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Lobo MC, Whitehurst TS, Kaar SJ, Howes OD. New and emerging treatments for schizophrenia: a narrative review of their pharmacology, efficacy and side effect profile relative to established antipsychotics. Neurosci Biobehav Rev 2022; 132:324-361. [PMID: 34838528 DOI: 10.1016/j.neubiorev.2021.11.032] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/13/2021] [Accepted: 11/21/2021] [Indexed: 01/07/2023]
Abstract
Schizophrenia is associated with substantial unmet needs, highlighting the necessity for new treatments. This narrative review compares the pharmacology, clinical trial data and tolerability of novel medications to representative antipsychotics. Cariprazine, brexpiprazole and brilaroxazine are partial dopamine agonists effective in acute relapse. Lumateperone (serotonin and dopamine receptor antagonist) additionally benefits asocial and depressive symptoms. F17464 (D3 antagonist and 5-HT1A partial agonist) has one positive phase II study. Lu AF35700 (dopamine and serotonin receptor antagonist) was tested in treatment-resistance with no positive results. Pimavanserin, roluperidone, ulotaront and xanomeline do not act directly on the D2 receptor at clinical doses. Initial studies indicate pimavanserin and roluperidone improve negative symptoms. Ulotaront and xanomeline showed efficacy for positive and negative symptoms of schizophrenia in phase II trials. BI 409306, BI 425809 and MK-8189 target glutamatergic dysfunction in schizophrenia, though of these only BI 425809 showed efficacy. These medications largely have favourable cardiometabolic side-effect profiles. Overall, the novel pharmacology, clinical trial and tolerability data indicate these compounds are promising new additions to the therapeutic arsenal.
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Affiliation(s)
- Maria C Lobo
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; MRC London Institute of Medical Sciences, Hammersmith Hospital, London, UK; Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, UK; South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, UK.
| | - Thomas S Whitehurst
- MRC London Institute of Medical Sciences, Hammersmith Hospital, London, UK; Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, UK.
| | - Stephen J Kaar
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, UK.
| | - Oliver D Howes
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, UK; South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, UK; H. Lundbeck UK, Ottiliavej 9, 2500, Valby, Denmark.
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Scarborough J, Mattei D, Dorner-Ciossek C, Sand M, Arban R, Rosenbrock H, Richetto J, Meyer U. Symptomatic and preventive effects of the novel phosphodiesterase-9 inhibitor BI 409306 in an immune-mediated model of neurodevelopmental disorders. Neuropsychopharmacology 2021; 46:1526-1534. [PMID: 33941860 PMCID: PMC8209175 DOI: 10.1038/s41386-021-01016-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/23/2021] [Accepted: 04/08/2021] [Indexed: 02/03/2023]
Abstract
BI 409306, a phosphodiesterase-9 inhibitor under development for treatment of schizophrenia and attenuated psychosis syndrome (APS), promotes synaptic plasticity and cognition. Here, we explored the effects of BI 409306 treatment in the polyriboinosinic-polyribocytidilic acid (poly[I:C])-based mouse model of maternal immune activation (MIA), which is relevant to schizophrenia and APS. In Study 1, adult offspring received BI 409306 0.2, 0.5, or 1 mg/kg or vehicle to establish an active dose. In Study 2, adult offspring received BI 409306 1 mg/kg and/or risperidone 0.025 mg/kg, risperidone 0.05 mg/kg, or vehicle, to evaluate BI 409306 as add-on to standard therapy for schizophrenia. In Study 3, offspring received BI 409306 1 mg/kg during adolescence only, or continually into adulthood to evaluate preventive effects of BI 409306. We found that BI 409306 significantly mitigated MIA-induced social interaction deficits and amphetamine-induced hyperlocomotion, but not prepulse inhibition impairments, in a dose-dependent manner (Study 1). Furthermore, BI 409306 1 mg/kg alone or in combination with risperidone 0.025 mg/kg significantly reversed social interaction deficits and attenuated amphetamine-induced hyperlocomotion in MIA offspring (Study 2). Finally, we revealed that BI 409306 1 mg/kg treatment restricted to adolescence prevented adult deficits in social interaction, whereas continued treatment into adulthood also significantly reduced amphetamine-induced hyperlocomotion (Study 3). Taken together, our findings suggest that symptomatic treatment with BI 409306 can restore social interaction deficits and dopaminergic dysfunctions in a MIA model of neurodevelopmental disruption, lending preclinical support to current clinical trials of BI 409306 in patients with schizophrenia. Moreover, BI 409306 given during adolescence has preventive effects on adult social interaction deficits in this model, supporting its use in people with APS.
