Viloxazine in the Management of CNS Disorders: A Historical Overview and Current Status.

Viloxazine has a long history of clinical use in Europe as an antidepressant, and has recently been repurposed into an extended-release form for the treatment of attention-deficit/hyperactivity disorder in the USA. An immediate-release formulation was approved for the treatment of depression in the UK in 1974, and was subsequently marketed there and in several European countries for 30 years with no major safety concerns. In contrast to first-generation antidepressants (e.g., tricyclic antidepressants, monoamine oxidase inhibitors), viloxazine was associated with a relatively low risk for cardiotoxicity. Gastrointestinal symptoms were the most commonly reported side effects. The therapeutic effects of viloxazine are thought to be primarily the result of its action as a norepinephrine reuptake inhibitor, although in vitro and preclinical in vivo animal data suggest that viloxazine may also impact the serotoninergic system. This review summarizes the evolving knowledge of viloxazine based on information from previously published preclinical and clinical investigations, and acquired unpublished historical study reports from both open-label and blinded controlled clinical trials. We review the chemical properties, mechanism of action, safety, and tolerability across these studies, and discuss the contemporary rationale for the development of this agent as an extended-release oral formulation for the treatment of attention-deficit/hyperactivity disorder.

Evaluation of the Effect of SPN-812 (Viloxazine Extended-Release) on QTc Interval in Healthy Adults.

OBJECTIVE: To assess the effects of a supratherapeutic dose of SPN-812, a drug currently under investigation as a treatment for attention-deficit/hyperactivity disorder, on cardiac repolarization (QTc) in healthy adults. METHODS: The study was conducted from June 27, 2018, to July 10, 2018. It had a double-blind, randomized, crossover design in which subjects received a 3-treatment sequence-placebo, 400 mg moxifloxacin, and 1,800 mg SPN-812 for 2 consecutive days (separated by at least a 3-day washout). The primary endpoint was the correlation between the change from baseline (CFB) in individual heart rate corrected QT interval (QTcI) (ΔQTcI) and viloxazine and 5-hydroxyviloxazine glucuronide (5-OH-VLX-gluc) plasma concentrations (Cps). The secondary endpoint was the time point placebo-adjusted CFB in QTcI (ΔΔQTcI) for viloxazine. For assay sensitivity, the correlations between moxifloxacin Cp and the ΔQTcI, and moxifloxacin and time point ΔΔQTcI were evaluated. Additional evaluations included Fridericia's formula QT correction, heart rate, and the PR and QRS intervals. Changes in electrocardiogram (ECG) morphology along with other safety parameters were also analyzed and reported. RESULTS: The correlation between ΔQTcI and viloxazine Cp demonstrated a statistically significant negative slope (P = .0012). 5-OH-VLX-gluc Cp and ΔQTcI also demonstrated a statistically significant negative slope (P = .0007). Secondary time point analyses showed no effect of SPN-812 on QTcI. Assay sensitivity with moxifloxacin was confirmed. Safety parameters were acceptable. CONCLUSIONS: This study demonstrated that SPN-812 had no effect on cardiac repolarization or other ECG parameters in healthy adults, suggesting that it is not associated with a risk for cardiac arrhythmias or other electrocardiographic parameters.

Metabolism and in vitro drug-drug interaction assessment of viloxazine.

Viloxazine is currently being developed as a treatment for attention deficit/hyperactivity disorder (ADHD). The aim of these studies is to update the understanding of the rat and human metabolism and the in vitro drug-drug interaction profile of viloxazine to a degree where it meets current regulatory standards for such investigations. In vivo absorption-distribution-metabolism-excretion (ADME) studies demonstrated that in humans 5-hydroxylation followed by glucuronidation is the major metabolic route. This route was also seen as a minor route in rats where the major route is O-deethylation with subsequent sulfation. In humans, the 5-hydoxylation pathway is mediated by CYP2D6. An estimate for the fraction of the metabolism via this pathway suggests a PM/EM difference of <2-fold, making it highly unlikely that this will be an issue of clinical significance. Viloxazine forms a unique N-carbamoyl glucuronide in humans. The chemical reactivity characteristics of this metabolite are similar to stable glucuronide conjugates and dissimilar from acyl glucuronides; therefore, it is regarded as a stable Phase II conjugate. In vitro drug-drug interaction (DDI) testing indicates that viloxazine is not a significant inhibitor or inducer of CYPs and transporters with the exception of CYP1A2.

