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Amisulpride, sold under the brand names Socian and Barhemsys, is a medication used in the treatment of schizophrenia, psychosis, depression, and nausea and vomiting. It is specifically used at lower doses intravenously to prevent and treat postoperative nausea and vomiting; at low doses by mouth to treat depression; and at higher doses by mouth to treat psychosis.
It is usually classed with the atypical antipsychotics. Chemically it is a benzamide and like other benzamide antipsychotics, such as sulpiride, it is associated with a high risk of elevating blood levels of the lactation hormone, prolactin (thereby potentially causing amenorrhoea, breast enlargement, even in males, galactorrhoea, infertility, impotence, breast pain, etc.), and a low risk, relative to the typical antipsychotics, of causing movement disorders.
Amisulpride is indicated for use in the United States in adults for the prevention of postoperative nausea and vomiting (PONV), either alone or in combination with an antiemetic of a different class; and to treat PONV in those who have received antiemetic prophylaxis with an agent of a different class or have not received prophylaxis.
Amisulpride is believed to work by blocking, or antagonizing, the dopamine D2 receptor, reducing its signalling. The effectiveness of amisulpride in treating dysthymia and the negative symptoms of schizophrenia is believed to stem from its blockade of the presynaptic dopamine D2 and D3 . These presynaptic receptors regulate the release of dopamine into the synapse, so by blocking them amisulpride increases dopamine concentrations in the synapse. This increased dopamine concentration is theorized to act on dopamine D1 receptors to relieve depressive symptoms (in dysthymia) and the negative symptoms of schizophrenia.
It was introduced by Sanofi-Aventis in the 1990s. Its patent expired by 2008, and generic drug became available. It is marketed in all English-speaking countries except for Canada.
Neither is it recommended to use amisulpride in patients with hypersensitivities to amisulpride or the excipients found in its dosage form.
Hyperprolactinaemia results from antagonism of the D2 receptors located on the lactotrophic cells found in the anterior pituitary gland. Amisulpride has a high propensity for elevating plasma prolactin levels as a result of its poor blood–brain barrier penetrability and hence the resulting greater ratio of peripheral D2 occupancy to central D2 occupancy. This means that to achieve the sufficient occupancy (~60–80%
There is tentative evidence that discontinuation of antipsychotics can result in transient withdrawal related rebound psychosis. It may also result in reoccurrence of the condition that is being treated. Rarely tardive dyskinesia can occur when the medication is stopped.
Amisulpride functions primarily as a dopamine D2 and D3 receptor antagonist. It has high affinity for these receptors with dissociation constants of 3.0 and 3.5 nM, respectively. Although standard doses used to treat psychosis inhibit dopaminergic neurotransmission, low doses preferentially block inhibitory presynaptic . This results in a facilitation of dopamine activity, and for this reason, low-dose amisulpride has also been used to treat dysthymia.
Amisulpride and its relatives sulpiride, levosulpiride, and sultopride have been shown to bind to the high-affinity GHB receptor at concentrations that are therapeutically relevant ( = 50 nM for amisulpride).
Amisulpride, sultopride and sulpiride respectively present decreasing in vitro affinities for the D2 receptor (IC50 = 27, 120 and 181 nM) and the D3 receptor (IC50 = 3.6, 4.8 and 17.5 nM).
Though it was long widely assumed that dopaminergic modulation is solely responsible for the respective antidepressant and antipsychotic properties of amisulpride, it was subsequently found that the drug also acts as a potent antagonist of the serotonin 5-HT7 receptor (Ki = 11.5 nM). Several of the other atypical antipsychotics such as risperidone and ziprasidone are potent antagonists at the 5-HT7 receptor as well, and selective antagonists of the receptor show antidepressant properties themselves. To characterize the role of the 5-HT7 receptor in the antidepressant effects of amisulpride, a study prepared 5-HT7 receptor knockout mice. The study found that in two widely used rodent models of depression, the tail suspension test, and the forced swim test, those mice did not exhibit an antidepressant response upon treatment with amisulpride. These results suggest that 5-HT7 receptor antagonism mediates the antidepressant effects of amisulpride.
