, Jonas, Kanes, Doherty); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh); Nathan Kline Institute for Psychiatric Research and Department of Psychiatry, New York University School of Medicine, New York (Iosifescu); Biogen, Cambridge, Mass. (Kotecha, Forrestal)
| | - Sagar V Parikh
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville (Clayton); Sage Therapeutics, Cambridge, Mass. (Lasser, Jung, Jonas, Kanes, Doherty); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh); Nathan Kline Institute for Psychiatric Research and Department of Psychiatry, New York University School of Medicine, New York (Iosifescu); Biogen, Cambridge, Mass. (Kotecha, Forrestal)
| | - Dan V Iosifescu
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville (Clayton); Sage Therapeutics, Cambridge, Mass. (Lasser, Jung, Jonas, Kanes, Doherty); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh); Nathan Kline Institute for Psychiatric Research and Department of Psychiatry, New York University School of Medicine, New York (Iosifescu); Biogen, Cambridge, Mass. (Kotecha, Forrestal)
| | - JungAh Jung
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville (Clayton); Sage Therapeutics, Cambridge, Mass. (Lasser, Jung, Jonas, Kanes, Doherty); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh); Nathan Kline Institute for Psychiatric Research and Department of Psychiatry, New York University School of Medicine, New York (Iosifescu); Biogen, Cambridge, Mass. (Kotecha, Forrestal)
| | - Mona Kotecha
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville (Clayton); Sage Therapeutics, Cambridge, Mass. (Lasser, Jung, Jonas, Kanes, Doherty); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh); Nathan Kline Institute for Psychiatric Research and Department of Psychiatry, New York University School of Medicine, New York (Iosifescu); Biogen, Cambridge, Mass. (Kotecha, Forrestal)
| | - Fiona Forrestal
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville (Clayton); Sage Therapeutics, Cambridge, Mass. (Lasser, Jung, Jonas, Kanes, Doherty); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh); Nathan Kline Institute for Psychiatric Research and Department of Psychiatry, New York University School of Medicine, New York (Iosifescu); Biogen, Cambridge, Mass. (Kotecha, Forrestal)
| | - Jeffrey Jonas
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville (Clayton); Sage Therapeutics, Cambridge, Mass. (Lasser, Jung, Jonas, Kanes, Doherty); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh); Nathan Kline Institute for Psychiatric Research and Department of Psychiatry, New York University School of Medicine, New York (Iosifescu); Biogen, Cambridge, Mass. (Kotecha, Forrestal)
| | - Stephen J Kanes
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville (Clayton); Sage Therapeutics, Cambridge, Mass. (Lasser, Jung, Jonas, Kanes, Doherty); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh); Nathan Kline Institute for Psychiatric Research and Department of Psychiatry, New York University School of Medicine, New York (Iosifescu); Biogen, Cambridge, Mass. (Kotecha, Forrestal)
| | - James Doherty
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville (Clayton); Sage Therapeutics, Cambridge, Mass. (Lasser, Jung, Jonas, Kanes, Doherty); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh); Nathan Kline Institute for Psychiatric Research and Department of Psychiatry, New York University School of Medicine, New York (Iosifescu); Biogen, Cambridge, Mass. (Kotecha, Forrestal)
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Sonoyama T, Shimizu R, Kubota R, Matsuo Y, Okutsu D, Yamanaka H, Takasu K, Ogawa K, Motomiya T. Pharmacokinetics, safety, and tolerability of single and multiple doses of zuranolone in Japanese and White healthy subjects: A phase 1 clinical trial. Neuropsychopharmacol Rep 2023; 43:346-358. [PMID: 37366077 PMCID: PMC10496058 DOI: 10.1002/npr2.12359] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 06/28/2023] Open
Abstract
AIM This phase 1 study assessed the pharmacokinetics, safety, and tolerability of zuranolone in Japanese and White healthy adults, and Japanese healthy elderly subjects. METHODS This single-center study consisted of three parts. In Part A (randomized, double-blind), the safety, tolerability, and pharmacokinetics of single dose and 7-day consecutive multiple doses of zuranolone 10, 20, and 30 mg and placebo were assessed in 36 Japanese adults, 24 White adults, and 12 Japanese elderly (aged 65-75 years) subjects. In Part B (randomized, open-label, crossover), the effect of food intake on the pharmacokinetics and safety of single-dose zuranolone 30 mg was evaluated in 12 Japanese adults. In Part C (randomized, double-blind, crossover), the effects of single-dose zuranolone 10 and 30 mg and placebo on electroencephalography parameters were evaluated in eight Japanese adults. RESULTS Single and multiple doses of zuranolone were safe and well tolerated in all subjects. Linear pharmacokinetics were observed in the studied dose range. Time to steady-state plasma concentration was within 72 h for Japanese and White adults. Pharmacokinetic profiles were comparable between Japanese and White adults and between Japanese adults and Japanese elderly subjects. Plasma exposures of zuranolone were greater in the fed versus fasted state. Single-dose zuranolone 30 mg increased low-beta electroencephalography power. CONCLUSION In healthy Japanese subjects, zuranolone was well tolerated; pharmacokinetic profile was unaffected by ethnicity or age; plasma exposures were greater in the fed state. The increased low-beta electroencephalography power with the 30-mg dose is consistent with γ-aminobutyric acid receptor type A activation by zuranolone.