Prolonged stationary colonic motility recording in seven patients with severe constipation secondary to antidepressants.

The aim of this study was to determine whether the colonic motor profile of seven patients with constipation secondary to antidepressants differed from the motility of seven patients with idiopathic constipation and seven healthy volunteers. All constipated patients had very severe constipation. Colonic manometric recordings were performed for 24 h. The number of high amplitude propagating contractions (HAPC) was lower in the two groups of constipated patients than in controls. No HAPC were observed in 5/7 patients with constipation secondary to antidepressants and in 1/7 patients with idiopathic constipation. The overall area under the curve (AUC) in the left colon was lower in the two constipated patient groups than in controls. AUC increased after a 1000-kcal standard meal given at noon in controls but not in the two groups of constipated patients. In conclusion, in patients with constipation secondary to antidepressants, the overall AUC was as poor as in patients with idiopathic constipation, and no colonic response to eating was observed. Moreover, the number of HAPC was more markedly decreased in patients with constipation secondary to antidepressants than in patients with idiopathic constipation.

Biological parameters in major depression: effects of paroxetine, viloxazine, moclobemide, and electroconvulsive therapy. Relation to early clinical outcome.

BACKGROUND: Clinical and pharmacologic studies report a relative or absolute serotonergic deficiency in major depression; however, the variability of clinical characteristics of illness has led to controversial results. In the present work, we looked for a possible relationship between i) biochemical values that indirectly reflect aminergic neurons activity and clinical characteristics and ii) their evolution and the early clinical outcome under antidepressive therapies (ATs). METHODS: Platelet serotonin content, platelet monoamine oxydase activity, and urinary biopterins were measured in 27 depressed patients before and during four different ATs (paroxetine, viloxazine, moclobemide, or electroconvulsive therapy). Depressive symptomatology and its evolution under ATs were quantified using three clinical rating scales. RESULTS: A severe symptomatology, high serotonin (5-HT) platelet content, and high or low urinary B could represent risk factors leading to a smaller or delayed response to an AT. Furthermore, the early improvement under ATs was negatively correlated to pretreatment 5-HT platelet content. CONCLUSIONS: Determination of 5-HT level could be useful in the choice of an AT.

2-(Methyleneaminoxy)methylmorpholine derivatives. Synthesis and antidepressant activity.

The 3-(methyleneaminoxy)methylmorpholines 2 were synthesized as analogues of viloxazine 1, an antidepressant drug, in which the aryloxymethyl group is substituted by a (methyleneaminoxy)methyl moiety (MAOMM). Compounds 2 were tested as potential antidepressant agents by using the test of antagonism to reserpine-induced hypothermy in mice. In addition, their anticholinergic and antihistaminic activity on isolated preparations and their ability to antagonize the toxicity induced by adrenaline in mice were evaluated. "In vivo" and "in vitro" tests showed that some compounds of type 2 possess a pharmacological profile similar to that of viloxazine 1.

Elevation of plasma phenytoin by viloxazine in epileptic patients: a clinically significant drug interaction.

The effect of viloxazine (150-300 mg daily for 21 days) on plasma phenytoin levels at steady state was examined in 10 epileptic patients stabilised on a fixed phenytoin dosage. After starting viloxazine treatment, plasma phenytoin concentrations increased by 37% on average (range 7-94%) from a mean value of 18.8 micrograms/ml at baseline to a mean value of 25.7 micrograms/ml during the last week of combined therapy. In four patients the rise in plasma phenytoin was associated with the development of signs of phenytoin toxicity. Discontinuation of viloxazine resulted in return of plasma phenytoin towards baseline values and disappearance of the clinical symptoms. The mechanism of interaction probably involves inhibition of phenytoin metabolism by viloxazine. Careful monitoring of plasma phenytoin levels is recommended in patients treated with phenytoin who need to be started on viloxazine therapy.

Behavioral indices of beta receptor subsensitivity after chronic treatment with viloxazine in the mouse.

