Reviewing the role of the genes G72 and DAAO in glutamate neurotransmission in schizophrenia.

We review the role of two susceptibility genes; G72 and DAAO in glutamate neurotransmission and the aetiology of schizophrenia. The gene product of G72 is an activator of DAAO (D-amino acid oxidase), which is the only enzyme oxidising D-serine. D-serine is an important co-agonist for the NMDA glutamate receptor and plays a role in neuronal migration and cell death. Studies of D-serine revealed lower serum levels in schizophrenia patients as compared to healthy controls. Furthermore, administration of D-serine as add-on medication reduced the symptoms of schizophrenia. The underlying mechanism of the involvement of G72 and DAAO in schizophrenia is probably based on decreased levels of D-serine and decreased NMDA receptor functioning in patients. The involvement of this gene is therefore indirect support for the glutamate dysfunction hypothesis in schizophrenia.     

N-Methyl-D-aspartate (NMDA) receptor-based treatment approaches in schizophrenia: the first decade

The study of excitatory amino acids (EAA) [e.g. glutamate (Glu), aspartate] as neurotransmitters has resulted in many new and fundamental concepts in neuroscience. Much of this progress centres upon the role of N-methyl-D-aspartate (NMDA) subtype of Glu receptors in central nervous system synaptic transmission and plasticity. A leading hypothesis suggests that deficits in NMDA receptor-mediated neurotransmission may be central to the pathophysiology of schizophrenia. The conceptual foundation of this hypothesis derives from the clinical effects of NMDA receptor antagonists, such as phencyclidine (PCP) and ketamine and from post-mortem findings in brain samples of schizophrenia patients. Consequently, at present there is an intense search for pharmacological strategies capable of facilitating NMDA receptor function in this illness. During the last decade, a first generation of small clinical studies has focused on assessing the therapeutic potential of glycine-(Gly) site agonists of the NMDA receptor, such as Gly, D-serine and D-cycloserine. The results of these studies indicate that this type of compound may reduce negative symptoms and executive cognitive deficits in schizophrenia patients. Furthermore, preliminary findings suggest that patients having low serum Gly levels may represent the population of choice for treatment with Gly-site agonists. Additional potential schizophrenia treatments that may affect mainly NMDA receptor neurotransmission are : (i) other full and partial Gly-site agonists - in course of development for clinical use, and (ii) Gly transport antagonists that can inhibit Gly reuptake from neuronal synapses. Moreover, the antipsychotic action of some typical and atypical neuroleptics may be mediated by their agonistic activity at the strychnine-insensitive NMDA receptor-associated Gly site. After decades of relative neglect, the role of glutamatergic neurotransmission in the pathophysiology and therapeutics of schizophrenia is presently in process of conceptualization. In this context, it is likely that the development of NMDA receptor-based approaches for the treatment of this illness will continue. This trend is already supported by available clinical findings with Gly-site agonists and may herald an important, innovative development in the pharmacological treatment of neuropsychiatric syndromes.     

Glycine modulators in schizophrenia

N-methyl-D-aspartate (NMDA) receptor dysfunction may play a key role in the pathophysiology of schizophrenia. Recent studies have investigated the ability of NMDA/glycine-site modulators to ameliorate persistent negative and cognitive symptoms. Several full or partial glycine-site agonists, including glycine, D-serine and D-cycloserine, have shown effectiveness in small-scale clinical trials. Glycine levels in brain are regulated by GLYT1-type glycine transporters. Recently developed glycine transport inhibitors (GTI) have preclinical behavioral effects similar to those of glycine or D-serine, and may represent a 'next generation' approach to the treatment of the persistent negative and cognitive symptoms of schizophrenia.     

Genetic data supporting the NMDA glutamate receptor hypothesis for schizophrenia

The Dopamine Hypothesis has been the leading theory used to explain the mechanism of the clinical manifestation of schizophrenia symptoms for decades. It is unclear if excess dopaminergic activity is the primary pathophysiology causing psychosis or if this dopamine excess is triggered by upstream, downstream or neurodevelopmental abnormalities. A corollary hypothesis suggests that the glutamatergic system may be involved in the pathogenesis of schizophrenia, and that dysfunction of the glutamate system may actually lead to dopamine excess. The NMDA Receptor Hypofunction Hypothesis suggests that malfunctioning NMDA receptors may be the cause for the theoretically hypofunctioning glutamate system. This paper seeks to describe and discuss the potential underlying genetic vulnerabilities of the NMDA receptor and how aberrant genes coding for this receptor may lead to schizophrenia symptoms.     

