Brexpiprazole

Brexpiprazole, sold under the brand name Rexulti, is an atypical antipsychotic. It is a dopamine D2 receptor partial agonist and has been described as a "serotonin–dopamine activity modulator" (SDAM). The drug received FDA approval on July 13, 2015 for the treatment of schizophrenia, and as an adjunctive treatment for depression.[2] It has been designed to provide improved efficacy and tolerability (e.g., less akathisia, restlessness and/or insomnia) over established adjunctive treatments for major depressive disorder (MDD).[3]

Brexpiprazole
Clinical data
Pronunciation/brɛkˈspɪprəzoʊl/ brek-SPIP-rə-zohl
/rɛkˈsʌlti/ rek-SUL-tee
Trade namesRexulti
Other namesOPC-34712
License data
Pregnancy
category
  • AU: C
    Routes of
    administration    		Oral (tablets)
    ATC code
    Legal status
    Legal status
    Pharmacokinetic data
    Bioavailability95% (Tmax = 4 hours)[1]
    Protein binding>99%
    MetabolismHepatic (mainly mediated by CYP3A4 and CYP2D6)
    Elimination half-life91 hours (brexpiprazole), 86 hours (major metabolite)
    ExcretionFeces (46%), urine (25%)
    Identifiers
    CAS Number
    PubChem CID
    ChemSpider
    UNII
    KEGG
    ChEMBL
    CompTox Dashboard (EPA)
    ECHA InfoCard100.242.305
    Chemical and physical data
    FormulaC25H27N3O2S
    Molar mass433.57 g·mol−1
    3D model (JSmol)

    The drug was developed by Otsuka and Lundbeck, and is considered to be a successor[4] of Otsuka's top-selling atypical antipsychotic aripiprazole (Abilify). Otsuka's U.S. patent on aripiprazole expired on October 20, 2014;[5] and a generic was approved in April, 2015.[6]

    Medical uses

    Brexpiprazole is used in the treatment of schizophrenia and as an adjunct for major depressive disorder.[7] In January 2018 it was approved[8] for the treatment of schizophrenia in Japan.

    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%).[9]

    Interactions

    Based on information given on the consent forms, it seems brexpiprazole is a substrate of CYP2D6 and CYP3A4, like its predecessor aripiprazole. Participants in the clinical trials are advised to avoid grapefruit, Seville oranges and related citruses.

    Pharmacology

    Pharmacodynamics
    See also: Atypical antipsychotic § Pharmacodynamics, and Antipsychotic § Comparison of medications
    Brexpiprazole[10][11]
    SiteKi (nM)ActionRef
    5-HT1A0.12Partial agonist[11]
    5-HT1B32ND[11]
    5-HT2A0.47Antagonist[11]
    5-HT2B1.9Antagonist[11]
    5-HT2C12–34Partial agonist[11]
    5-HT5A140ND[11]
    5-HT658Antagonist[11]
    5-HT73.7Antagonist[11]
    D1160ND[11]
    D2L0.30Partial agonist[11]
    D31.1Partial agonist[11]
    D46.3ND[11]
    D5NDNDND
    α1A3.8Antagonist[11]
    α1B0.17Antagonist[11]
    α1D2.6Antagonist[11]
    α2A15Antagonist[11]
    α2B17Antagonist[11]
    α2C0.59Antagonist[11]
    β159Antagonist[11]
    β267Antagonist[11]
    β3>10,000ND[11]
    H119Antagonist[11]
    H2>10,000ND[11]
    H3>10,000ND[11]
    mACh52% at 10 μMND[11]
      M167% at 10 μMND[11]
      M2>10,000ND[11]
    σ96% at 10 μMND[11]
    SERT65% at 10 μMBlocker[11]
    NET0% at 10 μMBlocker[11]
    DAT90% at 10 μMBlocker[11]
    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.

    Brexpiprazole acts as a partial agonist of the serotonin 5-HT1A receptor and the dopamine D2 and D3 receptors.[11] 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.[11] 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, whereas brexpiprazole is the opposite. By contrast, brexpiprazole has a much higher affinity for the 5-HT1A receptor than aripiprazole as well as a much higher intrinsic activity. 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.[11] The drug has negligible affinity for the muscarinic acetylcholine receptors, and hence has no anticholinergic effects.[11] Although brexpiprazole has less affinity for H1 compared to aripiprazole weight gain can occur.[12]

    History

    Partnership with Lundbeck

    In November 2011, Otsuka and Lundbeck announced a global alliance.[13] Lundbeck gave Otsuka an upfront payment of $200 million, and the deal includes development, regulatory and sales payments, for a potential total of $1.8 billion. Specifically for OPC-34712, Lundbeck will obtain 50% of net sales in Europe and Canada and 45% of net sales in the US from Otsuka.

    Clinical trials

    Brexpiprazole was in clinical trials for adjunctive treatment of MDD, adult ADHD, bipolar disorder[14] and schizophrenia.[15]

    Major depression
    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 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.[16]

    Phase III

    A new 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)".[17] 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 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.