The aim of the experiments was to determine whether chronic pretreatment with viloxazine decreased the sensitivity of mice to the sedative effects of a beta agonist clenbuterol. Mice were subjected to chronic oral treatment with viloxazine (128 mg/kg twice daily) and then given a single administration of 32 mg/kg PO followed by clenbuterol (0.125 mg/kg IP) before being tested in a standard photocell activity meter. Imipramine, administered at the same doses in the same experimental conditions, was used as a comparison compound. The results showed that chronic but not acute viloxazine decreased the hypoactivity induced by clenbuterol, suggesting the induction of beta receptor subsensitivity. With imipramine the results were in the same direction but less clear. The findings are discussed in terms of the eventual specificity of the viloxazine effect to subsensitivity in beta-2 receptors.

An open field study of antidepressant drugs.

Eight psychotropic drugs, mainly acting on the catecholaminergic systems, were investigated in an open field setting. All drugs but one showed a significant reduction in overall activity over time. Only piribedil at 32 mg/kg showed an increase, while 2 mg/kg showed a decrease over time. Amineptine and nomifensine significantly increased and salbutamol significantly decreased both ambulation and rearing with dose. For viloxazine, metapramine, piribedil and piracetam no significant dose effects were revealed at the doses tested. It is concluded that no clear correlation between clinically reported antidepressant efficacy and the selected open field variables can be demonstrated. However, some of the dopaminergic drugs have substantial activating properties, which might render them dependence-producing properties.

[Behavior analysis based on neurochemical mechanisms of action of viloxazine and mianserin]. / Povedencheski analiz vurkhu nevrokhimichnite mekhanizmi na deistvie na viloksazina i mianserina.

Neuropharmacological study was undertaken on the preparations viloxazine (emovit "Phafmachim" People's Republic of Bulgaria) and mianserin (lerivon "Organon" Holand). Comparative experiments were performed with chlorimipramine ("Spofa", CSSR). The behaviour of mice was evaluated by the test "haloperidol catalepsy" after acute and chronic administration of aforementioned antidepressants. Effects of the preparations were also investigated on the background of hypothermia and stereotypy, induced by apomorphine. The influence of antidepressants after acute and chronic (7 and 14 days) administration was studied on serotonin effect in the central nervous system by examining the influence of the preparations on tics of the head, induced by 5-hydroxytryptophan in mice. An analysis was made on the spectrum of action of the preparations on mediator systems of central nervous system and it was established that after chronic application of mianserin together with its serotoninolytic properties there were effects on adrenergic systems of the central nervous system as well.

3-[(2-ethoxyphenoxy)methyl]piperidine derivatives. Synthesis and antidepressant activity.

The 3-[(2-ethoxyphenoxy)methyl]piperidine derivatives 3-5 were synthesized and screened as potential antidepressant agents by the reserpine interaction test in mice and the evaluation of reuptake inhibition of biogenic amines in pig brain synaptosomal fractions. In addition, their anticonvulsant activity, tested by pentyleneetrazole antagonism, and approximate acute toxicity were evaluated. In vivo and in vitro tests showed that compounds 3 and 5 possess a biological activity comparable to that of the antidepressant drug viloxazine.

Viloxazine as a betamimetic antidepressant drug.

A comparison was made between the effects of maprotiline, the sole action of which is to inhibit the reuptake of noradrenaline, of salbutamol and of viloxazine on hypothermia induced by reserpine, oxotremorine or apomorphine. The dose/effect curves in the three tests showed a similarity in profile between viloxazine and salbutamol, whereas no resemblance was evident between these two drugs and maprotiline. These facts suggest that viloxazine which has a weak effect on noradrenaline reuptake acts probably as antidepressant by betamimetic activity.

Inhibition of monoamine oxidase by viloxazine in rats.

Biochemical and pharmacological investigations about the effect of the antidepressant drug viloxazine (Vivalan) on catecholamine metabolism in rats led to the following results: Viloxazine exerts a dose and time dependent inhibition of monoamine oxidase activity of brain and liver mitochondrial fraction and tissue homogenates of hypothalamus, heart, liver, and adrenal glands, both in vitro and after oral and parenteral administration in vivo. Consequently, an increase in catecholamine concentrations in brain of rats could be observed after pretreatment with viloxazine. In addition brain serotonin concentrations rose and 5-hydroxy-indoleacetic acid was diminished. However, characterization of inhibition of monoamine oxidase activity by viloxazine in vitro revealed: Compared to the specific inhibitors clorgyline for MAO-A- and pargyline for MAO-B-activity, viloxazine was a very weak inhibitor both for MAO-A and MAO-B in vitro. The type of inhibition was competitive and reversible. From the presented results and the results obtained by other laboratories it is concluded that inhibition of monoamine oxidase activity by viloxazine, although clearly demonstrated in animal experiments, may not be the only mechanism for an antidepressant action of the drug in man.