Amisulpride also appears to bind with high affinity to the serotonin 5-HT2B receptor (Ki = 13 nM), where it acts as an antagonist. The clinical implications of this, if any, are unclear. In any case, there is no evidence that this action mediates any of the therapeutic effects of amisulpride.
Amisulpride shows stereoselectivity in its actions. Aramisulpride (( R)-amisulpride) has higher affinity for the 5-HT7 receptor (Ki = 47 nM vs. 1,900 nM) while esamisulpride (( S)-amisulpride) has higher affinity for the D2 receptor (4.0 nM vs. 140 nM).
Through a high direct unmetabolized excretion, it has, despite its high usual dose, also high affinity for dopamine-D2-D3-receptors. Also the available literature gives us hints about also relatively high receptor dissociation kinetics (through a delayed but high occupancy at dopamine receptors after 6 hours from a 100 mg exposure).
Not just is this level of occupation (90%) enough for the normally therapeutic adwished level of the needing receptors occupated against schizophrenia, but even with this occurring after a single dose of amisulprid (compared with the receptoroccupation of about 12% in the striatalregion of the brain when taken cariprazine (which reaches an occupation between 63-69% not until several weeks and doses of administration)).
So one can say that the dynamics of dopamine-receptor occupation and how this does affect the human body are very complex, for example can the body and the brain work totally accurately even when over 90% of the dopamine receptors are occupied, yet though does the triggering of presynaptic auto-receptors to enhance mood in cases of dysthymia depending on an insaturated occupation of postsynaptic D2 receptors. However, this dopamine exposure could be slightly more "balanced" providing some little advantages over haloperidol in using it for drug exposure. Due to its lack of compensatory serotonin effects and also not having an anticholinergic profile, it may not considered as an effective alternative if akathisia is a problem.
Two trials (Trials 1 and 2) enrolled subjects scheduled to have surgery. Subjects were randomly assigned to receive either amisulpride or a placebo drug at the beginning of general anesthesia. In Trial 1, subjects received amisulpride or placebo alone, and in Trial 2, they received amisulpride or placebo in combination with one medication approved for prevention of nausea and vomiting. Neither the subjects nor the health care providers knew which treatment was being given until after the trial was complete.
The trials counted the number of subjects who had no vomiting and did not use additional medications for nausea or vomiting in the first day (24 hours) after the surgery. The results then compared amisulpride to placebo.
The other two trials (Trials 3 and 4) enrolled subjects who were experiencing nausea and vomiting after surgery. In Trial 3, subjects did not receive any medication to prevent nausea and vomiting before surgery and in Trial 4 they received the medication, but the treatment did not work. In both trials, subjects were randomly assigned to receive either amisulpride or placebo. Neither the subjects nor the health care providers knew which treatment was being given until after the trial was complete.
The trials counted the number of subjects who had no vomiting and did not use additional medications for nausea or vomiting in the first day (24 hours) after the treatment. The trial compared amisulpride to placebo.
The FDA has not approved amisulpride for use in any psychiatric indication. LB Pharmaceuticals is developing N-methyl amisulpride for the use in the treatment of schizophrenia; a Phase 2 first-in-patient study is planned for 2023.
An IV formulation of Amisulpride was approved for the treatment of postoperative nausea and vomiting ("PONV") in the United States in February 2020.
Adverse effects
The adverse effect frequencies listed below are when prescribed as an antipsychotic, at much higher doses than are used to treat depression and nausea and vomiting.
(2025). 9780071624428, McGraw-Hill Professional. ISBN 9780071624428) of the central D2 receptors in order to elicit its therapeutic effects a dose must be given that is enough to saturate peripheral D2 receptors including those in the anterior pituitary.
