Brexpiprazole

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Brexpiprazole
Brexpiprazole.svg
Brexpiprazole molecule ball.png
Clinical data
Pronunciation /brɛkˈspɪprəzoʊl/ brek-SPIP-rə-zohl
Trade names Rexulti, Rxulti, others
Other namesOPC-34712
AHFS/Drugs.com Monograph
MedlinePlus a615046
License data
Pregnancy
category
Routes of
administration 		By mouth
Drug class Atypical antipsychotic
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability 95% (Tmax = 4 hours) [11]
Protein binding >99%
Metabolism Liver (mainly mediated by CYP3A4 and CYP2D6)
Elimination half-life 91 hours (brexpiprazole), 86 hours (major metabolite)
Excretion Feces (46%), urine (25%)
Identifiers
  • 7-[4-[4-(1-benzothiophen-4-yl)piperazin-1-yl]butoxy]quinolin-2(1H)-one
CAS Number
PubChem CID
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard 100.242.305 OOjs UI icon edit-ltr-progressive.svg
Chemical and physical data
Formula C25H27N3O2S
Molar mass 433.57 g·mol−1
3D model (JSmol)
  • O=C5/C=C\c4ccc(OCCCCN3CCN(c1cccc2sccc12)CC3)cc4N5
  • InChI=1S/C25H27N3O2S/c29-25-9-7-19-6-8-20(18-22(19)26-25)30-16-2-1-11-27-12-14-28(15-13-27)23-4-3-5-24-21(23)10-17-31-24/h3-10,17-18H,1-2,11-16H2,(H,26,29)
  • Key:ZKIAIYBUSXZPLP-UHFFFAOYSA-N

Brexpiprazole, sold under the brand name Rexulti among others, is an atypical antipsychotic medication used for the treatment of major depressive disorder, schizophrenia, and agitation associated with dementia due to Alzheimer's disease. [11] [13] [14]

Contents

The most common side effects include akathisia (a constant urge to move) and weight gain. [12] The most common side effects among people with agitation associated with dementia due to Alzheimer's disease include headache, dizziness, urinary tract infection, nasopharyngitis, and sleep disturbances (both somnolence and insomnia). [13]

Brexpiprazole was developed by Otsuka and Lundbeck, and is considered to be a successor to aripiprazole (Abilify). [15] It was approved for medical use in the United States in July 2015. [16] [17] A generic version was approved in August 2022. [18] Brexpiprazole is the first treatment approved by the US Food and Drug Administration (FDA) for agitation associated with dementia due to Alzheimer's disease. [13]

Medical uses

Rexuti.png
brexpiprazole blister pack Brexpiprazole001.png
brexpiprazole blister pack

In the United States and Canada, brexpiprazole is indicated as an adjunctive therapy to antidepressants for the treatment of major depressive disorder and for the treatment of schizophrenia. [7] [11] [19] [20] In May 2023, the indication for brexpiprazole was expanded in the US to include the treatment of agitation associated with dementia due to Alzheimer's disease. [13]

In Australia and the European Union, brexpiprazole is indicated for the treatment of schizophrenia. [2] [12]

In 2020, it was approved in Brazil only as an adjunctive to the treatment of major depressive disorder. [21] [22]

Side effects

The most common adverse events associated with brexpiprazole (all doses of brexpiprazole cumulatively greater than or equal to 5% vs. placebo) were upper respiratory tract infection (6.9% vs. 4.8%), akathisia (6.6% vs. 3.2%), weight gain (6.3% vs. 0.8%), and nasopharyngitis (5.0% vs. 1.6%). [23] Brexpiprazole can cause impulse control disorders. [24]

Pharmacology

Pharmacodynamics

Brexpiprazole [25] [26] [27] [28]
SiteHuman Ki (nM)IA (%)ActionRef
SERT Tooltip Serotonin transporter65% at 10 μMBlocker [26]
NET Tooltip Norepinephrine transporter0% at 10 μMBlocker [26]
DAT Tooltip Dopamine transporter90% at 10 μMBlocker [26]
5-HT1A 0.12~60%Partial agonist [26]
5-HT1B 32ND [26]
5-HT2A 0.47Antagonist [26]
5-HT2B 1.9Antagonist [26]
5-HT2C 34Antagonist [26]
5-HT5A 140ND [26]
5-HT6 58Antagonist [26]
5-HT7 3.7Antagonist [26]
D1 160ND [26]
D2L 0.30~45%Partial agonist [26]
D3 1.1~15%Partial agonist [26]
D4 6.3ND [26]
D5 NDNDND
α1A 3.8Antagonist [26]
α1B 0.17Antagonist [26]
α1D 2.6Antagonist [26]
α2A 15Antagonist [26]
α2B 17Antagonist [26]
α2C 0.59Antagonist [26]
β1 59Antagonist [26]
β2 67Antagonist [26]
β3 >10,000ND [26]
H1 19Antagonist [26]
H2 >10,000ND [26]
H3 >10,000ND [26]
mACh Tooltip Muscarinic acetylcholine receptor52% at 10 μMND [26]
   M1 67% at 10 μMND [26]
   M2 >10,000ND [26]
σ 96% at 10 μMND [26]
Values are Ki (nM). The smaller the value, the more strongly the drug binds to the site. Most or all data are for human cloned proteins.

