Pharmacological strategies for the management of comorbid depression and schizophrenia

ABSTRACT

Introduction: Depressive symptoms may occur in any phase of schizophrenia and can have far-reaching consequences.

Areas covered: The author focuses on recent reviews and meta-analyses dealing with the prevalence, importance, etiopathogenesis, and pharmacotherapy of comorbid depression and schizophrenia. Depressive symptoms in acute episodes may improve in parallel with psychosis due to antipsychotic treatment. Therefore, the first step is to evaluate the current antipsychotic treatment of psychotic symptoms and consider changing the dosage. A second step is switching antipsychotic medications, since there are indications that some medications are slightly more effective in reducing depressive symptoms than others. For persistent depressive episodes, additional therapeutic interventions are indicated. Most guidelines recommend the administration of antidepressants as an add-on treatment with a limited evidence level. Immunotherapeutic strategies could be successful, at least in some schizophrenia patients.

Expert opinion: In the near future, precision psychiatry should enable clinicians to recognize specific biotypes with unique biosignatures that will guide accurate and prompt clinical management for individual patients.     

Pharmacological characterization of presynaptic alpha-adrenoceptors in the modulation of the 5-hydroxytryptamine release from vascular adrenergic nerves in the rat

The role of presynaptic alpha-adrenoceptors in modulation of the 5-hydroxytryptamine (5-HT) release from vascular adrenergic nerves was investigated in the perfused mesenteric vascular bed of the rat. After treatment with 5-HT (10 microM) for 15 min, the vasoconstrictor response to periarterial nerve stimulation (PNS, 4 to 16 Hz, 2 msec in duration for 30 sec) was greatly potentiated without significantly affecting the pressor response to exogenously administered noradrenaline (0.5 nmol). The potentiating effect was more pronounced at low frequencies of PNS (4 and 8 Hz). The potentiation of the pressor response to PNS after 5-HT treatment did not occur in the presence of LY53857 (0.01 microM), a selective 5-HT2 receptor antagonist. The enhanced pressor response to PNS seen after 5-HT treatment was further exaggerated in the presence of clonidine (0.1 and 1 microM), a preferential alpha 2-adrenoceptor agonist, while methoxamine (1 and 10 microM), a selective alpha 1-adrenoceptor agonist, did not affect the enhanced PNS response. This effect of clonidine was more pronounced in low frequencies of PNS (4 and 8 Hz) and was abolished by LY53857 (0.01 microM). In the perfused mesenteric vascular bed labelled with [3H]-5-HT, PNS (8 Hz) evoked an increase of tritium efflux in the perfusate. The PNS-evoked tritium efflux was facilitated by yohimbine (0.1 to 1 microM), an alpha 2-adrenoceptor antagonist, and prazosin, a selective alpha 1-adrenoceptor antagonist, at a high concentration (1 microM), while LY53857 (0.01 to 0.1 microM) and a low concentration of prazosin (0.1 microM) had no effect on the tritium efflux. Clonidine (0.01 to 1 microM) produced a dose-dependent increase of PNS-evoked tritium efflux, while methoxamine (0.1 to 10 microM) was without effect. The monoamine uptake inhibitor, cocaine (10 microM) produced a significant inhibition of the PNS-evoked tritium efflux. The effects of clonidine and cocaine on the PNS-evoked tritium efflux were antagonized by yohimbine (1 microM). These results suggest that the release of 5-HT from adrenergic nerve endings by PNS is modulated by presynaptic alpha 2-adrenoceptors.     

Pharmacological modulation of circadian rhythms: a new drug target in psychotherapeutics

Daily variation in an organism's physiology and behaviour is regulated by the synchrony that is achieved between the internal timing mechanisms - the circadian rhythms of the biological clock - and the prevailing environmental cues. Proper synchrony constitutes an adaptive response; improper or lost synchrony may well yield maladaptation and, in the case of humans, a psychiatric disorder. On a basic level, the circadian system is comprised of three parts: a central oscillator, its various neuronal inputs and its outputs. For all three of these parts, the dissemination of new information is moving at an unprecedented pace, and the number of molecular targets for the opportunistic pharmacologist is growing in step. Monoamines, neuropeptides, kinases - sorting through all these, much less developing one into a drug discovery programme, may be the biggest challenge. However, the potential benefits in targeting a basic flaw in a fundamental biological system may be enormous.     

