Nefazodone
Nefazodone.svg
Nefazodone ball-and-stick model.png
Clinical data
Trade namesSerzone, Dutonin, Nefadar, others
Other namesBMY-13754-1; MJ-13754-1; MJ-13754; MS-13754
AHFS/Drugs.comMonograph
MedlinePlusa695005
Pregnancy
category
  • C
Routes of
administration		By mouth
ATC code
Legal status
Legal status
  • AU: S4 (Prescription only)
  • In general: ℞ (Prescription only)
Pharmacokinetic data
Bioavailability20% (variable)[1]
Protein binding99% (loosely)[1]
MetabolismLiver (CYP3A4, CYP2D6)[2]
Metabolites• Hydroxynefazodone[1]
• mCPP[1]
• p-Hydroxynefazodone[2]
• Triazoledione[1]
Elimination half-life• Nefazodone: 2–4 hours[1]
• Hydroxynefazodone: 1.5–4 hours[1]
• Triazoledione: 18 hours[1]
• mCPP: 4–8 hours[1]
ExcretionUrine: 55%
Feces: 20–30%
Identifiers
  • 1-(3-[4-(3-chlorophenyl)piperazin-1-yl]propyl)-3-ethyl-4-(2-phenoxyethyl)-1H-1,2,4-triazol-5(4H)-one
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
Chemical and physical data
FormulaC25H32ClN5O2
Molar mass470.01 g·mol−1
3D model (JSmol)
  • Clc4cccc(N3CCN(CCCN1/N=C(\N(C1=O)CCOc2ccccc2)CC)CC3)c4
  • InChI=1S/C25H32ClN5O2/c1-2-24-27-31(25(32)30(24)18-19-33-23-10-4-3-5-11-23)13-7-12-28-14-16-29(17-15-28)22-9-6-8-21(26)20-22/h3-6,8-11,20H,2,7,12-19H2,1H3 checkY
  • Key:VRBKIVRKKCLPHA-UHFFFAOYSA-N checkY
  (verify)

Nefazodone, sold formerly under the brand names Serzone, Dutonin, and Nefadar among others, is an atypical antidepressant medication which is used in the treatment of depression and for other uses.[3][4][5][6] It has been mostly withdrawn from the market due to toxicity.[7][8] The medication is taken by mouth.[9]

Side effects of nefazodone include dry mouth, sleepiness, nausea, dizziness, blurred vision, weakness, lightheadedness, confusion, and postural low blood pressure, among others.[9] Rarely, nefazodone can cause serious liver damage, with an incidence of death or liver transplantation of about 1 in every 250,000 to 300,000 people per year.[9] Nefazodone is a phenylpiperazine compound and is related to trazodone. It has been described as a serotonin antagonist and reuptake inhibitor (SARI) due to its combined actions as a potent antagonist of the serotonin 5-HT2A and 5-HT2C receptors and weak serotonin–norepinephrine–dopamine reuptake inhibitor (SNDRI).

Nefazodone was introduced for medical use in 1994.[6][10][7] Generic versions were introduced in 2003.[11] Serious liver toxicity was first reported with nefazodone in 1998, and it was withdrawn from most markets by 2004.[7][8] However, as of 2023, it continues to be available in the United States in generic from one manufacturer, Teva Pharmaceuticals.[12]

Medical uses

Nefazodone is used to treat major depressive disorder, aggressive behavior, anxiety,[13] and panic disorder.[14]

Available forms

Nefazodone is available as 50 mg, 100 mg, 150 mg, 200 mg, and 250 mg tablets for oral ingestion.[15]

Contraindications

Contraindications include the coadministration of terfenadine, astemizole, cisapride, pimozide, or carbamazepine. Nefazodone is contraindicated in patients who were withdrawn from nefazodone because of evident liver injury as well as those that have shown hypersensitivity to the drug, its inactive ingredients, or other phenylpiperazine antidepressants. Furthermore, the coadministration of triazolam and nefazodone should be avoided for all patients, including the elderly, since it causes a significant increase in the plasma level of triazolam and not all commercially available dosage forms of triazolam permit a sufficient dosage reduction. If coadministrated, a 75% reduction in the initial dosage of triazolam is recommended.[15]