Direct and indirect modulation of the N-methyl D-aspartate receptor

The dopamine hypothesis of schizophrenia has been a driving force in guiding both theories of pathophysiology of schizophrenia, and drug discovery efforts in this area. While this path has been fruitful in producing a deeper understanding of the disorder and a variety of antipsychotic drugs, it is generally recognized that targeting the D(2) dopamine receptor has multiple shortcomings. Recently, alterations in the glutamatergic system have been proposed to play a key role in the neurochemical disruptions underlying schizophrenia. In particular, the similarities between the symptoms of schizophrenia and the psychotomimetic effects of non-competitive N-methyl D-aspartate (NMDA) receptor antagonists such as phencyclidine have spurred interest in the possibility that an NMDA receptor hypofunctional state might underlie schizophrenia. In this review, we summarize the NMDA hypofunction hypothesis of schizophrenia, and focus on the NMDA receptor as a potential target for novel antipsychotic agents. Both modulatory sites on the NMDA receptor, as well as G-protein coupled receptors such as the muscarinic and metabotropic glutamate receptors that modulate the NMDA receptor, are potential targets for the development of novel compounds that could ameliorate the symptoms of schizophrenia.     

Glutamate hypothesis of schizophrenia and targets for new antipsychotic drugs]

N-methyl-D-aspartate (NMDA) receptor antagonists such as phencyclidine (PCP) and ketamine have been known to cause schizophrenia-like psychosis (positive symptoms, negative symptoms, cognitive dysfunction) in humans. A dysfunction of glutamatergic neurotransmission may play an important role in the pathophysiology of schizophrenia. In this review, the glutamate hypothesis of schizophrenia, especially the mechanism of neurotoxicity of NMDA receptor antagonist in the posterior cingulate cortex and retrosplenial cortex of the brain, is summarized. Furthermore, the roles of the posterior cingulate cortex and the retrosplenial cortex in the pathophysiology of schizophrenia and Alzheimer's disease are also discussed. Moreover, the glycine site of the NMDA receptor, metabotropic glutamate receptor, AMPA receptor, and antioxidant glutathione as novel potential targets for the treatment of schizophrenia are discussed.     

Ionotropic glutamate receptors as therapeutic targets in schizophrenia

Evidence implicating dysfunction of glutamatergic neurotransmission rests largely on the finding that antagonists of the NMDA subtype of glutamate receptor, especially the dissociative anesthetics like ketamine, can reproduce the full range of symptoms as well as the physiologic manifestation of schizophrenia such as hypofrontality, impaired prepulse inhibition and enhanced subcortical dopamine release. To test the hypothesis that schizophrenia may result from NMDA receptor hypofunction a number of clinical trials have examined the effects of agents that act on the glycine modulatory site on the NMDA receptor. Glycine, D-serine, and the partial agonist, D-cycloserine, have been shown to improve cognition and decrease negative symptoms in schizophrenic subjects receiving typical antipsychotics. Results with D-cycloserine suggest that clozapine may enhance glycine modulatory site occupancy. Preliminary results with an allosteric modulator of the AMPA subtype of glutamate receptor suggest enhanced cognitive functions in subjects treated with clozapine.     

Metabotropic glutamate receptors: potential drug targets for the treatment of schizophrenia

Schizophrenia is a debilitating chronic psychiatric illness affecting 1% of the population. The cardinal features of schizophrenia are positive symptoms (thought disorder, hallucinations, catatonic behavior), negative symptoms (social withdrawal, anhedonia, apathy) and cognitive impairment. Although progress in elucidating the aetiology of schizophrenia has been slow, new insights on the neurochemical and neurophysiological mechanisms underlying the pathophysiology of this illness are beginning to emerge. The glutamate/N-methyl-D-aspartate (NMDA) hypofunction hypothesis of schizophrenia is supported by observations that administration of NMDA glutamate receptor antagonists such as phencyclidine (PCP) or ketamine induces psychosis in humans; moreover, decreased levels of glutamate and changes in several markers of glutamatergic function occur in schizophrenic brain. Administration of PCP or ketamine to rodents elicits an increase in locomotion and stereotypy accompanied by an increase in glutamate efflux in several brain regions. Systemic administration of group II metabotropic glutamate (mGlu) receptor agonists suppresses PCP-induced behavioral effects and the increase in glutamate efflux. Activation of group II mGlu receptors (mGlu2 and mGlu3) decreases glutamate release from presynaptic nerve terminals, suggesting that group II mGlu receptor agonists may be beneficial in the treatment of schizophrenia. In addition, pharmacological manipulations that enhance NMDA function may be efficacious antipsychotics. Selective activation of mGlu5 receptors significantly potentiates NMDA-induced responses, supporting this novel approach for the treatment of schizophrenia. The glutamate hypothesis of schizophrenia predicts that agents that restore the balance in glutamatergic neurotransmission will ameliorate the symptomatology associated with this illness. Development of potent, efficacious, systemically active drugs will help to address the antipsychotic potential of these novel therapeutics. This review will discuss recent progress in elucidating the pharmacology and function of group II mGlu and mGlu5 receptors in the context of current hypotheses on the pathophysiology of schizophrenia and the need for new and better antipsychotics.     