IA = Intrinsic Activity

Brexpiprazole acts as a partial agonist of the serotonin 5-HT1A receptor and the dopamine D2 and D3 receptors. [26] Partial agonists have both blocking properties and stimulating properties at the receptor they bind to. The ratio of blocking activity to stimulating activity determines a portion of its clinical effects. Brexpiprazole has more blocking and less stimulating activity at the dopamine receptors than its predecessor, aripiprazole, which may decrease its risk for agitation and restlessness. [26] Specifically, where aripiprazole has an intrinsic activity or agonist effect at the D2 receptor of 60%+, brexpiprazole has an intrinsic activity at the same receptor of about 45%. For aripiprazole, this means more dopamine receptor activation at lower doses, with blockade being reached at higher doses, while brexpiprazole has the inverse effect because a partial agonist competes with dopamine. [29] [30] [31] [32] Brexpiprazole has a high affinity for the 5-HT1A receptor, acting as a potent antagonist at 5-HT2A receptors, and a potent partial agonist at dopamine D2 receptors with lower intrinsic activity compared to aripiprazole. [33] In vivo characterization of brexpiprazole shows that it may act as a near-full agonist of the 5-HT1A receptor. This may further underlie a lower potential than aripiprazole to cause treatment-emergent, movement-related disorders such as akathisia due to the downstream dopamine release that is triggered by 5-HT1A receptor agonism. It is also an antagonist of the serotonin 5-HT2A, 5-HT2B, and 5-HT7 receptors, which may contribute to antidepressant effect. It also binds to and blocks the α1A-, α1B-, α1D-, and α2C-adrenergic receptors. [26] The drug has negligible affinity for the muscarinic acetylcholine receptors, and hence has no anticholinergic effects. [26] Although brexpiprazole has less affinity for H1 compared to aripiprazole, weight gain can occur. [34]

History

Clinical trials

Brexpiprazole was in clinical trials for adjunctive treatment of major depressive disorder, adult attention deficit hyperactivity disorder, bipolar disorder, [35] schizophrenia, [36] and agitation associated with dementia due to Alzheimer's disease. [13]

Major depressive disorder

Phase II

The phase II multicenter, double-blind, placebo-controlled study randomized 429 adult MDD patients who exhibited an inadequate response to one to three approved antidepressant treatments (ADTs) in the current episode. The study was designed to assess the efficacy and safety of brexpiprazole as an adjunctive treatment to standard antidepressant treatment. The antidepressants included in the study were desvenlafaxine, escitalopram, fluoxetine, paroxetine, sertraline, and venlafaxine. [37]

Phase III

A phase III study was in the recruiting stage: "Study of the Safety and Efficacy of Two Fixed Doses of OPC-34712 as Adjunctive Therapy in the Treatment of Adults With Major Depressive Disorder (the Polaris Trial)". [38] Its goal is "to compare the effect of brexpiprazole to the effect of placebo (an inactive substance) as add on treatment to an assigned FDA approved antidepressant treatment (ADT) in patients with major depressive disorder who demonstrate an incomplete response to a prospective trial of the same assigned FDA approved ADT". Estimated enrollment was 1250 volunteers.

Adult attention deficit hyperactivity disorder

  • Attention Deficit/Hyperactivity Disorder (STEP-A) [39]

Schizophrenia

Phase I
  • Trial to Evaluate the Effects of OPC-34712 (brexpiprazole) on QT/QTc in Subjects With Schizophrenia or Schizoaffective Disorder [40]
Phase II
  • A Dose-finding Trial of OPC-34712 in Patients With Schizophrenia [41]
Phase III
  • Efficacy Study of OPC-34712 in Adults With Acute Schizophrenia (BEACON) [42] [43]
  • Study of the Effectiveness of Three Different Doses of OPC-34712 in the Treatment of Adults With Acute Schizophrenia (VECTOR) [44]
  • A Long-term Trial of OPC-34712 in Patients With Schizophrenia [45]

Agitation associated with dementia due to Alzheimer's disease

The effectiveness of brexpiprazole for the treatment of agitation associated with dementia due to Alzheimer's disease was determined through two 12-week, randomized, double-blind, placebo-controlled, fixed-dose studies. [13] In these studies, participants were required to have a probable diagnosis of Alzheimer's dementia; have a score between 5 and 22 on the Mini-Mental State Examination, a test that detects whether a person is experiencing cognitive impairment; and exhibit the type, frequency, and severity of agitation behaviors that require medication. [13] Trial participants ranged between 51 and 90 years of age. [13]