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Affiliation(s)
- Takuhiro Sonoyama
- Medical Science Department, Drug Development and Regulatory Science DivisionShionogi & Co., Ltd.OsakaJapan
| | - Ryosuke Shimizu
- Clinical Pharmacology & Pharmacokinetics, Drug Development and Regulatory Science DivisionShionogi & Co., Ltd.OsakaJapan
| | - Ryuji Kubota
- Clinical Pharmacology & Pharmacokinetics, Drug Development and Regulatory Science DivisionShionogi & Co., Ltd.OsakaJapan
| | - Yumiko Matsuo
- Clinical Pharmacology & Pharmacokinetics, Drug Development and Regulatory Science DivisionShionogi & Co., Ltd.OsakaJapan
| | - Daiki Okutsu
- Clinical Research Department, Drug Development and Regulatory Science DivisionShionogi & Co., Ltd.OsakaJapan
| | - Hideki Yamanaka
- Clinical Research Department, Drug Development and Regulatory Science DivisionShionogi & Co., Ltd.OsakaJapan
| | - Keiko Takasu
- Laboratory for Drug Discovery and Disease Research, Pharmaceutical Research DivisionShionogi & Co., Ltd.OsakaJapan
| | - Koichi Ogawa
- Laboratory for Drug Discovery and Disease Research, Pharmaceutical Research DivisionShionogi & Co., Ltd.OsakaJapan
| | - Tomoko Motomiya
- Project Management Department, Drug Development and Regulatory Science DivisionShionogi & Co., Ltd.OsakaJapan
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33
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Cutler AJ, Mattingly GW, Maletic V. Understanding the mechanism of action and clinical effects of neuroactive steroids and GABAergic compounds in major depressive disorder. Transl Psychiatry 2023; 13:228. [PMID: 37365161 DOI: 10.1038/s41398-023-02514-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 05/12/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023] Open
Abstract
The pathophysiology of major depressive disorder (MDD) is thought to result from impaired connectivity between key brain networks. Gamma-aminobutyric acid (GABA) is the key inhibitory neurotransmitter in the brain, working primarily via GABAA receptors, with an important role in virtually all physiologic functions in the brain. Some neuroactive steroids (NASs) are positive allosteric modulators (PAMs) of GABAA receptors and potentiate phasic and tonic inhibitory responses via activation of synaptic and extrasynaptic GABAA receptors, respectively. This review first discusses preclinical and clinical data that support the association of depression with diverse defects in the GABAergic system of neurotransmission. Decreased levels of GABA and NASs have been observed in adults with depression compared with healthy controls, while treatment with antidepressants normalized the altered levels of GABA and NASs. Second, as there has been intense interest in treatment approaches for depression that target dysregulated GABAergic neurotransmission, we discuss NASs approved or currently in clinical development for the treatment of depression. Brexanolone, an intravenous NAS and a GABAA receptor PAM, is approved by the U.S. Food and Drug Administration for the treatment of postpartum depression (PPD) in patients 15 years and older. Other NASs include zuranolone, an investigational oral GABAA receptor PAM, and PH10, which acts on nasal chemosensory receptors; clinical data to date have shown improvement in depressive symptoms with these investigational NASs in adults with MDD or PPD. Finally, the review discusses how NAS GABAA receptor PAMs may potentially address the unmet need for novel and effective treatments with rapid and sustained antidepressant effects in patients with MDD.
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34
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Covey DF, Evers AS, Izumi Y, Maguire JL, Mennerick SJ, Zorumski CF. Neurosteroid enantiomers as potentially novel neurotherapeutics. Neurosci Biobehav Rev 2023; 149:105191. [PMID: 37085023 PMCID: PMC10750765 DOI: 10.1016/j.neubiorev.2023.105191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 04/23/2023]
Abstract
Endogenous neurosteroids and synthetic neuroactive steroids (NAS) are important targets for therapeutic development in neuropsychiatric disorders. These steroids modulate major signaling systems in the brain and intracellular processes including inflammation, cellular stress and autophagy. In this review, we describe studies performed using unnatural enantiomers of key neurosteroids, which are physiochemically identical to their natural counterparts except for rotation of polarized light. These studies led to insights in how NAS interact with receptors, ion channels and intracellular sites of action. Certain effects of NAS show high enantioselectivity, consistent with actions in chiral environments and likely direct interactions with signaling proteins. Other effects show no enantioselectivity and even reverse enantioselectivity. The spectrum of effects of NAS enantiomers raises the possibility that these agents, once considered only as tools for preclinical studies, have therapeutic potential that complements and in some cases may exceed their natural counterparts. Here we review studies of NAS enantiomers from the perspective of their potential development as novel neurotherapeutics.
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Affiliation(s)
- Douglas F Covey
- Departments of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA; Developmental Biology, Washington University School of Medicine, St. Louis, MO, USA; Anesthesiology Washington University School of Medicine, St. Louis, MO, USA; The Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, MO, USA
| | - Alex S Evers
- Developmental Biology, Washington University School of Medicine, St. Louis, MO, USA; Anesthesiology Washington University School of Medicine, St. Louis, MO, USA; The Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, MO, USA
| | - Yukitoshi Izumi
- Departments of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA; The Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, MO, USA
| | - Jamie L Maguire
- Department of Neuroscience, Tufts University School of Medicine, Boston, MA, USA
| | - Steven J Mennerick
- Departments of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA; The Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, MO, USA
| | - Charles F Zorumski
- Departments of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA; The Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, MO, USA.
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35
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Shad MU. Recent Developments in Pharmacotherapy of Depression: Bench to Bedside. J Pers Med 2023; 13:jpm13050773. [PMID: 37240943 DOI: 10.3390/jpm13050773] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/20/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
For the last 70 years, we did not move beyond the monoamine hypothesis of depression until the approval of the S-enantiomer of ketamine, an N-methyl-D-aspartate (NMDA) receptor blocker and the first non-monoaminergic antidepressant characterized by rapid antidepressant and antisuicidal effects. A similar profile has been reported with another NMDA receptor antagonist, dextromethorphan, which has also been approved to manage depression in combination with bupropion. More recently, the approval of a positive allosteric modulator of GABA-A receptors, brexanolone, has added to the list of recent breakthroughs with the relatively rapid onset of antidepressant efficacy. However, multiple factors have compromised the clinical utility of these exciting discoveries in the general population, including high drug acquisition costs, mandatory monitoring requirements, parenteral drug administration, lack of insurance coverage, indirect COVID-19 effects on healthcare systems, and training gaps in psychopharmacology. This narrative review aims to analyze the clinical pharmacology of recently approved antidepressants and discuss potential barriers to the bench-to-bedside transfer of knowledge and clinical application of exciting recent discoveries. Overall, clinically meaningful advances in the treatment of depression have not reached a large proportion of depressed patients, including those with treatment-resistant depression, who might benefit the most from the novel antidepressants.