Targeting glutamate system for novel antipsychotic approaches: relevance for residual psychotic symptoms and treatment resistant schizophrenia

Antipsychotics are the mainstay of schizophrenia treatment. However, approximately one third of schizophrenic patients do not respond or respond poorly to antipsychotics. Therefore, there is a need for new approaches that can improve schizophrenia treatment significantly. Promising strategies arise from the modulation of glutamatergic system, according to its proposed involvement in schizophrenia pathogenesis. In this review, we critically updated preclinical and clinical data on the modulation of glutamate N-methyl-D-aspartate (NMDA) receptor activity by NMDA-Rs co-agonists, glycine transporters inhibitors, AMPAkines, mGluR5 agonists, NMDA-Rs partial agonists. We focused on: 1) preclinical results in animal models mimicking the pathophysiology of psychosis, mainly believed to be responsible of negative and cognitive symptoms, and predicting antipsychotic-like activity of these compounds; and 2) clinical efficacy in open-label and double-blind trials. Albeit promising preclinical findings for virtually all compounds, clinical efficacy has not been confirmed for D-cycloserine. Contrasting evidence has been reported for glycine and D-serine, that may however have a role as add-on agents. More promising results in humans have been found for glycine transporter inhibitors. AMPAkines appear to be beneficial as pro-cognitive agents, while positive allosteric modulators of mGluR5 have not been tested in humans. Memantine has been proposed in early stages of schizophrenia, as it may counteract the effects of glutamate excitotoxicity correlated to high glutamate levels, slowing the progression of negative symptoms associated to more advanced stages of the illness.     

Glutamatergic animal models of schizophrenia

Dysregulation of glutamate neurotransmission has been implicated in schizophrenia primarily because antagonists of the n-methyl-d-aspartate (NMDA) subtype of glutamate receptors exacerbate preexisting symptoms of schizophrenia in patients and produce behavioral disruptions that resemble some symptoms of schizophrenia in healthy individuals. Given this, NMDA receptor antagonists have been used extensively to model aspects of the disease in laboratory animals and have provided a useful preclinical tool for testing novel treatment strategies. More recent genetic and postmortem findings have implicated proteins other than the NMDA receptor in the pathophysiology of schizophrenia which play a role in regulation of the glutamate synapse. Animal models developed based on these findings have the potential of increasing our mechanistic understanding of the disease. Here we review some of the pertinent literature related to pharmacological and genetic animal models of glutamate dysfunction in schizophrenia.     

Abnormal kainate receptor expression in prefrontal cortex in schizophrenia.

Abnormalities of molecules associated with the glutamate synapse have been implicated in the pathophysiology of schizophrenia. Of the many glutamate receptors, those most commonly suggested to be involved in schizophrenia are the ionotropic subtypes, the NMDA, AMPA, and kainate receptors. Both the NMDA and AMPA subtypes have been extensively studied in postmortem brains of individuals with schizophrenia, but relatively little is known about the expression of the kainate subtype of glutamate receptor. In this study, we have determined cortical and striatal kainate receptor expression in brains from persons with schizophrenia and a comparison group, using both in situ hybridization and receptor autoradiography. At the level of subunit mRNA expression, a shift in subunit stoichiometry was evident in multiple regions of the prefrontal cortex, with increased expression of gluR7 mRNA and decreased expression of KA2 mRNA. Decreased kainate receptor binding was also observed in the subjects with schizophrenia, but was restricted to infragranular laminae of the prefrontal cortex. No differences in kainate receptor binding or subunit mRNA levels were found in striatum or occipital cortex, suggesting that these findings may be restricted to association cortex. These data add to the growing literature implicating ionotropic glutamate receptor disturbances in schizophrenia, and indicate that in addition to AMPA and NMDA receptors, the kainate receptors are also abnormally expressed in this illness.     