Side effects

Common and mild side effects of nefazodone reported in clinical trials more often than placebo include dry mouth (25%), sleepiness (25%), nausea (22%), dizziness (17%), blurred vision (16%), weakness (11%), lightheadedness (10%), confusion (7%), and orthostatic hypotension (5%). Rare and serious adverse reactions may include allergic reactions, fainting, painful/prolonged erection, and jaundice.[9] Nefazodone is not especially associated with increased appetite and weight gain.[16] It is also known for having low levels of sexual side effects in comparisons to SSRIs.[17][18]

Nefazodone can cause severe liver damage, leading to a need for liver transplant, and death. The incidence of severe liver damage is approximately 1 in every 250,000 to 300,000 patient-years.[6][9] By the time that it started to be withdrawn from the market in 2003, nefazodone had been associated with at least 53 cases of liver injury, with 11 deaths, in the United States,[19] and 51 cases of liver toxicity, with 2 cases of liver transplantation, in Canada.[20][21] In a Canadian study which found 32 cases in 2002, it was noted that databases like that used in the study tended to include only a small proportion of suspected drug reactions.[21]

Protocols are that nefazodone should not be used in patients who have a pre-existing liver condition. Prior to treatment liver enzymes should be tested to make sure there is not an underlying liver condition. If serum AST or serum ALT levels are more than 3 times the upper limit of normal (ULN) should be permanently withdrawn from the drug. Regular enzyme labs should be done every 6 months. Due to liver issues nefazodone should not be a first line treatment.[22]

Interactions

Nefazodone is a potent inhibitor of CYP3A4, and may interact adversely with many commonly used medications that are metabolized by CYP3A4.[23][24][25]

Pharmacology

Pharmacodynamics

Nefazodone[26]
Site Ki (nM) Species Ref
SERT 200–459 Human [27][28]
NET 360–618 Human [27][28]
DAT 360 Human [27]
5-HT1A 80 Human [29]
5-HT2A 26 Human [29]
5-HT2C 72 Human [30]
α1 5.5–48 Human [29][28]
  α1A 48 Human [30]
α2 84–640 Human [29][28]
β >10,000 Rat [31]
D2 910 Human [29]
H1 ≥370 Human [29][30]
mACh >10,000 Human [29]
Notes: Values are Ki (nM). The smaller the value, the more strongly the drug binds to the site.

Nefazodone acts primarily as a potent antagonist of the serotonin 5-HT2A receptor and to a lesser extent of the serotonin 5-HT2C receptor.[29] It also has high affinity for the α1-adrenergic receptor and serotonin 5-HT1A receptor, and relatively lower affinity for the α2-adrenergic receptor and dopamine D2 receptor.[29] Nefazodone has low but significant affinity for the serotonin, norepinephrine, and dopamine transporters as well, and therefore acts as a weak serotonin-norepinephrine-dopamine reuptake inhibitor (SNDRI).[27] It has low but potentially significant affinity for the histamine H1 receptor, where it is an antagonist, and hence may have some antihistamine activity.[29][30] Nefazodone has negligible activity at muscarinic acetylcholine receptors, and accordingly, has no anticholinergic effects.[27]

Pharmacokinetics

The bioavailability of nefazodone is low and variable, about 20%.[1] Its plasma protein binding is approximately 99%, but it is bound loosely.[1]