Discontinuation
The British National Formulary recommends a gradual withdrawal when discontinuing antipsychotics to avoid acute withdrawal syndrome or rapid relapse. (2009). 9780853698456, Royal Pharmaceutical Society of Great Britain. ISBN 9780853698456 Symptoms of withdrawal commonly include nausea, vomiting, and loss of appetite. Other symptoms may include restlessness, increased sweating, and trouble sleeping. Less commonly there may be a feeling of the world spinning, numbness, or muscle pains. Symptoms generally resolve after a short period of time.
Overdose
Torsades de pointes is common in overdose. Amisulpride is moderately dangerous in overdose (with the TCAs being very dangerous and the SSRIs being modestly dangerous). (2025). 9780470979488, Wiley-Blackwell. ISBN 9780470979488
Interactions
Amisulpride should not be used in conjunction with drugs that prolong the QT interval (such as citalopram, bupropion, clozapine, tricyclic antidepressants, sertindole, ziprasidone, etc.), as this can cause potential life threatening arrhythmias (Torsades de pointes, Ventricular tachycardia, and Ventricular fibrillation)
Pharmacology
Pharmacodynamics
+ Amisulpride Values are Ki (nM). The smaller the value, the more strongly the drug binds to the site. (2025). 9781461368571, Springer US. ISBN 9781461368571
Pharmacokinetics
The oral bioavailability of amisulpride is 48%. Its plasma protein binding is 16%. The drug is drug metabolism by the liver but its metabolism is minimal. Its elimination half-life is 12hours. Amisulpride is eliminated in urine (23–46%) and feces and is excretion mostly unchanged.
Chemistry
Amisulpride is a benzamide derivative. It is structurally related to other benzamide dopamine receptor antagonists employed as and including levosulpiride, metoclopramide, nemonapride, remoxipride, sulpiride, sultopride, tiapride, and veralipride. Chemically, it is also known as aminosultopride, differing from sultopride only in possessing an amine substituent on its benzene ring.
History
Amisulpride was introduced by Sanofi-Aventis in the 1990s. Its patent expired by 2008, and generic drug became available.
United States clinical development
The U.S. Food and Drug Administration (FDA) approved a 10 mg/4mL amisulpride IV formulation for use in post-operative nausea based on evidence from four clinical trials of 2323 subjects undergoing surgery or experiencing nausea and vomiting after the surgery. The trials were conducted at 80 sites in the United States, Canada and Europe.
Society and culture
Brand names
Brand names include: Amazeo, Amipride (Australia), Amival, Deniban, Solian (Australia, Ireland, RU, United Kingdom, South Africa), Soltus, Sulpitac (India), Sulprix (Australia), Midora (RO) and Socian (Brazil).
Availability
Amisulpride is not approved by the Food and Drug Administration for use in the United States in psychiatric indications, but it is approved and in use throughout Europe, Asia, Mexico, New Zealand and Australia to treat psychosis and schizophrenia.
Research
Bipolar depression
SEP-4199 (non-racemic amisulpride), an 85:15 ratio of aramisulpride (( R)-amisulpride) to esamisulpride (( S)-amisulpride), which is theorized to provide more balanced serotonin 5-HT7 and dopamine D2 receptor antagonism than racemate amisulpride (a 50:50 ratio of its ( R)- and ( S)-), is or was under development by Sunovion Pharmaceuticals for the treatment of bipolar depression in the United States and other countries. However, its development may have been discontinued.
Chemotherapy-induced nausea and vomiting
The intravenous formulation of amisulpride approved for treatment of postoperative nausea and vomiting is additionally under development for the treatment of chemotherapy-induced nausea and vomiting.
Chemical derivatives
A more lipophilic and centrally permeable derivative of amisulpride, N-methylamisulpride (developmental code name LB-102), is under development by LB Pharmaceuticals for the treatment of schizophrenia in the United States and other countries.
See also
External links
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