Selective norepinephrine reuptake inhibitors (sNRIs) are a class of drugs that have been marketed as antidepressants and are used for various mental disorders, mainly depression and attention deficit hyperactivity disorder (ADHD). The norepinephrine transporter (NET) serves as the fundamental mechanism for the inactivation of noradrenergic signaling because of the NET termination in the reuptake of norepinephrine (NE). The selectivity and mechanism of action for the NRI drugs remain mostly unresolved and, to date, only a limited number of NRI-selective inhibitors are available. The first commercially available selective NRI was the drug viloxazine (Qelbree), developed as an antidepressant but later marketed as a treatment for ADHD. Reboxetine (Edronax) was developed as a first-line therapy for major depressive disorder. Atomoxetine (Strattera) is another potent and selective NRI which is also effective and well-tolerated for the treatment of ADHD in adults, particularly for those patients at risk of substance abuse.
Medical uses
Atomoxetine is sold under the brand name Strattera and was first approved for medical use in the United States in 2002. Its indication is for the treatment of attention deficit hyperactivity disorder (ADHD) in children over 6 years of age, adolescents and adults. Atomoxetine selectively inhibits norepinephrine reuptake by blocking the presynaptic norepinephrine transporter (NET) in the brain. Research has suggested that it also inhibits the reuptake of serotonin by binding to the selective serotonin transporter. However it is not known whether the therapeutic effects of atomoxetine is due to its blockage of the NET or both norepinephrine- and serotonin transporters. Reboxetine, sold under the brand name Edronax, is a selective norepinephrine reuptake inhibitor and acts by binding to the NET and blocking the reuptake of norepinephrine in the extracellular fluids. Its indication is for acute treatment of depression or major depression disorder. Reboxetine was first approved for marketing in Europe in 1997, however, in the United States its application for approval was rejected.
Medication Brand name Medical uses Introduced Chemical structure Atomoxetine Strattera Attention deficit hyperactivity disorder (ADHD), Cognitive disengagement syndrome (CDS) 2002 Reboxetine Edronax Major depressive disorder 1997 Viloxazine Qelbree Attention deficit hyperactivity disorder (ADHD), Depression 1974
Adverse effects Side effects Selective NRIs are generally well tolerated but the most common side effects reported are headache, dry mouth, abdominal pain, loss of appetite, nausea, vomiting, and drowsiness. An increase in heart rate and blood pressure have been reported but are usually not clinically important. Sexual adverse effects are mostly related to erectile dysfunction and decreased libido, but they are significantly less common than with serotonergic drugs. Other side effects are urinary retention, constipation, sweating and insomnia. What can be considered serious side effects are thoughts of suicide, aggressiveness and hallucinations.
Interactions If people are using sNRI drugs they should not take MAO inhibitors at the same time. That can increase the plasma concentration of NRIs in the body.
Beware of taking atomoxetine in combination with: CYP2D6 inhibitors (e.g., fluoxetine, paroxetine and quinidine) can increase exposure for atomoxetine and it can also increase atomoxetine steady-state plasma concentration. Antihypertensive drugs because it can possibly increase the blood pressure β2-agonist e.g. albuterol because it may increase the efficacy of albuterol on the cardiovascular system. Medicines that affect norepinephrine (e.g. venlafaxine, imipramine, mirtazapine) should be used with caution when administered with atomoxetine due to possible synergy or synergistic effects on pharmacodynamic effects.
Beware of taking reboxetine in combination with: Antifungals, e.g. ketoconazole. Antibiotics, e.g. erythromycin, rifampicin. Ergot derivatives used to treat migraine or Parkinson's disease may cause an increase in blood pressure. Any potassium-depleting diuretics (medicines for eliminating water), e.g. thiazides. Carbamazepine and phenobarbital, medicines used to control fits or seizures. Herbal medicines that contain St. John's Wort.
Contraindications A few contraindications should be taken into account for atomoxetine. The first one is hypersensitivity; patients known to be hypersensitive to atomoxetine or other constituents of the product should avoid using it. MAO inhibitors (MAOI) should also be taken into account for contraindications. Atomoxetine should not be taken within 2 weeks after discontinuing an MAOI or completely avoid taking MAOI. The same applies to treatment with an MAOI, that it should not be initiated within 2 weeks after discontinuing atomoxetine. Serious and sometimes fatal reactions may occur when atomoxetine and drugs that affect brain monoamine concentration are given concurrently or in close proximity. Examples of reactions are hyperthermia, inflexibility, myoclonus and altered mental states that include extreme agitation, possibly progressing to delirium and coma. Increased risk of mydriasis was associated with Strattera use in clinical trials. Therefore, the use of Strattera is not recommended in patients with narrow angle glaucoma. Patients with pheochromocytoma or a history of pheochromocytoma should not take Strattera because serious reactions (elevated blood pressure and tachyarrhythmia) have been reported in patients who received Strattera. Last but not least, patients with severe cardiac or vascular disorders should not be using Strattera.