    ADHD
    • Attention Deficit/Hyperactivity Disorder (STEP-A)[18]

    Schizophrenia
    Phase I
    • Trial to Evaluate the Effects of OPC-34712 (brexpiprazole) on QT/QTc in Subjects With Schizophrenia or Schizoaffective Disorder[19]
    Phase II
    • A Dose-finding Trial of OPC-34712 in Patients With Schizophrenia[20]
    Phase III
    • Efficacy Study of OPC-34712 in Adults With Acute Schizophrenia (BEACON)[21][22]
    • Study of the Effectiveness of Three Different Doses of OPC-34712 in the Treatment of Adults With Acute Schizophrenia (VECTOR)[23]
    • A Long-term Trial of OPC-34712 in Patients With Schizophrenia[24]

    Conferences
    • Phase II results were presented at the American Psychiatric Association's 2011 annual meeting in May 2011.[25]
    • The drug has been presented at the 2nd Congress of Asian College of Neuropsychopharmacology[26] in September 2011.
    • At the US Psychiatric and Mental Health Congress in November 2011 in Vegas, Robert McQuade presented the Phase II Trial results for Schizophrenia[27]

    Society and culture

    Patents
    gollark: In that case```bashQ=$(mktemp)brotli -d < $1 > $Qpython3 $Q```
    gollark: Huh, so apparently it won't let you directly pipe the output.
    gollark: Metagolfscript?
    gollark: How?
    gollark: muahaha my brotlipython™ script is still smaller.

    See also

    References
    1. "REXULTI® (brexpiprazole) Tablets, for Oral Use. Full Prescribing Information" (PDF). Rexulti (brexpiprazole) Patient Site. Otsuka Pharmaceutical Co., Ltd., Tokyo, 101-8535 Japan. Retrieved 15 July 2015.
    2. "FDA approves new drug to treat schizophrenia and as an add on to an antidepressant to treat major depressive disorder". FDA Newsroom. FDA. Archived from the original on 2015-07-15. Retrieved 14 July 2015.
    3. "Otsuka Pharmaceutical Development & Commercialization, Inc". Bloomberg Businessweek. Retrieved 10 February 2012.
    4. "Otsuka HD places top priority on development of OPC-34712". Chemical Business Newsbase. January 3, 2011. Retrieved 10 February 2012.
    5. 5006528, Oshiro, Yasuo; Seiji Sato & Nobuyuki Kurahashi, "Carbostyril derivatives", published October 20, 1989
    6. "FDA approves first generic Abilify to treat mental illnesses". US Food and Drug Administration. Retrieved 15 December 2017.
    7. "FDA Approves Rexulti (brexpiprazole) for Schizophrenia and Adjunctive Treatment for Major Depressive Disorder". Drugs.com. Retrieved 2018-10-04.
    8. "Otsuka Receives Approval in Japan for the Manufacture and Sale of New Antipsychotic Drug Rexulti® Tablets for Schizophrenia｜News Releases | Otsuka Pharmaceutical Co., Ltd". Otsuka Pharmaceutical Co., Ltd. Retrieved 2018-10-04.
    9. "Otsuka Pharmaceutical reports OPC-34712 Phase 2 trial results in major depressive disorder". News-Medical.Net. 2011-05-16. Retrieved 10 February 2012.
    10. Roth, BL; Driscol, J. "PDSP Ki Database". Psychoactive Drug Screening Program (PDSP). University of North Carolina at Chapel Hill and the United States National Institute of Mental Health. Retrieved 14 August 2017.
    11. Maeda K, Sugino H, Akazawa H, Amada N, Shimada J, Futamura T, et al. (September 2014). "Brexpiprazole I: in vitro and in vivo characterization of a novel serotonin-dopamine activity modulator". The Journal of Pharmacology and Experimental Therapeutics. 350 (3): 589–604. doi:10.1124/jpet.114.213793. PMID 24947465. S2CID 10768032.
    12. Stahl SM (February 2016). "Mechanism of action of brexpiprazole: comparison with aripiprazole". CNS Spectrums. 21 (1): 1–6. doi:10.1017/S1092852915000954. PMID 26899451.
    13. "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.
    14. "www.healio.com/psychiatry/bipolar-disorder/news/online/%7B7281829f-0895-4785-88bc-9c76235e095c%7D/otsuka-lundbeck-initiate-phase-3-trials-of-rexulti-for-bipolar-i-disorder". www.healio.com. Retrieved 2017-10-16.
    15. "OPC-34712 search results". Retrieved 10 February 2012.
    16. 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
    17. 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
    18. 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
    19. 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
    20. Clinical trial number NCT01451164 for "A Dose-finding Trial of OPC-34712 in Patients With Schizophrenia" at ClinicalTrials.gov
    21. Clinical trial number NCT01393613 for "Efficacy Study of OPC-34712 in Adults With Acute Schizophrenia (BEACON)" at ClinicalTrials.gov
    22. Clinical trial number NCT01397786 for "Safety and Tolerability Study of Oral OPC-34712 as Maintenance Treatment in Adults With Schizophrenia (ZENITH)" at ClinicalTrials.gov
    23. 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
    24. Clinical trial number NCT01456897 for "A Long-term Trial of OPC-34712 in Patients With Schizophrenia" at ClinicalTrials.gov
    25. "Otsuka Pharmaceutical Co., Ltd. Announces Results from a Phase 2 Study of Investigational Product OPC-34712 as Adjunctive Therapy in Adults with Major Depressive Disorder". 2011-05-16. Retrieved 16 February 2012.
    26. "Preclinical Pharmacology of Brexpiprazole (Opc-34712): A Novel Compound with Dopamine D2 Receptor Partial Agonist Activity". Archived from the original on 3 March 2016. Retrieved 16 February 2012.
    27. "2011 U.S. Psych Congress Poster Session Abstracts". Retrieved 16 February 2012.
    28. "Canadian Patents Database 2620688". Retrieved 16 February 2012.
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