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Affiliation(s)
- Joseph Scarborough
- Institute of Pharmacology and Toxicology, University of Zürich-Vetsuisse, Zürich, Switzerland
| | - Daniele Mattei
- Institute of Pharmacology and Toxicology, University of Zürich-Vetsuisse, Zürich, Switzerland
| | - Cornelia Dorner-Ciossek
- Department of CNS Discovery Research, Boehringer Ingelheim Pharma GmbH & Co KG, Biberach an der Riss, Germany
| | - Michael Sand
- Department of Medicine, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - Roberto Arban
- Department of CNS Discovery Research, Boehringer Ingelheim Pharma GmbH & Co KG, Biberach an der Riss, Germany
| | - Holger Rosenbrock
- Department of CNS Discovery Research, Boehringer Ingelheim Pharma GmbH & Co KG, Biberach an der Riss, Germany
| | - Juliet Richetto
- Institute of Pharmacology and Toxicology, University of Zürich-Vetsuisse, Zürich, Switzerland
- Neuroscience Center Zürich, University of Zürich and ETH Zürich, Zürich, Switzerland
| | - Urs Meyer
- Institute of Pharmacology and Toxicology, University of Zürich-Vetsuisse, Zürich, Switzerland.
- Neuroscience Center Zürich, University of Zürich and ETH Zürich, Zürich, Switzerland.
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Ceraso A, Lin JJ, Schneider-Thoma J, Siafis S, Tardy M, Komossa K, Heres S, Kissling W, Davis JM, Leucht S. Maintenance treatment with antipsychotic drugs for schizophrenia. Cochrane Database Syst Rev 2020; 8:CD008016. [PMID: 32840872 PMCID: PMC9702459 DOI: 10.1002/14651858.cd008016.pub3] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The symptoms and signs of schizophrenia have been linked to high levels of dopamine in specific areas of the brain (limbic system). Antipsychotic drugs block the transmission of dopamine in the brain and reduce the acute symptoms of the disorder. An original version of the current review, published in 2012, examined whether antipsychotic drugs are also effective for relapse prevention. This is the updated version of the aforesaid review. OBJECTIVES To review the effects of maintaining antipsychotic drugs for people with schizophrenia compared to withdrawing these agents. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials including the registries of clinical trials (12 November 2008, 10 October 2017, 3 July 2018, 11 September 2019). SELECTION CRITERIA We included all randomised trials comparing maintenance treatment with antipsychotic drugs and placebo for people with schizophrenia or schizophrenia-like psychoses. DATA COLLECTION AND ANALYSIS We extracted data independently. For dichotomous data we calculated risk ratios (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated mean differences (MD) or standardised mean differences (SMD), again based on a random-effects model. MAIN RESULTS The review currently includes 75 randomised controlled trials (RCTs) involving 9145 participants comparing antipsychotic medication with placebo. The trials were published from 1959 to 2017 and their size ranged between 14 and 420 participants. In many studies the methods of randomisation, allocation and blinding were poorly reported. However, restricting the analysis to studies at low risk of bias gave similar results. Although this and other potential sources of bias limited the overall quality, the efficacy of antipsychotic drugs for maintenance treatment in schizophrenia was clear. Antipsychotic drugs were more effective than placebo in preventing relapse at seven to 12 months (primary outcome; drug 24% versus placebo 61%, 30 RCTs, n = 4249, RR 0.38, 95% CI 0.32 to 0.45, number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 3; high-certainty evidence). Hospitalisation was also reduced, however, the baseline risk was lower (drug 7% versus placebo 18%, 21 RCTs, n = 3558, RR 0.43, 95% CI 0.32 to 0.57, NNTB 8, 95% CI 6 to 14; high-certainty evidence). More participants in the placebo group than in the antipsychotic drug group left the studies early due to any reason (at seven to 12 months: drug 36% versus placebo 62%, 24 RCTs, n = 3951, RR 0.56, 95% CI 0.48 to 0.65, NNTB 4, 95% CI 3 to 5; high-certainty evidence) and due to inefficacy of treatment (at seven to 12 months: drug 18% versus placebo 46%, 24 RCTs, n = 3951, RR 0.37, 95% CI 0.31 to 0.44, NNTB 3, 95% CI 3 to 4). Quality of life might be better in drug-treated participants (7 RCTs, n = 1573 SMD -0.32, 95% CI to -0.57 to -0.07; low-certainty evidence); probably the same for social functioning (15 RCTs, n = 3588, SMD -0.43, 95% CI -0.53 to -0.34; moderate-certainty evidence). Underpowered data revealed no evidence of a difference between groups for the outcome 'Death due to suicide' (drug 0.04% versus placebo 0.1%, 19 RCTs, n = 4634, RR 0.60, 95% CI 0.12 to 2.97,low-certainty evidence) and for the number of participants in employment (at 9 to 15 months, drug 39% versus placebo 34%, 3 RCTs, n = 593, RR 1.08, 95% CI 0.82 to 1.41, low certainty evidence). Antipsychotic drugs (as a group and irrespective of duration) were associated with more participants experiencing movement disorders (e.g. at least one movement disorder: drug 14% versus placebo 8%, 29 RCTs, n = 5276, RR 1.52, 95% CI 1.25 to 1.85, number needed to treat for an additional harmful outcome (NNTH) 20, 95% CI 14 to 50), sedation (drug 8% versus placebo 5%, 18 RCTs, n = 4078, RR 1.52, 95% CI 1.24 to 1.86, NNTH 50, 95% CI not significant), and weight gain (drug 9% versus placebo 6%, 19 RCTs, n = 4767, RR 1.69, 95% CI 1.21 to 2.35, NNTH 25, 95% CI 20 to 50). AUTHORS' CONCLUSIONS For people with schizophrenia, the evidence suggests that maintenance on antipsychotic drugs prevents relapse to a much greater extent than placebo for approximately up to two years of follow-up. This effect must be weighed against the adverse effects of antipsychotic drugs. Future studies should better clarify the long-term morbidity and mortality associated with these drugs.