Hair follicle-targeting drug delivery strategies for the management of hair follicle-associated disorders

The hair follicle is not only a critical penetration route in percutaneous absorption but also has been recognized to be a target for hair follicle-associated disorders, such as androgenetic alopecia(AGA) and acne vulgaris. Hair follicle-targeting drug delivery systems allow for controlled drug release and enhance therapeutic efficacy with minimal side effects, exerting a promising method for the management of hair follicle-associated dysfunctions. Therefore,they have obtained much attention in ...     

Pharmacological modulation of endothelin-induced contraction of guinea-pig isolated airways and thromboxane release.

1. The aim of the present experiments was to study the possible involvement of known bronchoconstrictor substances in mediating the myotropic action of endothelin-1 (ET-1, human-porcine endothelin) in guinea-pig isolated airways. 2. ET-1 (1-100 nM) caused a dose-dependent contraction of guinea-pig trachea, upper bronchus and parenchyma. The contractions developed slowly, reaching maximal values 4-6 min after addition of the peptide. 3. The contractile action of ET-1 was significantly attenuated by indomethacin (10 microM), a cyclo-oxygenase blocker. BM 13505 (5 microM), a thromboxane receptor antagonist, FPL 55712 (19 microM) and YM 16638 (1 microM), antagonists of the sulphidopeptide leukotrienes, BN 52021 (10 microM) and WEB 2086 (1 microM), platelet-activating factor receptor antagonists in all three tissue preparations studied. 4. Pretreatment of the airway tissues with compound U 75302 (3 microM), a selective leukotriene B4 receptor antagonist, or with a mixture of antagonists containing methysergide (0.75 microM), phentolamine (0.4 microM), propranolol (13 microM), atropine (0.4 microM) and diphenhydramine (0.45 microM) did not modify the myotropic action of ET-1. 5. ET-1, 10 and 100 nM induced three, and nine fold increases in thromboxane A2 release from lung parenchymal strips. 6. ET-1-induced thromboxane A2 release was completely abolished by indomethacin, and was significantly attenuated by BN 52021, WEB 2086 and FPL 55712. Neither BM 13505 nor YM 16638 exerted a significant effect on thromboxane release.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pharmacological strategies for the prevention of Alzheimer's disease

This review examines key pharmacological strategies that have been clinically studied for the primary or secondary prevention of Alzheimer's disease. Much information (neuropsychological, genetic and imaging) is already available to characterise an individual's risk for developing Alzheimer's disease. However, regulatory pathways for obtaining a prevention indication are less well charted, and such trials tend to involve 3- to 7-year studies of 1000 - 5000 individuals, depending on baseline status. Treatments developed for prevention will also need to have superior safety. For these reasons, > 100 proprietary pharmacological products are currently being developed for an Alzheimer's disease treatment, but only a few are being studied for prevention. Randomised trial data are available for antihypertensive agents (calcium channel blockers, angiotensin-converting enzyme inhibitors), pravastatin, simvastatin, conjugated oestrogen, raloxifene, rofecoxib, CX516 (AMPA agonist) and cholinesterase inhibitors regarding efficacy for Alzheimer's disease prevention. At least four large prevention trials of conjugated oestrogen, selenium and vitamin E, Ginkgo biloba and statins are currently underway. Strategies using other agents have not yet been evaluated in Alzheimer's disease prevention clinical trials. These include anti-amyloid antibodies, active immunisation, selective secretase inhibitors and modulators, microtubule stabilisers (e.g., paclitaxel), R-flurbiprofen, xaliproden, ONO-2506, FK962 (somatostatin releaser), SGS 742 (GABA(B) antagonist), TCH 346 (apoptosis inhibitor), Alzhemedtrade mark, phophodiesterase inhibitors, rosiglitazone, leuprolide, interferons, metal-protein attenuating compounds (e.g., PBT2), CX717, rasagaline, huperzine A, antioxidants and memantine. Studies combining lifestyle modification and drug therapy have not been conducted. Full validation of surrogate markers for disease progression (such as amyloid imaging) should further facilitate drug development. Reducing the complexity of prevention trials and gaining regulatory consensus of design is a high priority for the field.     

