Article: Ziprasidone

Ziprasidone
Systematic (IUPAC) name
6-chloro-5-[2-[4-(7-thia-8-azabicyclo [4.3.0]nona-1,3,5,8-tetraen-9-yl) piperazin-1-yl]ethyl]-1,3-dihydroindol-2-one
Identifiers
CAS number	146939-27-7
ATC code	N05AE04
PubChem	60854
DrugBank	APRD00540
Chemical data
Formula	C21H21ClN4OS
Mol. weight	412.936
Pharmacokinetic data
Bioavailability	100% (intramuscular) 60% (orally)
Metabolism	hepatic (aldehyde reductase)
Half life	2 - 5 hours
Excretion	?
Therapeutic considerations
Pregnancy cat.	USA: C
Legal status	Rx only
Routes	oral, intramuscular

Ziprasidone (marketed as Geodon®, Zeldox®) was the fifth atypical antipsychotic to gain FDA approval. Ziprasidone is Food and Drug Administration (FDA) approved for the treatment of schizophrenia, and the intramuscular injection form of ziprasidone is approved for acute agitation in schizophrenic patients. Ziprasidone has also received approval for acute treatment of mania associated with bipolar disorder. The brand name Geodon® has been suggested to bring to mind the phrase 'down (don) to earth (geo)' referring to the goals of the medication.

Pharmacology

Ziprasidone has a high affinity for dopamine, serotonin, and alpha-adrenergic receptors and a medium affinity for histaminic receptors. Ziprasidone is somewhat unique among the "atypicals" in that it also displays some inhibition of synaptic reuptake of serotonin and norepinephrine, although the clinical significance of this is unknown. The mechanism of action of ziprasidone is unknown. However it is theorized that its antipsychotic activity is mediated primarily by antagonism at dopamine receptors, specifically D2. Serotonin antagonism may also play a role in the effectiveness of ziprasidone, but the significance of 5-HT2A antagonism is debated among researchers. Antagonism at histaminic and alpha adrenergic receptors likely explains some of the side effects of ziprasidone, such as sedation and orthostasis.

Pharmacokinetics

The systemic bioavailability of ziprasidone administered intramuscularly is 100%, or 60%, administered orally with food. After a single dose intramuscular administration, the peak serum concentration typically occurs at about 60 minutes after the dose is administered, or earlier. Steady state plasma concentrations are achieved within one to three days. The mean half-life (T 1/2) ranges from two to five hours. Exposure increases in a dose-related manner and following three days of intramuscular dosing, little accumulation is observed.

Metabolism

Ziprasidone is hepatically metabolized by aldehyde reductase. Minor metabolism occurs via cytochrome P450 3A4. Medication that induce (e.g carbamazepine) or inhibit (e.g. ketoconazole) CYP3A4 have been shown to decrease and increase, respectively, blood levels of ziprasidone. There are no known induces or inhibitors of aldehyde reductase.

Adverse events

Ziprasidone may increase the QTc interval in some patients and may increase the risk of a type of heart arrythmia known as torsades de pointes. Ziprasidone should be used cautiously in patients taking other medications likely to interact with ziprasidone or increase the QTc interval.

This medication also can cause birth defects. Ziprasidone actually has not been studied in humans, but studies in laboratory have shown that this medication may cause birth defects.

Adverse events reported for ziprasidone include sedation, insomnia, orthostasis, akathisia and other permanent extrapyramidal side-effects such as tardive dyskinesia. Rarely, temporary speech disorders may result.

The medication can cause any conceivable side effect. See the FDA label for more information.

Recently, the FDA required the manufacturers of all atypical antipsychotics to include a warning about the risk of hyperglycemia and Type II diabetes with atypical antipsychotics. Some evidence suggests that ziprasidone may not be as bad as some of the other atypical antipsychotics at causing insulin resistance and weight gain. In fact, in a trial of long term therapy with ziprasidone, overweight patients (BMI>27) actually had a mean weight loss overall. Ziprasidone, though, is not a weight loss drug. The weight loss reflected in this study on ziprasidone was really reflective of patients who had gained weight on other antipsychotics who were now trending back toward their baseline. According to the manufacturer insert ziprasidone caused an average weight gain of 2.2kg.