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Affiliation(s)
- Mujeeb U Shad
- Valley Health System (VHS), Las Vegas, NV 89118, USA
- The Department of Psychiatry, University of Nevada, Las Vegas, School of Medicine, The Touro University of Nevada College of Osteopathic Medicine (TUNCOM), Henderson, NV 89014, USA
- The University of Nevada, Las Vegas, NV 89154, USA
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36
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Ali M, Ullah I, Diwan MN, Aamir A, Awan HA, Waris Durrani A, Qudrat QU, Shoib S, De Berardis D. Zuranolone and its role in treating major depressive disorder: a narrative review. Horm Mol Biol Clin Investig 2023:hmbci-2022-0042. [PMID: 36848317 DOI: 10.1515/hmbci-2022-0042] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 12/11/2022] [Indexed: 02/28/2023]
Abstract
Major Depressive Disorder (MDD) is a mood disorder classified as a persistent depressive mood and loss of interest lasting for more than two weeks and accompanied by a list of symptoms outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) diagnostic criteria. MDD affects approximately 264 million people worldwide and is the most prevailing form of neuropsychiatric disorder. Owing to the probable hypothesized pathophysiology of MDD being an outcome of abnormalities in the amino acid neurotransmitter system, including glutamate (the primary excitatory neurotransmitter) and γ-aminobutyric acid (GABA), SAGE-217 (Zuranolone) is being evaluated as a possible therapeutic treatment for MDD. Zuranolone is a synthetic, neuroactive steroid (NAS) and positive allosteric modulator (PMA) of GABAA receptors, regulating both synaptic and extra-synaptic release of GABA. It is administered as a once-daily oral dose for 2 weeks due to its low-moderate clearance. A change in total HAM-D score from baseline was the primary end-point of all the trials. A phase II trial conducted to evaluate the efficacy and safety of Zuranolone (30 mg, once-daily dose), described a significant reduction in total HAM-D score at day 14 and reported the drug to be well tolerated with headache, dizziness, nausea, and somnolence as the most common adverse events (AE). Additional phase III trials were also conducted to evaluate similar outcomes, the interim topline results of which have been released. Consequently, this article attempts to briefly analyze the pharmacology of Zuranolone, review the available clinical data and outcomes regarding its use, and evaluate its place as a prospective novel therapy in the effective management of MDD.
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Affiliation(s)
- Muneeza Ali
- Department of Internal Medicine, Dow Medical College, Karachi, Pakistan.,Department of Internal Medicine, Peshawar, Pakistan
| | - Irfan Ullah
- Department of Internal Medicine, Kabir Medical College, Gandhara University, Peshawar, Pakistan
| | - Mufaddal Najmuddin Diwan
- Department of Internal Medicine, Dow Medical College, Karachi, Pakistan.,Department of Internal Medicine, Peshawar, Pakistan
| | - Alifiya Aamir
- Department of Internal Medicine, Dow Medical College, Karachi, Pakistan.,Department of Internal Medicine, Peshawar, Pakistan
| | - Hashir Ali Awan
- Department of Internal Medicine, Dow Medical College, Karachi, Pakistan.,Department of Internal Medicine, Peshawar, Pakistan
| | - Abdul Waris Durrani
- Department of Internal Medicine, Kabir Medical College, Gandhara University, Peshawar, Pakistan
| | - Qudrat Ullah Qudrat
- Department of Internal Medicine, Kabir Medical College, Gandhara University, Peshawar, Pakistan
| | - Sheikh Shoib
- Department of Psychiatry, Jawahar Lal Nehru Memorial Hospital, Srinagar, Kashmir, India.,Sharda University, Greater Noida, Uttar Pradesh, India.,Mind Wellness Center, Nawab Bazar, Srinagar, India
| | - Domenico De Berardis
- NHS, Department of Mental Health, Psychiatric Service for Diagnosis and Treatment, Hospital "G. Mazzini", ASL 4, Teramo, Italy
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37
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Abstract
Treatment of major depressive disorder (MDD) including treatment-resistant depression (TRD) remains a major unmet need. Although there are several classes of dissimilar antidepressant drugs approved for MDD, the current drugs have either limited efficacy or are associated with undesirable side effects and withdrawal symptoms. The efficacy and side effects of antidepressant drugs are mainly attributed to their actions on different monoamine neurotransmitters (serotonin, norepinephrine, and dopamine). Development of new antidepressants with novel targets beyond the monoamine pathways may fill the unmet need in treatment of MDD and TRD. The recent approval of intranasal Esketamine (glutamatergic agent) in conjunction with an oral antidepressant for the treatment of adult TRD patients was the first step toward expanding beyond the monoamine targets. Several other glutamatergic (AXS-05, REL-1017, AV-101, SLS-002, AGN24175, and PCN-101) and GABAergic (brexanolone, zuranolone, and ganaxolone) drugs are currently in different stages of clinical development for MDD, TRD and other indications. The renaissance of psychedelic drugs and the emergence of preliminary positive clinical trial results with psilocybin, Ayahuasca, 5-methoxy-N,N-dimethyltryptamine (5-MeO-DMT), and lysergic acid diethylamide (LSD) may pave the way towards establishing this class of drugs as effective therapies for MDD, TRD and other neuropsychiatric disorders. Going beyond the monoamine targets appears to be an effective strategy to develop novel antidepressant drugs with superior efficacy, safety, and tolerability for the improved treatment of MDD and TRD.