Pharmacological strategies for inhibition of thrombin activity

For decades, the options for therapeutic anticoagulation were limited to unfractionated heparin (UFH) and vitamin K antagonists (VKA), and their well-known limitations had to be accepted. With the introduction of the various LMWHs, the short-term anticoagulation could be much improved. The heparins delivered the proof of concept that FXa and thrombin represent suitable targets for therapeutic anticoagulation. Consequently, the search for new anticoagulants focus on inhibitors of thrombin or FXa. Apart from the VKA, the anticoagulants presently available or in an advanced stage of development can thus be divided in two classes: One are the glyco-anticoagulants with the natural sulfated glycosaminoglycans (GAGs) (UFH, LMWHs, and danaparoid) and the synthetic oligosaccharides (OS) (fondaparinux, idraparinux, and SR123781A). The other class are the xenobiotic anticoagulants, i.e. proteins and synthetic chemical entities. Die glyco-anticoagulants act partially (GAGs) or exclusively (oligosaccharides) by catalysing antithrombin, whereas the xenobiotic anticoagulants are direct inhibitors of either thrombin or FXa. At present, three direct thrombin inhibitors (DTI) (lepirudin, argatroban, and bivalirudin) are clinically used for limited indications, whereas there is still no direct FXa inhibitor available. The DTI ximelagatran represented the first oral anticoagulant since the introduction of VKA, but was withdrawn due to safety concerns. Among numerous drug candidates in the clinical development, two orally active anticoagulants dabigatran etexilate, a DTI, and rivaroxaban, the direct FXa inhibitor, are in the most advanced stage of development and may allow a paradigm change in anticoagulation in the foreseeable future. This review describes the pharmacological profile of all these anticoagulants.     

Pharmacological modulation of gap junction function with the novel compound rotigaptide: a promising new principle for prevention of arrhythmias

Existing anti-arrhythmic therapy is hampered by lack of efficacy and unacceptable side effects. Thus, ventricular tachycardia and fibrillation remains the strongest predictor of in-hospital mortality in patients with myocardial infarction. In atrial fibrillation, rhythm control with conventional ion channel blockers provide no therapeutic benefit relative to rate control. Several lines of research indicate that impaired gap junctional cell-to-cell coupling between neighbouring cardiomyocytes is critical for the development of cardiac re-entry arrhythmias. Rotigaptide is the first drug that has been developed to prevent arrhythmias by re-establishing gap junctional intercellular communication. During conditions with acute cardiac ischaemia, rotigaptide effectively prevents induction of both ventricular and atrial tachyarrhythmia. Moreover, rotigaptide effectively prevents ischaemia reperfusion arrhythmias. At the cellular level, rotigaptide inhibits ischaemia-induced dephosphorylation of Ser297 and Ser368, which is considered important for the gating of connexin43 gap junction channels. No drug-related toxicity has been demonstrated at plasma concentrations 77,000 times above therapeutic concentrations. In rats and dogs, rotigaptide reduces infarct size following myocardial infarction. A series of phase I trials has been completed in which rotigaptide has been administered intravenously to ~200 healthy persons. No drug-related side effects have been demonstrated in healthy human beings. Clinical safety, tolerability and efficacy in patients with heart disease are being evaluated in ongoing clinical trials. Rotigaptide represents a pioneering pharmacological principle with a highly favourable preclinical and clinical safety profile, which makes this molecule a promising drug candidate for the prevention of cardiac arrhythmias.     

Community-acquired pneumonia: new management strategies for evolving pathogens and antimicrobial susceptibilities

Community-acquired pneumonia (CAP) is still one of the leading causes of mortality and morbidity. The most common bacterial cause of CAP is Streptococcus pneumoniae. The increase in antimicrobial resistance has raised concerns about the efficacy of available therapies, and a call for the reassessment of both existing and newer therapeutic agents. Although microbiological breakpoints are useful for monitoring the emergence of resistance, the current National Committee for Clinical Laboratory Standards (NCCLS) guidelines make no distinction between clinical and microbiological breakpoints. Recent changes in NCCLS breakpoints for extended spectrum cephalosporins have provided a more meaningful approach to susceptibility testing and to consideration of the site of infection. Further controversy surrounds the clinical guidelines relating to CAP in terms of which antimicrobial agents should be given empirically to which types of patients. Within this review, the role of monotherapy versus the need for combination antimicrobial therapy, which often includes a macrolide and an extended spectrum cephalosporin such as ceftriaxone, is discussed. This review also discusses the various aspects of antimicrobial susceptibilities of S. pneumoniae, the drivers and influences of increasing resistance, the clinical relevance of this resistance and possible therapeutic options in the face of changing susceptibilities and mixed bacterial aetiologies. New guidelines from the IDSA attempt to embrace these changes.     

Pharmacological modulation of the heat shock response

Life presents a continuous series of stresses. Increasing the adaptation capacity of the organism is a long-term survival factor of various organisms and has become an attractive field of intensive therapeutic research. Induction of the heat shock response promotes survival after a wide variety of environmental stresses. Preclinical studies have proven that physiological and pharmacological chaperone inducers and co-inducers are an efficient therapeutic approach in different acute and chronic diseases. In this chapter, we summarize current knowledge of the current state of chaperone modulation and give a comprehensive list of the main drug candidates.     