Society and culture

In January 2018, it was approved for the treatment of schizophrenia in Japan. [46]

Economics

In November 2011, Otsuka Pharmaceutical and Lundbeck announced a global alliance. [47]

Patents

Research

Brexpiprazole was under development for the treatment of attention deficit hyperactivity disorder (ADHD) as an adjunct to stimulants, but was discontinued for this indication. [49] [50] [51] It reached phase II clinical trials for this use prior to discontinuation. [51]

Brexpiprazole has shown promise in clinical trials for the treatment of borderline personality disorder. [52]

Related Research Articles

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References

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  33. ↑ Kikuchi T, Maeda K, Suzuki M, Hirose T, Futamura T, McQuade RD (June 2021). "Discovery research and development history of the dopamine D2 receptor partial agonists, aripiprazole and brexpiprazole". Neuropsychopharmacology Reports. 41 (2): 134–143. doi:10.1002/npr2.12180. PMC   8340839 . PMID   33960741.
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  35. ↑ "Otsuka, Lundbeck initiate phase 3 trials of Rexulti for bipolar I disorder". www.healio.com. Retrieved 16 October 2017.
  36. ↑ "OPC-34712 search results" . Retrieved 10 February 2012.
  37. ↑ Clinical trial number NCT00797966 for "Study of the Safety and Efficacy of OPC-34712 as Adjunctive Therapy in the Treatment of Patients With Major Depressive Disorder" at ClinicalTrials.gov
  38. ↑ Clinical trial number NCT01360632 for "Study of the Safety and Efficacy of Two Fixed Doses of OPC-34712 as Adjunctive Therapy in the Treatment of Adults With Major Depressive Disorder (the Polaris Trial)" at ClinicalTrials.gov
  39. ↑ Clinical trial number NCT01074294 for "Study of the Safety and Efficacy of OPC-34712 as a Complementary Therapy in the Treatment of Adult Attention Deficit/Hyperactivity Disorder (STEP-A)" at ClinicalTrials.gov
  40. ↑ Clinical trial number NCT01423916 for "Trial to Evaluate the Effects of OPC-34712 on QT/QTc in Subjects With Schizophrenia or Schizoaffective Disorder" at ClinicalTrials.gov
  41. ↑ Clinical trial number NCT01451164 for "A Dose-finding Trial of OPC-34712 in Patients With Schizophrenia" at ClinicalTrials.gov
  42. ↑ Clinical trial number NCT01393613 for "Efficacy Study of OPC-34712 in Adults With Acute Schizophrenia (BEACON)" at ClinicalTrials.gov
  43. ↑ Clinical trial number NCT01397786 for "Safety and Tolerability Study of Oral OPC-34712 as Maintenance Treatment in Adults With Schizophrenia (ZENITH)" at ClinicalTrials.gov
  44. ↑ Clinical trial number NCT01396421 for "Study of the Effectiveness of Three Different Doses of OPC-34712 in the Treatment of Adults With Acute Schizophrenia (VECTOR)" at ClinicalTrials.gov
  45. ↑ Clinical trial number NCT01456897 for "A Long-term Trial of OPC-34712 in Patients With Schizophrenia" at ClinicalTrials.gov
  46. ↑ "Otsuka Receives Approval in Japan for the Manufacture and Sale of New Antipsychotic Drug Rexulti Tablets for Schizophrenia｜News Releases". Otsuka Pharmaceutical Co., Ltd. Retrieved 4 October 2018.
  47. ↑ "Lundbeck and Otsuka Pharmaceutical sign historic agreement to deliver innovative medicines targeting psychiatric disorders worldwide". Lundbeck. Archived from the original on 1 April 2012. Retrieved 10 February 2012.
  48. ↑ "Canadian Patents Database 2620688" . Retrieved 16 February 2012.
  49. ↑ "Brexpiprazole - Lundbeck/Otsuka". AdisInsight. Springer Nature Switzerland AG.
  50. ↑ Howland RH (April 2015). "Brexpiprazole: another multipurpose antipsychotic drug?". Journal of Psychosocial Nursing and Mental Health Services. 53 (4): 23–25. doi:10.3928/02793695-20150323-01. PMID   25856810.
  51. 1 2 Clinical trial number NCT01074294 for "A Phase 2, Multicenter, Randomized, Double-blind, Placebo Controlled Study of the Safety and Efficacy of OPC-34712 as Adjunctive Therapy in the Treatment of Adult Attention Deficit/Hyperactivity Disorder" at ClinicalTrials.gov
  52. ↑ Grant JE, Valle S, Chesivoir E, Ehsan D, Chamberlain SR (November 2021). "A double-blind placebo-controlled study of brexpiprazole for the treatment of borderline personality disorder". The British Journal of Psychiatry. 220 (2): 58–63. doi:10.1192/bjp.2021.159. PMC   7612273 . PMID   35049469.
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