The only contraindication that is reported in the IMB Micromedex database is prior hypersensitivity to the active compound, reboxetine.
Pharmacology
Role of norepinephrine Norepinephrine (NE), also known as noradrenaline, is a neurotransmitter that is released predominantly from the ends of sympathetic nerve fibers. The sympathetic nervous system is stimulated in fearful situations and elicits the fight-or-flight response both in animals and humans. This stimulus causes the release of catecholamines such as norepinephrine. The chemical class of catecholamines has positive chronotropic, inotropic and dromotropic effects which lead to increased heart rate, blood pressure, and cardiac output. NE is one of the crucial neurotransmitters in the central nervous system (CNS) and plays an important role in regulating blood pressure, energy metabolism and controlling flexor muscles. The substance has involvement in sleep and mood regulation, expression of behavior and the general degree of alertness and arousal. In the face of a threat, whether it's real or perceived, NE being the most prominent receptor modulator activates behavioral adaptions to maintain homeostasis. The physiological responses in these threatening situation creates emotions of stress and acute anxiety. Responses such as dilatation of bronchioles and pupils, increased heart rate and kidney renin secretion, constricted blood vessels and inhibited peristalsis. Norepinephrine is biosynthesized from the amino acid precursor tyrosine and then is sequentially hydroxylated to dihydroxyphenylalanine, also known as Dopa. Decarboxylation on Dopa generates the neurotransmitter dopamine, afterward when hydroxylated it produces norepinephrine.
Role of norepinephrine transporter (NET) Approximately 90% of released NE from the sympathetic nerve fibers is taken up again by postganglionic adrenergic neurons through the protein NET. The reuptake of NE is either repackaged into vesicles or degraded by the enzyme monoamine oxidase (MAO). The NET is located in the plasma membrane of noradrenergic neurons and serves as the fundamental mechanism by terminating the biological effects of NE in the synapse. The NE inactivation process, when taken up by the NET, is crucial in preventing too much increase in the NE concentration in the synaptic cleft. The reuptake of NE is competitive with various naturally occurring amines and drugs.
Mechanism of action NET is a target for drugs, that are potent and selective or mixed NET inhibitors (e.g. atomoxetine and reboxetine), named NRI, have been successfully developed to treat various mental disorders, but unfortunately also drugs of abuse (e.g. cocaine). The NRI drugs used medically for mental disorders include attention-deficit hyperactivity disorder (ADHD), depression, anxiety disorders, mood disorders, personality disorders, bipolar disorder, psychosexual disorders and schizophrenia. NRI drugs bind to the NET and inhibit the reuptake of NE. These drugs therefore increase the availability of NE for binding to postsynaptic receptors that regulate adrenergic neurotransmission. Selective NRIs blocks only the monoamine transporter NET, excluding the other two monoamine transporters (DAT and SERT) for dopamine and serotonin. Because if the NRI drug affects those other monoamine transporters they would be called nonselective inhibitors. However, the selectivity and mechanism of action for the NRI drugs remain unknown and, to date, only a very limited number of NRI-selective inhibitors are available. Research has shown that these new ligands vary both in the selectivity and potency at each of these three monoamine transporter sites (NET, DAT and SERT). However, those ligands may be of value in clarifying the pharmacological mechanisms, and in the discovery of new selective NRI drugs with fewer side effects.
Pharmacokinetics + Drug Bioavailability Protein binding tmax (hours) t1/2 (hours) Atomoxetine 63-94% 98% 1 4,5-19 Reboxetine 94% 96-97% 2 12–12,5 ViloxazineER relative to IR: 88%76-82%: ~5 (3-9): 2-5 : 7 ± 4.7
tmax: Time to achieve a maximum plasma concentration t1/2: Biological half-life
Atomoxetine
The pharmacokinetics of atomoxetine are similar in children, teenagers and adults. Pharmacokinetics of atomoxetine has not been studied in children younger than 6 years old. Pharmacokinetic studies have shown that atomoxetine capsules and oral solutions are equivalent. Atomoxetine is very water soluble so it absorbed rapidly and completely after oral administration. Atomoxetine reaches Cmax 1 to 2 hours after administration. The bioavailability of atomoxetine after oral administration is 63-94%, it is dependent on individual differences in the first-pass metabolism. Atomoxetine is widely distributed and is highly (98%) bound to plasma proteins, mainly albumin. The volume of distribution for atomoxetine is 0.85 L/kg, with limited partitioning into red blood cells. Atomoxetine is mainly metabolized by the cytochrome P4502D6 (CYP2D6) enzyme system. The main metabolite formed is 4-hydroxyatomoxetine, which glucuronate rapidly. 4-hydroxyatomoxetine is equivalent to atomoxetine but is much lower in plasma. The mean elimination half-life of atomoxetine after oral administration is 3.6 hours in individuals in extensive metabolism and 21 hours in those with a slow metabolism. Atomoxetine is excreted mainly as 4-hydroxyatomoxetin-O-glucoronide with urine.
Reboxetine