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38
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Lambert PM, Ni R, Benz A, Rensing NR, Wong M, Zorumski CF, Mennerick S. Non-sedative cortical EEG signatures of allopregnanolone and functional comparators. Neuropsychopharmacology 2023; 48:371-379. [PMID: 36168047 PMCID: PMC9751067 DOI: 10.1038/s41386-022-01450-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/13/2022] [Accepted: 08/31/2022] [Indexed: 12/26/2022]
Abstract
Neurosteroids that positively modulate GABAA receptors are among a growing list of rapidly acting antidepressants, including ketamine and psychedelics. To develop increasingly specific treatments with fewer side effects, we explored the possibility of EEG signatures in mice, which could serve as a cross-species screening tool. There are few studies of the impact of non-sedative doses of rapid antidepressants on EEG in either rodents or humans. Here we hypothesize that EEG features may separate a rapid antidepressant neurosteroid, allopregnanolone, from other GABAA positive modulators, pentobarbital and diazepam. Further, we compared the actions GABA modulators with those of ketamine, an NMDA antagonist and prototype rapid antidepressant. We examined EEG spectra during active exploration at two cortical locations and examined cross-regional and cross-frequency interactions. We found that at comparable doses, the effects of allopregnanolone, despite purported selectivity for certain GABAAR subtypes, was indistinguishable from pentobarbital during active waking exploration. The actions of diazepam had recognizable common features with allopregnanolone and pentobarbital but was also distinct, consistent with subunit selectivity of benzodiazepines. Finally, ketamine exhibited no distinguishing overlap with allopregnanolone in the parameters examined. Our results suggest that rapid antidepressants with different molecular substrates may remain separated at the level of large-scale ensemble activity, but the studies leave open the possibility of commonalities in more discrete circuits and/or in the context of a dysfunctional brain.
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Affiliation(s)
- Peter M Lambert
- Department of Psychiatry, Washington University in St. Louis School of Medicine, 660S. Euclid Ave., MSC 8134-0181-0G, St. Louis, MO, 63110, USA.,Medical Scientist Training Program, Washington University in St. Louis School of Medicine, 660S. Euclid Ave., MSC 8134-0181-0G, St. Louis, MO, 63110, USA
| | - Richard Ni
- Department of Psychiatry, Washington University in St. Louis School of Medicine, 660S. Euclid Ave., MSC 8134-0181-0G, St. Louis, MO, 63110, USA
| | - Ann Benz
- Department of Psychiatry, Washington University in St. Louis School of Medicine, 660S. Euclid Ave., MSC 8134-0181-0G, St. Louis, MO, 63110, USA
| | - Nicholas R Rensing
- Department of Neurology, Washington University in St. Louis School of Medicine, 660S. Euclid Ave., MSC 8134-0181-0G, St. Louis, MO, 63110, USA
| | - Michael Wong
- Department of Neurology, Washington University in St. Louis School of Medicine, 660S. Euclid Ave., MSC 8134-0181-0G, St. Louis, MO, 63110, USA
| | - Charles F Zorumski
- Department of Psychiatry, Washington University in St. Louis School of Medicine, 660S. Euclid Ave., MSC 8134-0181-0G, St. Louis, MO, 63110, USA.,Taylor Family Institute for Innovative Psychiatric Research, Washington University in St. Louis School of Medicine, 660S. Euclid Ave., MSC 8134-0181-0G, St. Louis, MO, 63110, USA
| | - Steven Mennerick
- Department of Psychiatry, Washington University in St. Louis School of Medicine, 660S. Euclid Ave., MSC 8134-0181-0G, St. Louis, MO, 63110, USA. .,Taylor Family Institute for Innovative Psychiatric Research, Washington University in St. Louis School of Medicine, 660S. Euclid Ave., MSC 8134-0181-0G, St. Louis, MO, 63110, USA.
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Gao Q, Sun W, Wang YR, Li ZF, Zhao F, Geng XW, Xu KY, Chen D, Liu K, Xing Y, Liu W, Wei S. Role of allopregnanolone-mediated γ-aminobutyric acid A receptor sensitivity in the pathogenesis of premenstrual dysphoric disorder: Toward precise targets for translational medicine and drug development. Front Psychiatry 2023; 14:1140796. [PMID: 36937732 PMCID: PMC10017536 DOI: 10.3389/fpsyt.2023.1140796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
Premenstrual dysphoric disorder (PMDD) can be conceptualized as a disorder of suboptimal sensitivity to neuroactive steroid hormones. Its core symptoms (emotional instability, irritability, depression, and anxiety) are related to the increase of stress sensitivity due to the fluctuation of hormone level in luteal phase of the menstrual cycle. In this review, we describe the emotional regulatory effect of allopregnanolone (ALLO), and summarize the relationship between ALLO and γ-aminobutyric acid A (GABAA) receptor subunits based on rodent experiments and clinical observations. A rapid decrease in ALLO reduces the sensitivity of GABAA receptor, and reduces the chloride influx, hindered the inhibitory effect of GABAergic neurons on pyramidal neurons, and then increased the excitability of pyramidal neurons, resulting in PMDD-like behavior. Finally, we discuss in depth the treatment of PMDD with targeted GABAA receptors, hoping to find a precise target for drug development and subsequent clinical application. In conclusion, PMDD pathophysiology is rooted in GABAA receptor sensitivity changes caused by rapid changes in ALLO levels. Targeting GABAA receptors may alleviate the occurrence of PMDD.
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Affiliation(s)
- Qian Gao
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Jinan, China
- Chinese Medicine and Brain Science Core Facility, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Wei Sun
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yue-Rui Wang
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Jinan, China
- Chinese Medicine and Brain Science Core Facility, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zi-Fa Li
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Feng Zhao
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xi-Wen Geng
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Jinan, China
- Chinese Medicine and Brain Science Core Facility, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Kai-Yong Xu
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Dan Chen
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Kun Liu
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Jinan, China
- Chinese Medicine and Brain Science Core Facility, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Ying Xing
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Jinan, China
- Chinese Medicine and Brain Science Core Facility, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Wei Liu
- Department of Encephalopathy, The Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
- Wei Liu,
| | - Sheng Wei
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Jinan, China
- Chinese Medicine and Brain Science Core Facility, Shandong University of Traditional Chinese Medicine, Jinan, China
- *Correspondence: Sheng Wei,
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40
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Nutt DJ, Tyacke RJ, Spriggs M, Jacoby V, Borthwick AD, Belelli D. Functional Alternatives to Alcohol. Nutrients 2022; 14:nu14183761. [PMID: 36145137 PMCID: PMC9505959 DOI: 10.3390/nu14183761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/06/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
The consumption of alcohol is associated with well-known health harms and many governments worldwide are actively engaged in devising approaches to reduce them. To this end, a common proposed strategy aims at reducing alcohol consumption. This approach has led to the development of non-alcoholic drinks, which have been especially welcome by younger, wealthier, health-conscious consumers, who have been turning away from alcohol to look toward alternatives. However, a drawback of non-alcoholic drinks is that they do not facilitate social interaction in the way alcohol does, which is the main reason behind social drinking. Therefore, an alternative approach is to develop functional drinks that do not use alcohol yet mimic the positive, pro-social effects of alcohol without the associated harms. This article will discuss (1) current knowledge of how alcohol mediates its effects in the brain, both the desirable, e.g., antistress to facilitate social interactions, and the harmful ones, with a specific focus on the pivotal role played by the gamma-aminobutyric acid (GABA) neurotransmitter system and (2) how this knowledge can be exploited to develop functional safe alternatives to alcohol using either molecules already existing in nature or synthetic ones. This discussion will be complemented by an analysis of the regulatory challenges associated with the novel endeavour of bringing safe, functional alternatives to alcohol from the bench to bars.