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Affiliation(s)
- Anna Ceraso
- Department of Clinical and Experimental Sciences, Section of Psychiatry, University of Brescia, Brescia, Italy
| | - Jessie Jingxia Lin
- School of Nursing, The University of Hong Kong, Hong Kong SAR, Hong Kong
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Magdolna Tardy
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Technische Universität München Klinikum rechts der Isar, München, Germany
| | - Katja Komossa
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
| | | | - Werner Kissling
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - John M Davis
- Maryland Psychiatric Research Center, Baltimore, MD, USA
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Munich, Germany
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Rosenbrock H, Giovannini R, Schänzle G, Koros E, Runge F, Fuchs H, Marti A, Reymann KG, Schröder UH, Fedele E, Dorner-Ciossek C. The Novel Phosphodiesterase 9A Inhibitor BI 409306 Increases Cyclic Guanosine Monophosphate Levels in the Brain, Promotes Synaptic Plasticity, and Enhances Memory Function in Rodents. J Pharmacol Exp Ther 2019; 371:633-641. [PMID: 31578258 DOI: 10.1124/jpet.119.260059] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 09/25/2019] [Indexed: 12/15/2022] Open
Abstract
N-methyl-d-aspartate (NMDA) receptor-dependent long-term potentiation (LTP) is an established cellular model underlying learning and memory, and involves intracellular signaling mediated by the second messenger cyclic guanosine monophosphate (cGMP). As phosphodiesterase (PDE)9A selectively hydrolyses cGMP in areas of the brain related to cognition, PDE9A inhibitors may improve cognitive function by enhancing NMDA receptor-dependent LTP. This study aimed to pharmacologically characterize BI 409306, a novel PDE9A inhibitor, using in vitro assays and in vivo determination of cGMP levels in the brain. Further, the effects of BI 409306 on synaptic plasticity evaluated by LTP in ex vivo hippocampal slices and on cognitive performance in rodents were also investigated. In vitro assays demonstrated that BI 409306 is a potent and selective inhibitor of human and rat PDE9A with mean concentrations at half-maximal inhibition (IC50) of 65 and 168 nM. BI 409306 increased cGMP levels in rat prefrontal cortex and cerebrospinal fluid and attenuated a reduction in mouse striatum cGMP induced by the NMDA-receptor antagonist MK-801. In ex vivo rat brain slices, BI 409306 enhanced LTP induced by both weak and strong tetanic stimulation. Treatment of mice with BI 409306 reversed MK-801-induced working memory deficits in a T-maze spontaneous-alternation task and improved long-term memory in an object recognition task. These findings suggest that BI 409306 is a potent and selective inhibitor of PDE9A. BI 409306 shows target engagement by increasing cGMP levels in brain, facilitates synaptic plasticity as demonstrated by enhancement of hippocampal LTP, and improves episodic and working memory function in rodents. SIGNIFICANCE STATEMENT: This preclinical study demonstrates that BI 409306 is a potent and selective PDE9A inhibitor in rodents. Treatment with BI 409306 increased brain cGMP levels, promoted long-term potentiation, and improved episodic and working memory performance in rodents. These findings support a role for PDE9A in synaptic plasticity and cognition. The potential benefits of BI 409306 are currently being investigated in clinical trials.
