Quetiapine and its metabolite norquetiapine: translation from in vitro pharmacology to in vivo efficacy in rodent models.

BACKGROUND AND PURPOSE: Quetiapine has a range of clinical activity distinct from other atypical antipsychotic drugs, demonstrating efficacy as monotherapy in bipolar depression, major depressive disorder and generalized anxiety disorder. The neuropharmacological mechanisms underlying this clinical profile are not completely understood; however, the major active metabolite, norquetiapine, has been shown to have a distinct in vitro pharmacological profile consistent with a broad therapeutic range and may contribute to the clinical profile of quetiapine. EXPERIMENTAL APPROACH: We evaluated quetiapine and norquetiapine, using in vitro binding and functional assays of targets known to be associated with antidepressant and anxiolytic drug actions and compared these activities with a representative range of established antipsychotics and antidepressants. To determine how the in vitro pharmacological properties translate into in vivo activity, we used preclinical animal models with translational relevance to established antidepressant-like and anxiolytic-like drug action. KEY RESULTS: Norquetiapine had equivalent activity to established antidepressants at the noradrenaline transporter (NET), while quetiapine was inactive. Norquetiapine was active in the mouse forced swimming and rat learned helplessness tests. In in vivo receptor occupancy studies, norquetiapine had significant occupancy at NET at behaviourally relevant doses. Both quetiapine and norquetiapine were agonists at 5-HT1A receptors, and the anxiolytic-like activity of norquetiapine in rat punished responding was blocked by the 5-HT1A antagonist, WAY100635. CONCLUSIONS AND IMPLICATIONS: Quetiapine and norquetiapine have multiple in vitro pharmacological actions, and results from preclinical studies suggest that activity at NET and 5-HT1A receptors contributes to the antidepressant and anxiolytic effects in patients treated with quetiapine.

Role of concomitant inhibition of the norepinephrine transporter for the antipsychotic effect of quetiapine.

Quetiapine alleviates both positive and negative symptoms as well as certain cognitive impairments in schizophrenia despite a low D2 receptor occupancy and may also be used as monotherapy in bipolar and major depressive disorder. The mechanisms underlying the broad clinical utility of quetiapine remain to be clarified, but may be related to the potent inhibition of the norepinephrine transporter (NET) by norquetiapine, the major metabolite of quetiapine in humans. Since norquetiapine is not formed in rodents we here investigated in rats whether NET-inhibition may, in principle, contribute to the clinical effectiveness of quetiapine and allow for its low D2 receptor occupancy, by combining quetiapine with the selective NET-inhibitor reboxetine. Antipsychotic-like activity was assessed using the conditioned avoidance response (CAR) test, dopamine output in the medial prefrontal cortex (mPFC) and the nucleus accumbens was measured using in vivo microdialysis, and NMDA receptor-mediated transmission was measured using intracellular electrophysiological recordings in pyramidal cells of the mPFC in vitro. Adjunct reboxetine potentiated the suppression of CAR by quetiapine. Moreover, concomitant administration of quetiapine and reboxetine resulted in a synergistic increase in cortical, but not accumbal, dopamine output. The combination of low, clinically relevant concentrations of quetiapine (60 nM) and reboxetine (20 nM) markedly facilitated cortical NMDA receptor-mediated transmission in contrast to either drug alone, an effect that could be inhibited by the D1 receptor antagonist SCH23390. We conclude that concomitant NET-inhibition by norquetiapine may contribute to the overall antipsychotic effectiveness of quetiapine in spite of its relatively low level of D2 occupancy.

Combined therapy with thioridazine decreases plasma levels of quetiapine inTaiwanese schizophrenic patients.