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41
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Suthoff E, Kosinski M, Arnaud A, Hodgkins P, Gunduz-Bruce H, Lasser R, Silber C, Sankoh AJ, Li H, Werneburg B, Jonas J, Doherty J, Kanes SJ, Bonthapally V. Patient-reported health-related quality of life from a randomized, placebo-controlled phase 2 trial of zuranolone in adults with major depressive disorder. J Affect Disord 2022; 308:19-26. [PMID: 35378149 DOI: 10.1016/j.jad.2022.03.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Major depressive disorder (MDD), a disabling, potentially life-threatening condition, negatively affects health-related quality of life (HRQoL). This secondary analysis aimed to understand the impact of the neuroactive steroid zuranolone on HRQoL using the Short Form-36v2 Health Survey (SF-36v2). METHODS Adult patients with MDD and 17-item Hamilton Rating Scale for Depression total score ≥22 were randomized 1:1 to receive zuranolone 30 mg or placebo for 2 weeks, with 4 weeks follow-up. SF-36v2 scores were assessed at Day 15 across 8 domains (Physical Functioning, Role Physical, Bodily Pain, General Health, Vitality, Social Functioning, Role Emotional, and Mental Health) and 2 summary scores (Physical and Mental Component), using a mixed-effects model for repeated measures. Correlations between SF-36v2 scores and clinician-reported efficacy endpoints were assessed using Pearson's correlation. RESULTS Eighty-nine patients were treated with zuranolone 30 mg (n = 45) or placebo (n = 44). In zuranolone-treated patients, HRQoL improved across all SF-36v2 domains and summary scores at Day 15. Improvements exceeding established minimally important difference thresholds were observed in Bodily Pain, General Health, Vitality, Social Functioning, Role Emotional, and Mental Health scores. Improvements in General Health, Vitality, Mental Health, and Mental Component Summary were statistically significant versus placebo (p ≤ 0.025). Clinician-rated endpoints negatively correlated with SF-36v2 scores. LIMITATIONS The small unipolar depression sample may not be representative of all US MDD patients. HRQoL measures could be impacted by factors unrelated to depression. CONCLUSIONS Zuranolone-treated patients reported rapid and significant improvements in HRQoL versus placebo at Day 15. HRQoL improvements correlated with improvements in clinician-rated assessments. TRIAL REGISTRATION clinicaltrials.gov:NCT03000530; https://clinicaltrials.gov/ct2/show/NCT03000530.
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Affiliation(s)
- Ellison Suthoff
- Sage Therapeutics, Inc., Cambridge, MA, United States of America.
| | | | - Alix Arnaud
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Paul Hodgkins
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | | | - Robert Lasser
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | | | - Abdul J Sankoh
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Haihong Li
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Brian Werneburg
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Jeffrey Jonas
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - James Doherty
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Stephen J Kanes
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
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42
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Rupprecht R, Wetzel CH, Dorostkar M, Herms J, Albert NL, Schwarzbach J, Schumacher M, Neumann ID. Translocator protein (18kDa) TSPO: a new diagnostic or therapeutic target for stress-related disorders? Mol Psychiatry 2022; 27:2918-2926. [PMID: 35444254 DOI: 10.1038/s41380-022-01561-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/25/2022] [Accepted: 03/31/2022] [Indexed: 12/11/2022]
Abstract
Efficient treatment of stress-related disorders, such as depression, is still a major challenge. The onset of antidepressant drug action is generally quite slow, while the anxiolytic action of benzodiazepines is considerably faster. However, their long-term use is impaired by tolerance development, abuse liability and cognitive impairment. Benzodiazepines act as positive allosteric modulators of ɣ-aminobutyric acid type A (GABAA) receptors. 3α-reduced neurosteroids such as allopregnanolone also are positive allosteric GABAA receptor modulators, however, through a site different from that targeted by benzodiazepines. Recently, the administration of neurosteroids such as brexanolone or zuranolone has been shown to rapidly ameliorate symptoms in post-partum depression or major depressive disorder. An attractive alternative to the administration of exogenous neurosteroids is promoting endogenous neurosteroidogenesis via the translocator protein 18k Da (TSPO). TSPO is a transmembrane protein located primarily in mitochondria, which mediates numerous biological functions, e.g., steroidogenesis and mitochondrial bioenergetics. TSPO ligands have been used in positron emission tomography (PET) studies as putative markers of microglia activation and neuroinflammation in stress-related disorders. Moreover, TSPO ligands have been shown to modulate neuroplasticity and to elicit antidepressant and anxiolytic therapeutic effects in animals and humans. As such, TSPO may open new avenues for understanding the pathophysiology of stress-related disorders and for the development of novel treatment options.