Nefazodone is metabolized in the liver, with the main enzyme involved thought to be CYP3A4.[2] The drug has at least four active metabolites, which include hydroxynefazodone, para-hydroxynefazodone, triazoledione, and meta-chlorophenylpiperazine.[1] Nefazodone has a short elimination half-life of about 2 to 4 hours.[1] Its metabolite hydroxynefazodone similarly has an elimination half-life of about 1.5 to 4 hours, whereas the elimination half-lives of triazoledione and mCPP are longer at around 18 hours and 4 to 8 hours, respectively.[1] Due to its long elimination half-life, triazole is the major metabolite and predominates in the circulation during nefazodone treatment, with plasma levels that are 4 to 10 times higher than those of nefazodone itself.[1][32] Conversely, hydroxynefazodone levels are about 40% of those of nefazodone at steady state.[1] Plasma levels of mCPP are very low at about 7% of those of nefazodone; hence, mCPP is only a minor metabolite.[1][32] mCPP is thought to be formed from nefazodone specifically by CYP2D6.[2][32]

The ratios of brain-to-plasma concentrations of mCPP to nefazodone are 47:1 in mice and 10:1 in rats, suggesting that brain exposure to mCPP may be much higher than plasma exposure.[1] Conversely, hydroxynefazodone levels in the brain are 10% of those in plasma in rats.[1] As such, in spite of its relatively low plasma concentrations, brain exposure to mCPP may be substantial, whereas that of hydroxynefazodone may be minimal.[1]

Chemistry

Nefazodone is a phenylpiperazine;[33] it is an alpha-phenoxyl derivative of etoperidone which in turn was a derivative of trazodone.[34]

History

Nefazodone was discovered by scientists at Bristol-Myers Squibb (BMS) who were seeking to improve on trazodone by reducing its sedating qualities.[34]

BMS obtained marketing approvals for nefazodone worldwide, including in the United States and Europe, in 1994.[6][10][7] It was marketed in the United States under the brand name Serzone[35] and in Europe under the brand name Dutonin.[36]

The first reports of serious liver toxicity with nefazodone were published in 1998 and 1999.[37][38] These instances were quickly followed by many additional cases.[39][19][20][21]

In 2002 the FDA obligated BMS to add a black box warning about potential fatal liver toxicity to the drug label.[40][8] Worldwide sales in 2002 were $409 million.[36]

In 2003 Public Citizen filed a citizen petition asking the FDA to withdraw the marketing authorization in the United States, and in early 2004 the organization sued the FDA to attempt to force withdrawal of the drug.[40][41] The FDA issued a response to the petition in June 2004 and filed a motion to dismiss, and Public Citizen withdrew the suit.[41]

Generic versions were introduced in the United States in 2003[11] and Health Canada withdrew the marketing authorization that year.[42]

Sales of nefazodone were about $100 million in 2003.[43] By that time, it was also being marketed under the additional brand names Serzonil, Nefadar, and Rulivan.[6]

In April 2004, BMS announced that it was going to discontinue the sale of Serzone in the United States in June 2004 and said that this was due to declining sales.[8][43] By that time, BMS had already withdrawn the drug from the market in Europe, Australia, New Zealand, and Canada.[8]

As of 2012, generic nefazodone was still available in the United States.[44]

In August 2020, Teva Pharmaceuticals placed nefazodone in shortage due to a shortage of a raw ingredient. On December 20, 2021, nefazodone was again made available in all strengths.[45][46]

Society and culture

Generic names

Nefazodone is the generic name of the drug and its INN and BAN, while néfazodone is its DCF and nefazodone hydrochloride is its USAN and USP.[3][4][47][5]

Brand names

Nefazodone has been marketed under a number of brand names including Dutonin (AT, ES, IE, UK), Menfazona (ES), Nefadar (CH, DE, NO, SE), Nefazodone BMS (AT), Nefazodone Hydrochloride Teva (US), Reseril (IT), Rulivan (ES), and Serzone (AU, CA, US).[4][5]

Research

Nefazodone was under development for the treatment of panic disorder, and reached phase 3 clinical trials for this indication, but development was discontinued in 2004.[48]

The use of nefazodone to prevent migraine has been studied, due to its antagonism of the serotonin 5-HT2A and 5-HT2C receptors.[49][50][51]

References

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