BACKGROUND: In this study, the authors studied the effect of thioridazine (TDZ) on the pharmacokinetic profile of quetiapine (QTP) in Taiwanese patients with schizophrenia. METHODS: Sixteen subjects with schizophrenia were recruited for this study. The authors pretreated 8 patients with TDZ 50 mg daily continuously given until the end of the study. QTP was administered to all the participants, and their doses were escalated to 300 mg once daily over a 7-day period and maintained for another week. On day 15, blood samples were collected at 12 time points within an 8-hour interval. The authors assayed the plasma levels of QTP with a high-performance liquid chromatography system coupled with ultraviolet detector. RESULTS: Significantly decreased plasma levels of QTP after oral administration were observed in patients comedicated with TDZ compared with the QTP monotherapy group at 1.5, 2, and 2.5 hours, and the P values were 0.046, 0.001, and 0.005, respectively. The Cmax of QTP was significantly lower in the group comedicated with TDZ (776.9 ± 175.2 versus 1452.3 ± 707.5 ng/mL; P = 0.002). The oral clearance of QTP was significantly higher in the combined group than in the monothreapy group (123.3 ± 66.8 versus 60.3 ± 28.5 L/h; P = 0.03). Other pharmacokinetic parameters were not significantly different. CONCLUSIONS: The coadministration of TDZ significantly decreased plasma QTP level and significantly increased the oral clearance of QTP. Although TDZ is switched to QTP, choosing larger doses of QTP for titration may be necessary to avoid the emergence of psychotic symptoms among schizophrenic patients.

Reversal of quetiapine-induced altered mental status with physostigmine: a case series.

Quetiapine overdose is a clinical entity commonly encountered in emergency departments. Quetiapine is a drug with many mechanisms, including antimuscarinic effects. Traditionally, treatment of quetiapine toxicity has been primarily supportive care. Case reports exist documenting improvement in mental status in these patients after administration of physostigmine, a carbamate capable of reversing antimuscarinic toxicity. In this descriptive case series, 3 patients with quetiapine toxicity treated with physostigmine are reported. In each case, the patient had significant altered mental status that was rapidly reversed with administration of physostigmine. In all 3 cases, patient disposition was changed to a lower level of care, requiring less invasive monitoring. In 1 case, intubation was prevented. Because quetiapine toxicity is commonly encountered and the use of physostigmine in this setting is a potentially practice-altering treatment, emergency physicians should be aware of this phenomenon.

Molecular geometries of dibenzothiazepinone and dibenzoxazepinone calcium antagonists.

A number of dibenzothiazepinones and dibenzoxazepinones have been designed, synthesized and evaluated as calcium antagonists. Molecular geometries of these dibenzotricyclic calcium antagonists have been studied using X-ray crystallography, molecular modeling and two-dimensional NMR spectroscopy. X-Ray diffraction reveals dibenzothiazepinone 1 and dibenzoxazepinone 2 to have, respectively, flexure angles of 108 degrees and 116.9 degrees between the two benzene rings. The molecular mechanics-optimized geometry of dibenzothiazepinone 1 shows a 7 degrees smaller flexure angle than the X-ray crystallographic result, while that of dibenzoxazepinone 2 has an angle only 2 degrees smaller than the X-ray result. AM1 and ab initio calculations show that the side chains can affect the geometry of the tricyclic nucleus and both 1 and 2 have negative electrostatic potentials around the bridged portion of the tricyclics. Two-dimensional NOESY NMR spectroscopy supports the extended geometry of the 6 carbon spacer as obtained from X-ray crystallography and molecular mechanics calculations. Vasorelaxation properties among these compounds appear to be relatively insensitive to the flexure angle and to chain length. Vasorelaxation is profoundly influenced by the nature of the basic terminal moiety.

Antagonism between dopaminergic and neuroleptic drugs. II. Chronic administration.

In this work the eeg and behavioural effects obtained after the administration of dopaminergic drugs (bromocriptine, apomorphine, piribedil) in rabbits chronically pretreated with haloperidol, chlorpromazine, clotiapine, are shown. The Monnier and Gangloff stereotaxic method was used. The aim of the study was to verify receptor supersensitivity by neurophysiologic methods. The neurophysiologic pattern of receptor supersensitivity induced by long-lasting treatment with neuroleptic drugs and its peculiarity are discussed.

Antagonism between dopaminergic and neuroleptic drugs. I. Acute administration.

In this paper we report our results concerning the antagonism between dopaminergic (bromocriptine, apomorphine, piribedil) and neuroleptic (haloperidol, chlorpromazine, reserpine, clotiapine) drugs on the eeg and behaviour of rabbits. The Monnier and Gangloff stereotaxic method was used in order to record cortical and deep structures. The use of neurophysiologic methods also enabled us to verify the magnitude and modes of the antagonism between the two types of drugs. Particularly, the dissociation between eeg and behavioural effects of this antagonism is discussed; this fact seems to confirm the hypothesis that dopaminergic drugs have a double point of attack in the CNS.