Significance of dysfunctional glutamatergic transmission for the development of psychotic symptoms

It has been postulated that disturbances in glutamatergic transmission may contribute to the pathophysiology of schizophrenia. This view is based on several findings: (1) the noncompetitive NMDA receptor antagonists, phencyclidine and ketamine, induce both positive and negative psychotic symptoms in humans, which closely resemble those observed in schizophrenia; (2) a number of animal studies have shown that neuroleptics that ameliorate symptoms of schizophrenia (e.g. clozapine) also inhibit the effects of NMDA antagonists; (3) postmortem and in vivo studies have revealed alterations in ionotropic glutamate receptors (NMDA, AMPA, KA) and their modulatory sites in schizophrenia; (4) compounds enhancing the function of NMDA receptors potentiate the antipsychotic effects of neuroleptics in schizophrenic patients.     

Inflammation and the glutamate system in schizophrenia: implications for therapeutic targets and drug development

Background: Despite the progress in antipsychotic therapy for schizophrenia, the effects are still not satisfactory. There is a high percentage of therapy-resistant patients and the overall course of the disease is unfavourable in many affected individuals. Therefore, other therapeutic targets than dopaminergic and serotonergic neurotransmitters are being considered. Objective: Glutamatergic hypofunction, mediated mainly by NMDA receptor blockade, is suggested to be indirectly responsible for dopaminergic dysfunction in schizophrenia. Increased levels of kynurenic acid (KYN-A), an endogenous NMDA receptor antagonist, resulting from disturbed tryptophan/kynurenine metabolism can explain psychotic symptoms and cognitive deterioration. Methods: The role of the immune system in the production of KYN-A and therapeutic targets in the immune and glutamate systems are outlined. Conclusions: Therapeutic consequences are discussed. Glutamate modulators that particularly influence the NMDA co-transmitters glycine and serine, including inhibitors of glycine transporters, are described and initial clinical evidence is discussed. Another target of the glutamate system is the metabotropic mGlu2/3 receptor; Preliminary clinical results of a study with a mGlu2/3 receptor agonist in schizophrenia are mentioned.     

Plasma glycine and serine levels in schizophrenia compared to normal controls and major depression: relation to negative symptoms

Previous studies have suggested decreased N-methyl-D-aspartate (NMDA)-type glutamate receptor function may contribute to increased negative symptoms in patients with schizophrenia. Consistent with this hypothesis, glycine, a co-agonist at NMDA receptors, has been reported to improve negative symptoms associated with the illness. This study was performed to determine if plasma levels of glycine or its ratio to serine, a precursor of glycine, are decreased in patients with schizophrenia compared to normal control subjects or patients with major depression. We also tested the hypothesis that these amino acids were correlated with negative symptoms in subjects with schizophrenia. Plasma levels of glycine, serine, and their ratio, were compared in 144 patients with schizophrenia, 44 patients with major depression, and 49 normal control subjects. All subjects were medication-free. Psychopathology was evaluated using the Brief Psychiatric Rating Scale (BPRS). Plasma glycine levels and glycine/serine ratios were decreased in patients with schizophrenia relative to control subjects and patients with major depression. By contrast, serine levels were increased in patients with schizophrenia compared to normal subjects but not compared to major depression. Patients with major depression also had increased plasma serine levels and decreased glycine/serine ratios compared to normal controls, but glycine levels were not different from those of normal controls. In subjects with schizophrenia, glycine levels predicted the Withdrawal-Retardation score (BPRS), whereas no such correlation was found in subjects with major depression. These results provide additional evidence that decreased availability of glycine may be related to the pathophysiology of negative symptoms. The decreases in plasma glycine levels support the evidence for an abnormality in the glutamatergic system in schizophrenia, and provide additional support for efforts to improve negative symptoms by augmentation of antipsychotic drugs with agonists at the glycine site of the NMDA receptor.     

Progress in the preparation and testing of glycine transporter type-1 (GlyT1) inhibitors