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Affiliation(s)
- Rainer Rupprecht
- Department of Psychiatry and Psychotherapy, University of Regensburg, 93053, Regensburg, Germany.
| | - Christian H Wetzel
- Department of Psychiatry and Psychotherapy, University of Regensburg, 93053, Regensburg, Germany
| | - Mario Dorostkar
- Center for Neuropathology and Prion Research, Ludwig-Maximilian-University Munich, 81377, Munich, Germany
| | - Jochen Herms
- Center for Neuropathology and Prion Research, Ludwig-Maximilian-University Munich, 81377, Munich, Germany.,German Center for Neurodegenerative Diseases (DZNE), 81377, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), 81377, Munich, Germany
| | - Nathalie L Albert
- Department of Nuclear Medicine, Ludwig-Maximilian-University Munich, 81377, Munich, Germany
| | - Jens Schwarzbach
- Department of Psychiatry and Psychotherapy, University of Regensburg, 93053, Regensburg, Germany
| | - Michael Schumacher
- Research Unit 1195, INSERM and University Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
| | - Inga D Neumann
- Department of Neurobiology and Animal Physiology, University Regensburg, 93040, Regensburg, Germany
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43
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Vasiliu O. Investigational Drugs for the Treatment of Depression (Part 1): Monoaminergic, Orexinergic, GABA-Ergic, and Anti-Inflammatory Agents. Front Pharmacol 2022; 13:884143. [PMID: 35774601 PMCID: PMC9237478 DOI: 10.3389/fphar.2022.884143] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/14/2022] [Indexed: 12/27/2022] Open
Abstract
Therapeutic management of depression has currently important limitations, and its low efficacy is reflected in high rates of non-response even after multiple trials of antidepressants. Almost two-thirds of the patients diagnosed with major depression who received a 4–6 weeks trial of antidepressant could not reach remission, and more than 30% of these patients are considered treatment-resistant. In bipolar depression, the situation is also discouraging if we analyze the high suicide rate, the risk for the treatment-emergent affective switch when antidepressants are added, the high rate of treatment resistance (up to 25%), and the severe functional impairments associated with these episodes. Therefore, new therapeutic agents are needed, as well as new pathogenetic models for depression. The vast majority of the currently approved antidepressants are based on the monoamine hypothesis, although new drugs exploiting different neurotransmitter pathways have been recently approved by FDA. Brexanolone, an allopregnanolone analog, is an example of such new antidepressants, and its approval for post-partum depression inspired the search for a new generation of neurosteroids and GABA-ergic modulators, with an easier way of administration and superior tolerability profile. Orexin receptors antagonists are also extensively studied for different psychiatric disorders, depression included, in phase II trials. Antiinflammatory drugs, both cyclo-oxygenase 2 inhibitors and biological therapy, are investigated in patients with depressive disorders based on the proven correlation between inflammation and mood disorders in preclinical and clinical studies. Also, a new generation of monoamine-based investigational drugs is explored, ranging from triple reuptake inhibitors to atypical antipsychotics, in patients with major depression. In conclusion, there is hope for new treatments in uni- and bipolar depression, as it became clear, after almost seven decades, that new pathogenetic pathways should be targeted to increase these patients’ response rate.
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44
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Cerne R, Lippa A, Poe MM, Smith JL, Jin X, Ping X, Golani LK, Cook JM, Witkin JM. GABAkines - Advances in the discovery, development, and commercialization of positive allosteric modulators of GABA A receptors. Pharmacol Ther 2022; 234:108035. [PMID: 34793859 PMCID: PMC9787737 DOI: 10.1016/j.pharmthera.2021.108035] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 11/08/2021] [Indexed: 12/25/2022]
Abstract
Positive allosteric modulators of γ-aminobutyric acid-A (GABAA) receptors or GABAkines have been widely used medicines for over 70 years for anxiety, epilepsy, sleep, and other disorders. Traditional GABAkines like diazepam have safety and tolerability concerns that include sedation, motor-impairment, respiratory depression, tolerance and dependence. Multiple GABAkines have entered clinical development but the issue of side-effects has not been fully solved. The compounds that are presently being developed and commercialized include several neuroactive steroids (an allopregnanolone formulation (brexanolone), an allopregnanolone prodrug (LYT-300), Sage-324, zuranolone, and ganaxolone), the α2/3-preferring GABAkine, KRM-II-81, and the α2/3/5-preferring GABAkine PF-06372865 (darigabat). The neuroactive steroids are in clinical development for post-partum depression, intractable epilepsy, tremor, status epilepticus, and genetic epilepsy disorders. Darigabat is in development for epilepsy and anxiety. The imidazodiazepine, KRM-II-81 is efficacious in animal models for the treatment of epilepsy and post-traumatic epilepsy, acute and chronic pain, as well as anxiety and depression. The efficacy of KRM-II-81 in models of pharmacoresistant epilepsy, preventing the development of seizure sensitization, and in brain tissue of intractable epileptic patients bodes well for improved therapeutics. Medicinal chemistry efforts are also ongoing to identify novel and improved GABAkines. The data document gaps in our understanding of the molecular pharmacology of GABAkines that drive differential pharmacological profiles, but emphasize advancements in the ability to successfully utilize GABAA receptor potentiation for therapeutic gain in neurology and psychiatry.
