Thioridazine

Thioridazine (Mellaril or Melleril) is a first generation antipsychotic drug belonging to the phenothiazine drug group and was previously widely used in the treatment of schizophrenia and psychosis. The branded product was withdrawn worldwide in 2005 because it caused severe cardiac arrhythmias. However, generic versions are still available in the US.[1]

"Aldazine" redirects here. For functional group, see Aldazines.

Thioridazine
Clinical data
AHFS/Drugs.comConsumer Drug Information
MedlinePlusa682119
License data
Pregnancy
category
  • AU: C
  • US: C (Risk not ruled out)
    Routes of
    administration    		Oral
    ATC code
    Legal status
    Legal status
    • Withdrawn by the manufacturer worldwide[1]
    Pharmacokinetic data
    Bioavailabilityincomplete
    Metabolismhepatic (at least partly mediated by CYP2D6)
    Elimination half-life21–24 hours[2]
    Excretionfaeces
    Identifiers
    CAS Number
    PubChem CID
    PubChem SID
    IUPHAR/BPS
    DrugBank
    ChemSpider
    UNII
    KEGG
    ChEBI
    ChEMBL
    CompTox Dashboard (EPA)
    ECHA InfoCard100.000.041
    Chemical and physical data
    FormulaC21H26N2S2
    Molar mass370.577 g·mol−1
    3D model (JSmol)
      (verify)

    Indications

    Thioridazine was voluntarily discontinued by its manufacturer, Novartis, worldwide because it caused severe cardiac arrhythmias.[1][3][4][5]

    Its primary use in medicine was the treatment of schizophrenia.[6] It was also tried with some success as a treatment for various psychiatric symptoms seen in people with dementia,[7] but chronic use of thioridazine and other anti-psychotics in people with dementia is not recommended.[8]

    Side effects

    For further information see: Phenothiazine

    Thioridazine prolongs the QTc interval in a dose-dependent manner.[9] It produces significantly less extrapyramidal side effects than most first-generation antipsychotics.[10][11] Its use, along with the use of other typical antipsychotics, has been associated with degenerative retinopathies.[12] It has a higher propensity for causing anticholinergic side effects coupled with a lower propensity for causing extrapyramidal side effects and sedation than chlorpromazine, but also has a higher incidence of hypotension and cardiotoxicity.[13] It is also known to possess a relatively high liability for causing orthostatic hypotension compared to other antipsychotics. Similarly to other first-generation antipsychotics it has a relatively high liability for causing prolactin elevation. It is moderate risk for causing weight gain.[14] As with all antipsychotics thioridazine has been linked to cases of tardive dyskinesia (an often permanent neurological disorder characterised by slow, repetitive, purposeless and involuntary movements, most often of the facial muscles, that is usually brought on by years of continued treatment with antipsychotics, especially the first-generation (or typical) antipsychotics such as thioridazine) and neuroleptic malignant syndrome (a potentially fatal complication of antipsychotic treatment).[9] Blood dyscrasias such as agranulocytosis, leukopenia and neutropenia are possible with thioridazine treatment.[9] Thioridazine is also associated with abnormal retinal pigmentation after many years of use.[15]

    Pharmacology

    Thioridazine has the following binding profile:[16]

    Biologic ProteinBinding affinity (Ki[nM])Binding affinity of Mesoridazine (Ki [nM])Binding affinity of Sulforidazine (Ki [nM])Notes
    SERT1259NDND
    NET842NDND
    DAT1684NDND
    5-HT1A144.35500 (HB)ND
    5-HT1B109NDND
    5-HT1D579NDND
    5-HT1E194NDND
    5-HT2A27.674.76 (HB)NDThe ratio of 5-HT2A to D2 receptor binding is believed to dictate whether or not most antipsychotics are atypical or typical. In thioridazine's case its ratio of 5-HT2A to D2 receptor binding is below the level that's believed to be required for atypicality despite its relatively low extrapyramidal side effect liability in practice.[6]
    5-HT2C53157NDBelieved to play a role in the weight gain-promoting effects of antipsychotics.[6]
    5-HT3>10000NDND
    5-HT5A364NDND
    5-HT657.05380ND
    5-HT79973 (RC)ND
    α1A3.152 (HB)NDLikely the receptor responsible for the orthostatic hypotension known to occur in individuals on thioridazine.[6]
    α1B2.4NDND
    α2A134.151612.9 (HB)ND
    α2B341.65NDND
    α2C74.9NDND
    β1>10000NDND
    β2>10000NDND
    M112.810NDThis receptor is believed to be the chief receptor responsible for the anticholinergic side effects of thioridazine (e.g. dry mouth, constipation, blurred vision, etc.). Likely plays a role in thioridazine's low extrapyramidal side effect liability as anticholinergic drugs such as benzatropine are routinely given to treat extrapyramidal side effects resulting from antipsychotic treatment.[6]
    M2286.3315ND
    M32990ND
    M4310.3319ND
    M512.6760ND
    D194.5NDND
    D20.44.30.25Believed to be the receptor responsible for the therapeutic effects of antipsychotics.[6]
    D31.52.60.7
    D41.59.1ND
    D5258NDND
    hERG191NDNDLikely involved in thioridazine's cardiac effects.
    H116.51.81 (HB)NDLikely responsible for the sedating effects of thioridazine.
    H2136NDNDRegulates the release of hydrochloric acid into the stomach.
    H42400NDND