Pharmacological modulation of the natriuretic peptide system

The natriuretic peptide (NP) system is a cardioprotective hormonal system that fails to meet its cardioprotective end point during the development of cardiovascular complications such as hypertension and heart failure. The use of NPs or orally-active drugs that enhance the function of the NP system, are being explored for the treatment of such disorders. Much of the recent research has focused on vasopeptidase inhibitors that can inhibit neutral endopeptidase (NEP) and angiotensin-converting enzyme (ACE) and thereby augment NP signalling while attenuating the renin–angiotensin–aldosterone system. These drugs offer several beneficial effects over conventional ACE inhibitors but the vasoactive peptide bradykinin, which is partly responsible for their beneficial effects, leads to serious side effects such as angioedema. The hope that these compounds will replace conventional drugs is fading away but they might be useful in targeted refractory populations immune to conventional drugs. The trends from the recent published patents suggest that pharmaceutical companies are exploring new strategies that include inhibition of endothelin-converting enzyme along with ACE and/or NEP. This comprehensive review will address the patents as well as basic and clinical pharmacology of leading compounds that exploit various strategies to modulate the NP system. This includes recombinant NPs, NP receptor ligands, vasopeptidase inhibitors and novel molecules that offer new strategic insights into the modulation of the NP system for the treatment of cardiovascular complications.     

Pharmacological modulation of transmitter release by inhibition of pressure-dependent potassium currents in vestibular hair cells

Vestibular vertigo may be induced by increases in the endolymphatic pressure that activate pressure-dependent K⁺ currents (I_K,p) in vestibular hair cells. I_K,p have been demonstrated to modulate transmitter release and are inhibited by low concentrations of cinnarizine. Beneficial effects against vestibular vertigo of cinnarizine have been attributed to its inhibition of calcium currents. Our aim was to determine the extent by which the inhibition of I_K,p by cinnarizine may alter the voltage response to stimulating currents and to analyze whether such alterations may be sufficient to modulate the activation of Ca²⁺ currents and transmitter release. Vestibular type II hair cells from guinea pigs were studied using the whole-cell patch-clamp technique. In current clamp, voltage responses to trains of stimulating currents were recorded. In voltage clamp, transmitter release was assessed from changes in the cell capacitance, as calculated from the phase shift during application of sine waves. Cinnarizine (0.05–3?µM) concentration dependently reversed the depressing effects of increases in the hydrostatic pressure (from 0.2 to 0.5 cm H₂O) on the voltage responses to stimulating currents. Voltage protocols that simulated these responses were applied in voltage clamp and revealed a significantly enhanced transmitter release in conditions mimicking an inhibition of I_K,p. Cinnarizine (≤0.5?µM) did not inhibit calcium currents. We conclude that cinnarizine, in pharmacologically relevant concentrations, enhances transmitter release in the presence of elevated hydrostatic pressure by an indirect mechanism, involving inhibition of I_K,p, enhancing depolarization, and increasing the voltage-dependent activation of Ca²⁺ currents, without directly affecting Ca²⁺ current.     

Pharmacological strategies for prevention of postoperative atrial fibrillation

Atrial fibrillation (AF) complicating cardiac surgery continues to be a major problem that increases the postoperative risk of stroke, myocardial infarction, heart failure and costs and can affect long-term survival. The incidence of AF after surgery has not significantly changed over the last two decades, despite improvement in medical and surgical techniques. The mechanism and pathophysiology underlying postoperative AF (PoAF) is incompletely understood and results from a combination of acute and chronic factors, superimposed on an underlying abnormal atrial substrate with increased interstitial fibrosis. Several anti-arrhythmic and non-anti-arrhythmic medications have been used for the prevention of PoAF, but the effectiveness of these strategies has been limited due to a poor understanding of the basis for the increased susceptibility of the atria to AF in the postoperative setting. In this review, we summarize the pathophysiology underlying the development of PoAF and evidence behind pharmacological approaches used for its prevention in the postoperative setting.     