The stereoselectivity of serotonin uptake in brain tissue and blood platelets: the topography of the serotonin uptake area.

This review concerns effects of stereoisomers on 5-HT uptake in brain tissue and/or blood platelets. All studies in which at least a pair of stereoisomers were used are considered. Differences between effects of stereoisomers of antidepressants as well as other drugs on 5-HT uptake are discussed. The findings indicate that 5-HT uptake is a stereoselective process. A topographical model of the 5-HT uptake area is proposed, based mainly on comparisons between spatial features of stereoisomers that inhibit 5-HT uptake.

Upregulation of gamma-aminobutyric acid (GABA) B binding sites in rat frontal cortex: a common action of repeated administration of different classes of antidepressants and electroshock.

The action of different classes of clinically effective antidepressants and electroshock on gamma-aminobutyric acid (GABA) B recognition sites in the frontal cortex was compared to that of other psychotropic agents. After either prolonged (6-18 days) s.c. infusion via osmotic minipumps or repeated i.p. injections of different antidepressants, or a series of electroshocks, treatment was halted and 72 hr later the animals were sacrificed, the brain was dissected and frozen. All major antidepressants (desipramine, amitryptyline or maprotiline), several newer compounds with reported antidepressant activity (viloxazine, zimelidine, fluoxetine, citalopram, progabide, fengabine, sodium valproate, mianserin, trazodone or nomifensine) as well as pargyline and repeated electroshocks, up-regulated GABA B binding in the rat frontal cortex but not hippocampus. This appeared to be a maximum binding effect, but in some instance the kinetics were more complex. Reserpine, diphenylhydantoin and phenobarbital down-regulated GABA B binding in the frontal cortex, whereas this was unaltered by haloperidol, chlorpromazine or diazepam administration. Desipramine up-regulated GABA B binding in a dose- and time-dependent manner (minimum effective dose, 1.25 mg/kg/day s.c. for 18 days; onset of action, 6 days at 5 mg/kg/day s.c.). Together with the rather sparse data in the literature on GABA in depression and antidepressant drug action, these findings support a common GABAergic mechanism of action of antidepressant drugs and electroshock, mediated via GABA B synapses.

[Concentration of biogenic amines in different brain structures of the rat adapted to chronic emotional stress]. / Soderzhanie biogennykh aminov v raznykh strukturakh mozga u krys, adaptirovavshikhsia k khronicheskomu émotsional'nomu stressu.

The level of noradrenaline (NA), dopamine (DA), serotonin (5-OT), and that of 5-oxyindolacetic acid was studied in four brain structures of rats having endured acute or chronic immobilization emotional stress. In stress adapted animals, NA level was normalized in the hypothalamus and increased in the midbrain. DA level was increased in the hypothalamus, the midbrain and the medulla, and 5-OT level was increased in most of the structures studied. During above-mentioned shifts, the animals did not react by additional changes of NA, DA, and 5-OT levels to subsequent immobilizations. Observed rearrangements of turnover of neurotransmitters may be considered as one of the forms of manifestation of chronic emotional stress adaptation mechanisms.

Characterization of the bupropion cue in the rat: lack of evidence for a dopaminergic mechanism.

Using a two-lever operant task rats were trained to discriminate 40 mg/kg IP of bupropion from saline. Despite bupropion's established dopaminergic activity in vitro and in vivo, it was found that the bupropion cue was neither mimicked by the dopaminergic drugs L-DOPA and bromocriptine nor blocked by a variety of neuroleptics (haloperidol, thioridazine, and thiothixene). In addition, bupropion was active in attenuating the behavior-suppressing effects of haloperidol, unlike amphetamine and the atypical antidepressants, nomifensine and viloxazine. The bupropion cue was not mimicked or disrupted by adrenergic or serotonergic drugs, but it did generalize to some stimulants (amphetamine, cocaine and caffeine) as well as to nomifensine and viloxazine. The generalizations were blocked by neuroleptics. These data indicate that bupropion's cue properties may not be based on its ability to modulate dopaminergic receptor activity. The possible involvement of phenylethylamine in the bupropion cue is also discussed.