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Affiliation(s)
- Rok Cerne
- Laboratory of Antiepileptic Drug Discovery, Ascension St. Vincent, Indianapolis, IN USA,Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, Ljubljana, Slovenia.,RespireRx Pharmaceuticals Inc, Glen Rock, NJ, USA,Department of Anatomy and Cell Biology, Indiana University/Purdue University, Indianapolis, IN, USA
| | - Arnold Lippa
- RespireRx Pharmaceuticals Inc, Glen Rock, NJ, USA
| | | | - Jodi L. Smith
- Laboratory of Antiepileptic Drug Discovery, Ascension St. Vincent, Indianapolis, IN USA
| | - Xiaoming Jin
- Department of Anatomy and Cell Biology, Indiana University/Purdue University, Indianapolis, IN, USA
| | - Xingjie Ping
- Department of Anatomy and Cell Biology, Indiana University/Purdue University, Indianapolis, IN, USA
| | - Lalit K. Golani
- Department of Chemistry and Biochemistry, Milwaukee Institute of Drug Discovery, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - James M. Cook
- RespireRx Pharmaceuticals Inc, Glen Rock, NJ, USA,Department of Chemistry and Biochemistry, Milwaukee Institute of Drug Discovery, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Jeffrey M. Witkin
- Laboratory of Antiepileptic Drug Discovery, Ascension St. Vincent, Indianapolis, IN USA,RespireRx Pharmaceuticals Inc, Glen Rock, NJ, USA,Department of Chemistry and Biochemistry, Milwaukee Institute of Drug Discovery, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
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45
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Zhang Y, Ke J, Zhou Y, Liu X, Huang T, Wang F. Sex-specific characteristics of cells expressing the cannabinoid 1 receptor in the dorsal horn of the lumbar spinal cord. J Comp Neurol 2022; 530:2451-2473. [PMID: 35580011 DOI: 10.1002/cne.25342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 12/20/2022]
Abstract
It is becoming increasingly clear that robust sex differences exist in the processing of acute and chronic pain in both rodents and humans. However, the underlying mechanism has not been well characterized. The dorsal horn of the lumbar spinal cord is the fundamental building block of ascending and descending pain pathways. It has been shown that numerous neurotransmitter and neuromodulator systems in the spinal cord, including the endocannabinoid system and its main receptor, the cannabinoid 1 receptor (CB1 R), play vital roles in processing nociceptive information. Our previous findings have shown that CB1 R mRNA is widely expressed in the brain in sex-dependent patterns. However, the sex-, lamina-, and cell-type-specific characteristics of CB1 R expression in the spinal cord have not been fully described. In this study, the CB1 R-iCre-EGFP mouse strain was generated to label and identify CB1 R-positive (CB1 RGFP ) cells. We reported no sex difference in CB1 R expression in the lumbar dorsal horn of the spinal cord, but a dynamic distribution within superficial laminae II and III in female mice between estrus and nonestrus phases. Furthermore, the cell-type-specific CB1 R expression pattern in the dorsal horn was similar in both sexes. Over 50% of CB1 RGFP cells were GABAergic neurons, and approximately 25% were glycinergic and 20-30% were glutamatergic neurons. The CB1 R-expressing cells also represented a subset of spinal projection neurons. Overall, our work indicates a highly consistent distribution pattern of CB1 RGFP cells in the dorsal horn of lumbar spinal cord in males and females.
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Affiliation(s)
- Yulin Zhang
- Shenzhen Key Lab of Translational Research for Brain Diseases, Shenzhen Key Lab of Drug Addiction, Guangdong Provincial Key Laboratory of Brain Connectome and Behavior, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.,College of Life Sciences, University of Chinese Academy of Sciences, Beijing, China
| | - Jin Ke
- Shenzhen Key Lab of Translational Research for Brain Diseases, Shenzhen Key Lab of Drug Addiction, Guangdong Provincial Key Laboratory of Brain Connectome and Behavior, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.,College of Life Sciences, University of Chinese Academy of Sciences, Beijing, China
| | - Yuan Zhou
- Shenzhen Key Lab of Translational Research for Brain Diseases, Shenzhen Key Lab of Drug Addiction, Guangdong Provincial Key Laboratory of Brain Connectome and Behavior, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.,College of Life Sciences, University of Chinese Academy of Sciences, Beijing, China
| | - Xue Liu
- Shenzhen Key Lab of Translational Research for Brain Diseases, Shenzhen Key Lab of Drug Addiction, Guangdong Provincial Key Laboratory of Brain Connectome and Behavior, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.,College of Life Sciences, University of Chinese Academy of Sciences, Beijing, China
| | - Tianwen Huang
- Shenzhen Key Lab of Translational Research for Brain Diseases, Shenzhen Key Lab of Drug Addiction, Guangdong Provincial Key Laboratory of Brain Connectome and Behavior, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Feng Wang
- Shenzhen Key Lab of Translational Research for Brain Diseases, Shenzhen Key Lab of Drug Addiction, Guangdong Provincial Key Laboratory of Brain Connectome and Behavior, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
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46
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Arnaud A, Bonthapally V. Zuranolone provides a rapid response without chronic dosing: Response to correspondence by ten Doesschate et al. J Affect Disord 2022; 301:445-447. [PMID: 35032505 DOI: 10.1016/j.jad.2022.01.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/19/2021] [Accepted: 01/11/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Alix Arnaud
- Sage Therapeutics Inc., 215 First St, Cambridge, MA 02142, United States
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47
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Rupprecht R, Rupprecht C, Di Benedetto B, Rammes G. Neuroinflammation and psychiatric disorders: Relevance of C1q, translocator protein (18 kDa) (TSPO), and neurosteroids. World J Biol Psychiatry 2022; 23:257-263. [PMID: 34320915 DOI: 10.1080/15622975.2021.1961503] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
There is increasing evidence that neuroinflammatory processes may play a role in the pathophysiology of psychiatric disorders. Recently, the complement protein C1q and the translocator protein (18 kDa) (TSPO) have attracted considerable interest in this context. C1q is a small molecule which is involved into synaptic pruning mechanisms, increases during ageing and may contribute to neurodegenerative disorders. TSPO is a transmembrane channel protein and mediates numerous biological functions such as bioenergetics and steroid synthesis. Meanwhile, there is evidence that both C1q and TSPO may be elevated in psychiatric disorders, e.g. major depression. Moreover, preclinical and first clinical studies suggest that TSPO ligands may exert antidepressant and anxiolytic properties by promoting endogenous neurosteroid synthesis. In addition, certain neurosteroids, e.g. allopregnanolone, are potent positive allosteric modulators of GABAA receptors and their composition is altered in depression and anxiety disorders. Recently, neurosteroid compounds such as brexanolone or zuranolone have been reported to reduce depressive and anxiety symptoms in postpartum depression and major depressive disorder. In conclusion, compounds enhancing GABAergic neurotransmission such as neurosteroids and TSPO ligands, which also may exert anti-inflammatory properties in concert with immunomodulators such as C1q may open new avenues for the treatment of psychiatric disorders.