Pharmacological modulation of I(Ks): potential for antiarrhythmic therapy

The slowly (I(Ks)) and rapidly (I(Kr)) activating delayed rectifier K(+) currents play important roles in cardiac ventricular repolarization. Compared with I(Kr), however, I(Ks) has important distinguishing characteristics, including beta-adrenergic receptor stimulation and accumulation at rapid rates that may impart significant therapeutic relevance. Therefore, development of selective I(Ks) inhibitors has been pursued as a strategy for providing potentially safer and more effective Class III antiarrhythmic agents and pharmacological tools for elucidating the normal physiological and potential pathological role of I(Ks) in cardiac repolarization. We have identified a series of 3-Acylamino-1,4 benzodiazepines that are very potent and selective inhibitors of I(Ks). A representative compound, L-768,673 (1) (IC(50)~8nM), has been extensively characterized for its pharmacologic activity. L-768,673 concentration-dependently prolongs action potential duration in a frequency-independent manner in vitro, but decreases transmural dispersion of refractoriness, a risk factor for arrhythmia induction. In conscious dogs, L 768,673 administered IV (0.3-100 micro g/kg) and PO (0.03-1 mg/kg) elicits consistent but limited (5-15%) QT(c) prolongation, and increases ventricular refractory period more at fast than at slow pacing rates, indicating a "forward" rate-dependence in vivo. In an anesthetized canine model of anterior myocardial infarction, I(Ks) blockers suppress the development of ischemic ventricular fibrillation at intravenous doses that minimally prolong the QT interval. I(Ks) blockers display an interesting and intriguing profile of effects on cardiac electrophysiologic parameters that differ in remarkable ways from other selective Class III agents such as I(Kr) blockers. It remains to be determined if these properties can be exploited clinically to provide more effective and safer treatment of cardiac arrhythmias.     

Pharmacological modulation of autophagy for Alzheimer's disease therapy: Opportunities and obstacles

Alzheimer's disease (AD) is a prevalent and deleterious neurodegenerative disorder characterized by an irreversible and progressive impairment of cognitive abilities as well as the formation of amyloid β (Aβ) plaques and neurofibrillary tangles (NFTs) in the brain. By far, the precise mechanisms of AD are not fully understood and no interventions are available to effectively slow down progression of the disease. Autophagy is a conserved degradation pathway that is crucial to maintain cellular homeostasis by targeting damaged organelles, pathogens, and disease-prone protein aggregates to lysosome for degradation. Emerging evidence suggests dysfunctional autophagy clearance pathway as a potential cellular mechanism underlying the pathogenesis of AD in affected neurons. Here we summarize the current evidence for autophagy dysfunction in the pathophysiology of AD and discuss the role of autophagy in the regulation of AD-related protein degradation and neuroinflammation in neurons and glial cells. Finally, we review the autophagy modulators reported in the treatment of AD models and discuss the obstacles and opportunities for potential clinical application of the novel autophagy activators for AD therapy.     

Pharmacological modulation of the inflammatory actions of platelets

Patients with inflammatory diseases often exhibit a change in platelet function, with these alterations being clearly distinct from the well-characterized role of platelets in haemostasis and thrombosis. It has recently been revealed that platelets can behave as innate inflammatory cells in immune responses with roles in leukocyte recruitment, migration into tissues, release of cytotoxic mediators, and in tissue remodelling following injury.Platelets exhibit a wide range of receptors for mediators involved in the inflammatory pathway and the immune response (Fig. 1). These include purinergic receptors, selectins, integrins, toll-like receptors, immunoglobulins, and chemokine receptors, but the precise role platelets play in the inflammatory process is still under investigation. Nevertheless, given that many of these receptors are distinct from those involved in thrombosis and haemostasis, this raises the real possibility of targeting these receptors to regulate inflammatory diseases without compromising haemostasis.     

Pharmacological modulation of the pneumotoxicity of 3-methylindole

The nature of the reactive metabolite of 3-methylindole is investigated using microsomal preparations prepared from the lungs of cattle. Nucleophilic thiol agents, glutathione, L-cysteine and $\text{N-}\text{acetyl-}\text{L}\text{-cysteine}$, protected microsomal proteins against alkylation by the reactive metabolite of 3-methylindole. The cytosol fraction from the lungs of cattle increased the protective effect of these thiol agents. Pretreatment of sheep with diethylmaleate, which depletes glutathione, increased the severity of the pneumotoxic effect of 3-methylindole, whereas pretreatment with L-cysteine decreased the severity of this effect. These findings are consistent with a hypothesis that an electrophilic reactive metabolite of 3-methylindole is responsible for its pneumotoxic effect and implies that glutathione and glutathione S-transferases are involved in the detoxification of this reactive metabolite. Nucleophilic thiol agents can be useful in the prevention of reactive metabolite induced-lung injury.