Clinically utilized antipsychotic agents share as a common mechanism the ability to antagonize dopamine D2 receptors and it is widely assumed that this activity contributes to their efficacy against the positive symptoms of schizophrenia. The efficacy of currently marketed antipsychotic agents on the negative and cognitive symptoms of this disease, however, is not optimal. One alternate hypothesis to the "dopamine hypothesis" of schizophrenia derives from the observation that antagonists of NMDA receptor activity better mimic the symptomatology of schizophrenia in its entirety than do dopamine agonists. Findings from this line of research have led to the NMDA receptor hypofunction (or glutamate dysfunction) hypothesis of schizophrenia, which complements existing research implicating dopamine dysfunction in the disease. According to the NMDA receptor hypofunction hypothesis, any treatment that enhances NMDA receptor activity may prove useful for the treatment of the complex symptoms that define schizophrenia. This idea is now supported by numerous clinical studies that have reported an efficacious response following treatment with activators of the NMDA receptor co-agonist glycineB site. One area of study, aimed at potentiating the NMDA receptor via activation of the glycineB site is small molecule blockade of the glycine reuptake transporter type 1 (GlyT1). Broadly, these efforts have focused on derivatives of the substrate inhibitor, sarcosine, and non-sarcosine based GlyT1 inhibitors. Accordingly, the following review discusses the development of both sarcosine and non-sarcosine based GlyT1 inhibitors and their current status as putative treatments for schizophrenia and other disorders associated with NMDA receptor hypoactivity.     

Recent advances in the discovery of D-amino acid oxidase inhibitors and their therapeutic utility in schizophrenia

D-amino acid oxidase (DAAO) catalyzes the oxidative metabolism of D-amino acids including D-serine, a full agonist at the allosteric glycine binding site of the NMDA receptor. D-serine was reported to improve negative and cognitive symptoms of schizophrenia, symptoms poorly addressed by the standard D2 antagonist therapies. Therefore, inhibition of DAAO has gained substantial interest as an effective way to increase D-serine levels in the brain. During the last several years, a growing number of structurally diverse DAAO inhibitors have been identified with significantly higher inhibitory potency compared to the conventional DAAO inhibitors. Some of these new generation of DAAO inhibitors are being evaluated for their ability to enhance D-serine levels in rodents and efficacy in animal models of schizophrenia. This article highlights the progress that has been made toward the discovery of DAAO inhibitors and recent efforts to exploit their therapeutic utility in schizophrenia.     

Glutamate signaling in the pathophysiology and therapy of schizophrenia

Glutamatergic neurotransmission, particularly through the N-methyl-d-aspartate (NMDA) receptor, has drawn attention for its role in the pathophysiology of schizophrenia. This paper reviews the neurodevelopmental origin and genetic susceptibility of schizophrenia relevant to NMDA neurotransmission, and discusses the relationship between NMDA hypofunction and different domains of symptom in schizophrenia as well as putative treatment modality for the disorder. A series of clinical trials and a meta-analysis which compared currently available NMDA-enhancing agents suggests that glycine, d-serine, and sarcosine are more efficacious than d-cycloserine in improving the overall psychopathology of schizophrenia without side effect or safety concern. In addition, enhancing glutamatergic neurotransmission via activating the AMPA receptor, metabotropic glutamate receptor or inhibition of d-amino acid oxidase (DAO) is also reviewed. More studies are needed to determine the NMDA vulnerability in schizophrenia and to confirm the long-term efficacy, functional outcome, and safety of these NMDA-enhancing agents in schizophrenic patients, particularly those with refractory negative and cognitive symptoms, or serious adverse effects while taking the existing antipsychotic agents.     

Inhibition of human serine racemase, an emerging target for medicinal chemistry

Proteins of glutamatergic NMDA receptor signaling pathways have been studied as targets for intervention in a variety of neuropathological conditions, including neurodegenerations, epilepsy, neuropathic pain, drug addiction, and schizophrenia. High activity NMDA-blocking agents have been designed to treat some of these disorders; however, their effect is often compromised by undesirable side effects. Therefore, alternative ways of modulating NMDA receptor function need to be sought after. The opening of the NMDA receptor ion channel requires occupation of two distinct binding sites, the glutamate site and the glycine site. It has been shown that D-serine, rather than glycine, can trigger the physiological NMDA receptor function. D-serine is a product of the activity of a specific enzyme, serine racemase (SR), which was identified a decade ago. SR has therefore emerged as a new potential target for the NMDA-receptor-based diseases. There is evidence linking increased levels of D-Ser to amyotrophic lateral sclerosis and Alzheimer's disease and decreased concentrations of D-serine to schizophrenia. SR is a pyridoxal-5'-phosphate dependent enzyme found in the cytosol of glial and neuronal cells. It is activated by ATP, divalent cations like Mg(2+) or Ca(2+), and reducing agents. This paper reviews the present literature on the activity and inhibition of mammalian SRs. It summarizes approaches that have been applied to design SR inhibitors and lists the known active compounds. Based on biochemical and docking analyses, i) we delineate for the first time the ATP binding site of human SR, and ii) we suggest possible mechanisms of action for the active compounds. In the end, we discuss the SR features that make the discovery of its inhibitors a challenging, yet very important, task of medicinal chemistry.