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Affiliation(s)
- Rainer Rupprecht
- Department of Psychiatry and Psychotherapy, University Regensburg, Regensburg, Germany
| | - Christian Rupprecht
- Experimental Neuropharmacology, Department of Anesthesiology, Technische Universität München, Munich, Germany
| | - Barbara Di Benedetto
- Department of Psychiatry and Psychotherapy, University Regensburg, Regensburg, Germany
| | - Gerhard Rammes
- Experimental Neuropharmacology, Department of Anesthesiology, Technische Universität München, Munich, Germany
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48
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Gunduz‐Bruce H, Takahashi K, Huang M. Development of neuroactive steroids for the treatment of postpartum depression. J Neuroendocrinol 2022; 34:e13019. [PMID: 34462985 PMCID: PMC9285576 DOI: 10.1111/jne.13019] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/22/2021] [Accepted: 07/25/2021] [Indexed: 01/25/2023]
Abstract
Postpartum depression (PPD) is a common major depressive episode surrounding childbirth, with estimated rates ranging from 5.5% to 23.5% of all live births across Europe and the USA based on the presence of key symptoms. PPD has been associated with significant impairments in both maternal functioning and mother-infant attachment, and these impairments can have lasting effects on the emotional and cognitive development of children. Although the precise pathophysiology of PPD is unknown, preclinical findings suggest that large fluctuations in neurosteroid hormone levels can induce physiological plasticity in the expression of functional GABAA receptors during pregnancy and the postpartum period, and that deficits in this plasticity may underpin a biological mechanism that contributes to the manifestation of depressive symptoms. Here, we review the controlled clinical trials to date that have assessed the efficacy of pharmacological treatments for PPD, including oestradiol, selective serotonin reuptake inhibitors, brexanolone (an iv formulation of allopregnanolone) and an investigational neuroactive steroid and GABAA positive allosteric modulator, zuranolone. Coupled with the GABAergic deficits implicated in major depressive disorder, these findings highlight not only the potential role of GABAA receptor plasticity in the pathophysiology of PPD, but also the novel therapeutic approach of using positive allosteric modulators targeting GABAergic transmission to treat women affected by PPD.
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49
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Manzella FM, Covey DF, Jevtovic-Todorovic V, Todorovic SM. Synthetic neuroactive steroids as new sedatives and anaesthetics: Back to the future. J Neuroendocrinol 2022; 34:e13086. [PMID: 35014105 PMCID: PMC8866223 DOI: 10.1111/jne.13086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 12/03/2021] [Accepted: 12/22/2021] [Indexed: 02/03/2023]
Abstract
Since the 1990s, there has been waning interest in researching general anaesthetics (anaesthetics). Although currently used anaesthetics are mostly safe and effective, they are not without fault. In paediatric populations and neonatal animal models, they are associated with learning impairments and neurotoxicity. In an effort to research safer anaesthetics, we have gone back to re-examine neuroactive steroids as anaesthetics. Neuroactive steroids are steroids that have direct, local effects in the central nervous system. Since the discovery of their anaesthetic effects, neuroactive steroids have been consistently used in human or veterinary clinics as preferred anaesthetic agents. Although briefly abandoned for clinical use due to unwanted vehicle side effects, there has since been renewed interest in their therapeutic value. Neuroactive steroids are safe sedative/hypnotic and anaesthetic agents across various animal species. Importantly, unlike traditional anaesthetics, they do not cause extensive neurotoxicity in the developing rodent brain. Similar to traditional anaesthetics, neuroactive steroids are modulators of synaptic and extrasynaptic γ-aminobutyric acid type A (GABAA ) receptors and their interactions at the GABAA receptor are stereo- and enantioselective. Recent work has also shown that these agents act on other ion channels, such as high- and low-voltage-activated calcium channels. Through these mechanisms of action, neuroactive steroids modulate neuronal excitability, which results in characteristic burst suppression of the electroencephalogram, and a surgical plane of anaesthesia. However, in addition to their interactions with voltage and ligand gated ions channels, neuroactive steroids interact with membrane bound metabotropic receptors and xenobiotic receptors to facilitate signaling of prosurvival, antiapoptotic pathways. These pathways play a role in their neuroprotective effects in neuronal injury and may also prevent extensive apoptosis in the developing brain during anaesthesia. The current review explores the history of neuroactive steroids as anaesthetics in humans and animal models, their diverse mechanisms of action, and their neuroprotective properties.
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Affiliation(s)
- Francesca M Manzella
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Neuroscience Graduate Program, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Douglas F Covey
- Department of Developmental Biology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
- Taylor Family Institute for Innovative Psychiatric Research, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Vesna Jevtovic-Todorovic
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Slobodan M Todorovic
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Neuroscience Graduate Program, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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50
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Belelli D, Phillips GD, Atack JR, Lambert JJ. Relating neurosteroid modulation of inhibitory neurotransmission to behaviour. J Neuroendocrinol 2022; 34:e13045. [PMID: 34644812 DOI: 10.1111/jne.13045] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/24/2021] [Accepted: 09/15/2021] [Indexed: 12/11/2022]
Abstract
Studies in the 1980s revealed endogenous metabolites of progesterone and deoxycorticosterone to be potent, efficacious, positive allosteric modulators (PAMs) of the GABAA receptor (GABAA R). The discovery that such steroids are locally synthesised in the central nervous system (CNS) promoted the thesis that neural inhibition in the CNS may be "fine-tuned" by these neurosteroids to influence behaviour. In preclinical studies, these neurosteroids exhibited anxiolytic, anticonvulsant, analgesic and sedative properties and, at relatively high doses, induced a state of general anaesthesia, a profile consistent with their interaction with GABAA Rs. However, realising the therapeutic potential of either endogenous neurosteroids or synthetic "neuroactive" steroids has proven challenging. Recent approval by the Food and Drug Administration of the use of allopregnanolone (brexanolone) to treat postpartum depression has rekindled enthusiasm for exploring their potential as new medicines. Although neurosteroids are selective for GABAA Rs, they exhibit little or no selectivity across the many GABAA R subtypes. Nevertheless, a relatively minor population of receptors incorporating the δ-subunit (δ-GABAA Rs) appears to be an important contributor to their behavioural effects. Here, we consider how neurosteroids acting upon GABAA Rs influence neuronal signalling, as well as how such effects may acutely and persistently influence behaviour, and explore the case for developing selective PAMs of δ-GABAA R subtypes for the treatment of psychiatric disorders.
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Affiliation(s)
- Delia Belelli
- Neuroscience, Division of Systems Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Grant D Phillips
- Neuroscience, Division of Systems Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - John R Atack
- Medicines Discovery Institute, Cardiff University, Cardiff, UK
| | - Jeremy J Lambert
- Neuroscience, Division of Systems Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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