    Note: The Binding affinities given are towards cloned human receptors unless otherwise specified

    Acronyms used
    HB – Human brain receptor
    RC – Cloned rat receptor
    ND – No data

    Metabolism

    Thioridazine is a racemic compound with two enantiomers, both of which are metabolized, according to Eap et al., by CYP2D6 into (S)- and (R)-thioridazine-2-sulfoxide, better known as mesoridazine,[17] and into (S)- and (R)-thioridazine-5-sulfoxide.[18] Mesoridazine is in turn metabolized into sulforidazine.[19] Thioridazine is an inhibitor of CYP1A2 and CYP3A4.[20]

    History

    The manufacturer Novartis/Sandoz/Wander of the brands of thioridazine, Mellaril in the US and Canada and Melleril in Europe, discontinued the drug worldwide in June 2005.[1][3]

    Antibiotic activity

    Thioridazine is known to kill extensively drug-resistant tuberculosis[21][22] and to make methicillin-resistant Staphylococcus aureus sensitive to β-lactam antibiotics.[23][24] A possible mechanism of action for the drug's antibiotic activity is via the inhibition of bacterial secretion pumps. The β-lactam antibiotic resistance is due to the secretion β-lactamase a protein that destroys antibiotics. If the bacteria cannot secrete the β-lactamase, then the antibiotic will be effective.[22]

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    gollark: Don't tell me I forgot to add *that* too...
    gollark: Great, I didn't add "sucks" to the negative word list!
    gollark: <@270210946201288714> The public key is `IgjuLVkKGYiyDIckqY_7`.
    gollark: The potatOS chat monitor flagged up an instance of blasphemy, but it's just this:

    References
    1. "SHARED CARE PROTOCOL Thioridazine" (PDF). NHS Lothian Joint Formulary. March 2012. Archived from the original (PDF) on 18 May 2015.
    2. Shvartsburd, A; Sajadi, C; Morton, V; Mirabi, M; Gordon, J; Smith, RC (August 1984). "Blood levels of haloperidol and thioridazine during maintenance neuroleptic treatment of schizophrenic outpatients". Journal of Clinical Psychopharmacology. 4 (4): 194–198. doi:10.1097/00004714-198408000-00004. PMID 6470190.
    3. Purhonen, M; Koponen, H; Tiihonen, J; Tanskanen, A (November 2012). "Outcome of patients after market withdrawal of thioridazine: A retrospective analysis in a nationwide cohort". Pharmacoepidemiology and Drug Safety. 21 (11): 1227–1231. doi:10.1002/pds.3346. PMID 22941581.
    4. "WHO Pharmaceuticals Newsletter 2005, No. 04: REGULATORY MATTERS: Thioridazine - Sale discontinued in Canada". Essential Medicines and Health Products Information Portal. 4 (2). World Health Organization. 2005. p. 5. Retrieved 28 October 2013.
    5. "Withdrawal of thioridazine" (PDF). Australian Prescriber. Vol. 30 no. 3. June 2007. p. 82.
    6. Brunton, L. L.; Chabner, B.; Knollmann, B. C., eds. (2011). Goodman & Gilman's The Pharmacological Basis of Therapeutics (12th ed.). New York: McGraw-Hill. ISBN 978-0-07-162442-8.
    7. Kirchner, V; Kelly, CA; Harvey, RJ (2001). "Thioridazine for dementia". The Cochrane Database of Systematic Reviews (3): CD000464. doi:10.1002/14651858.CD000464. PMC 7034526. PMID 11686961.
    8. Declercq T; et al. (March 2013). "Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia" (PDF). Cochrane Database Syst Rev. 3 (3): CD007726. doi:10.1002/14651858.CD007726.pub2. hdl:1854/LU-3109108. PMID 23543555.
    9. "THIORIDAZINE HYDROCHLORIDE tablet, film coated [Mutual Pharmaceutical]". DailyMed. Mutual Pharmaceutical. September 2010. Retrieved 28 October 2013.
    10. Fenton, M; Rathbone, J; Reilly, J; Sultana, A (July 2007). "Thioridazine for schizophrenia". The Cochrane Database of Systematic Reviews (3): CD001944. doi:10.1002/14651858.CD001944.pub2. PMC 6718212. PMID 17636691.
    11. Keks, N; McGrath, J; Lambert, T; Catts, S; Vaddadi, K; Burrows, G; Varghese, F; George, T; Hustig, H; Burnett, P; et al. (November 1994). "The Australian multicentre double-blind comparative study of remoxipride and thioridazine in schizophrenia". Acta Psychiatrica Scandinavica. 90 (5): 358–365. doi:10.1111/j.1600-0447.1994.tb01607.x. PMID 7872041.
    12. Fornaro, P; Calabria, G; Corallo, G; Picotti, GB (July 2002). "Pathogenesis of degenerative retinopathies induced by thioridazine and other antipsychotics: a dopamine hypothesis". Documenta Ophthalmologica. 105 (1): 41–49. doi:10.1023/A:1015768114192. PMID 12152801.
    13. "Martindale: The Complete Drug Reference". Medicines Complete. The Pharmaceutical Press. 18 August 2010. Retrieved 28 October 2013.
    14. "Selected adverse effects of antipsychotic medications for schizophrenia". UpToDate. Wolters Kluwer Health. Retrieved 24 October 2013.
    15. Scott, Alfred W. (1 December 1963). "Retinal Pigmentation in a Patient Receiving Thioridazine". Archives of Ophthalmology. 70 (6): 775–778. doi:10.1001/archopht.1963.00960050777009. ISSN 0003-9950.
    16. Roth, BL; Driscol, J (12 January 2011). "PDSP Ki Database". Psychoactive Drug Screening Program (PDSP). University of North Carolina at Chapel Hill and the United States National Institute of Mental Health. Archived from the original on 8 November 2013. Retrieved 28 October 2013.
    17. PubChem Substance Summary: Mesoridazine National Center for Biotechnology Information.
    18. Eap CB, Guentert TW, Schaublin-Loidl M, Stabl M, Koeb L, Powell K, Baumann P (March 1996). "Plasma levels of the enantiomers of thioridazine, thioridazine 2-sulfoxide, thioridazine 2-sulfone, and thioridazine 5-sulfoxide in poor and extensive metabolizers of dextromethorphan and mephenytoin". Clinical Pharmacology & Therapeutics. 59 (3): 322–31. doi:10.1016/S0009-9236(96)80010-5. PMID 8653995.
    19. PubChem Substance Summary: Sulforidazine National Center for Biotechnology Information.
    20. Daniel WA, Syrek M, Ryłko Z, Kot M (2001). "Effects of phenothiazine neuroleptics on the rate of caffeine demethylation and hydroxylation in the rat liver" (PDF). Pol J Pharmacol. 53 (6): 615–21. PMID 11985335.CS1 maint: multiple names: authors list (link)
    21. Amaral L, Boeree MJ, Gillespie SH, Udwadia ZF, van Soolingen D (June 2010). "Thioridazine cures extensively drug-resistant tuberculosis (XDR-TB) and the need for global trials is now!" (PDF). Int. J. Antimicrob. Agents. 35 (6): 524–6. doi:10.1016/j.ijantimicag.2009.12.019. PMID 20188526.
    22. Amaral, L; Viveiros, M (May 2012). "Why thioridazine in combination with antibiotics cures extensively drug-resistant Mycobacterium tuberculosis infections". International Journal of Antimicrobial Agents. 39 (5): 376–380. doi:10.1016/j.ijantimicag.2012.01.012. PMID 22445204.
    23. Thanacoody, HKR (November 2007). "Thioridazine: resurrection as an antimicrobial agent?". British Journal of Clinical Pharmacology. 64 (5): 566–574. doi:10.1111/j.1365-2125.2007.03021.x. PMC 2203271. PMID 17764469.
    24. Thorsing, M; Klitgaard, JK; Atilano, ML; Skov, MN; Kolmos, HJ; Filipe, SR; Kallipolitis, BH (May 2013). "Thioridazine Induces Major Changes in Global Gene Expression and Cell Wall Composition in Methicillin-Resistant Staphylococcus aureus USA300". PLOS ONE. 8 (5): e64518. doi:10.1371/journal.pone.0064518. PMC 3656896. PMID 23691239.

    Further reading
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