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Affiliation(s)
- Holger Rosenbrock
- Boehringer Ingelheim International GmbH, Biberach an der Riss, Germany (H.R., R.G., G.S., E.K., F.R., H.F., A.M., C.D.-C.); Leibniz Institute for Neurobiology, Magdeburg, Germany (K.G.R., U.H.S.); and Department of Pharmacy, Centre of Excellence for Biomedical Research, University of Genova, Genova, Italy (E.F.)
| | - Riccardo Giovannini
- Boehringer Ingelheim International GmbH, Biberach an der Riss, Germany (H.R., R.G., G.S., E.K., F.R., H.F., A.M., C.D.-C.); Leibniz Institute for Neurobiology, Magdeburg, Germany (K.G.R., U.H.S.); and Department of Pharmacy, Centre of Excellence for Biomedical Research, University of Genova, Genova, Italy (E.F.)
| | - Gerhard Schänzle
- Boehringer Ingelheim International GmbH, Biberach an der Riss, Germany (H.R., R.G., G.S., E.K., F.R., H.F., A.M., C.D.-C.); Leibniz Institute for Neurobiology, Magdeburg, Germany (K.G.R., U.H.S.); and Department of Pharmacy, Centre of Excellence for Biomedical Research, University of Genova, Genova, Italy (E.F.)
| | - Eliza Koros
- Boehringer Ingelheim International GmbH, Biberach an der Riss, Germany (H.R., R.G., G.S., E.K., F.R., H.F., A.M., C.D.-C.); Leibniz Institute for Neurobiology, Magdeburg, Germany (K.G.R., U.H.S.); and Department of Pharmacy, Centre of Excellence for Biomedical Research, University of Genova, Genova, Italy (E.F.)
| | - Frank Runge
- Boehringer Ingelheim International GmbH, Biberach an der Riss, Germany (H.R., R.G., G.S., E.K., F.R., H.F., A.M., C.D.-C.); Leibniz Institute for Neurobiology, Magdeburg, Germany (K.G.R., U.H.S.); and Department of Pharmacy, Centre of Excellence for Biomedical Research, University of Genova, Genova, Italy (E.F.)
| | - Holger Fuchs
- Boehringer Ingelheim International GmbH, Biberach an der Riss, Germany (H.R., R.G., G.S., E.K., F.R., H.F., A.M., C.D.-C.); Leibniz Institute for Neurobiology, Magdeburg, Germany (K.G.R., U.H.S.); and Department of Pharmacy, Centre of Excellence for Biomedical Research, University of Genova, Genova, Italy (E.F.)
| | - Anelise Marti
- Boehringer Ingelheim International GmbH, Biberach an der Riss, Germany (H.R., R.G., G.S., E.K., F.R., H.F., A.M., C.D.-C.); Leibniz Institute for Neurobiology, Magdeburg, Germany (K.G.R., U.H.S.); and Department of Pharmacy, Centre of Excellence for Biomedical Research, University of Genova, Genova, Italy (E.F.)
| | - Klaus G Reymann
- Boehringer Ingelheim International GmbH, Biberach an der Riss, Germany (H.R., R.G., G.S., E.K., F.R., H.F., A.M., C.D.-C.); Leibniz Institute for Neurobiology, Magdeburg, Germany (K.G.R., U.H.S.); and Department of Pharmacy, Centre of Excellence for Biomedical Research, University of Genova, Genova, Italy (E.F.)
| | - Ulrich H Schröder
- Boehringer Ingelheim International GmbH, Biberach an der Riss, Germany (H.R., R.G., G.S., E.K., F.R., H.F., A.M., C.D.-C.); Leibniz Institute for Neurobiology, Magdeburg, Germany (K.G.R., U.H.S.); and Department of Pharmacy, Centre of Excellence for Biomedical Research, University of Genova, Genova, Italy (E.F.)
| | - Ernesto Fedele
- Boehringer Ingelheim International GmbH, Biberach an der Riss, Germany (H.R., R.G., G.S., E.K., F.R., H.F., A.M., C.D.-C.); Leibniz Institute for Neurobiology, Magdeburg, Germany (K.G.R., U.H.S.); and Department of Pharmacy, Centre of Excellence for Biomedical Research, University of Genova, Genova, Italy (E.F.)
| | - Cornelia Dorner-Ciossek
- Boehringer Ingelheim International GmbH, Biberach an der Riss, Germany (H.R., R.G., G.S., E.K., F.R., H.F., A.M., C.D.-C.); Leibniz Institute for Neurobiology, Magdeburg, Germany (K.G.R., U.H.S.); and Department of Pharmacy, Centre of Excellence for Biomedical Research, University of Genova, Genova, Italy (E.F.)
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