Synonyms: Rexulti, OPC 34712
Therapy Type: Small Molecule (timeline)
Target Type: Other Neurotransmitters (timeline)
Condition(s): Alzheimer's Disease, Schizophrenia
U.S. FDA Status: Alzheimer's Disease (Phase 3), Schizophrenia (Approved)
Company: Lundbeck, Otsuka Pharmaceutical Co., Ltd.
Brexpiprazole is an orally available dopamine receptor D2 partial agonist. This quinolinone derivative is a successor to aripiprazole (Abilify, Aripiprex), an approved, widely used drug that is also a dopamine D2 receptor partial agonist. Brexpiprazole is being developed worldwide as an add-on therapy primarily for the treatment of depression and schizophrenia, but also for agitation and other behavioral symptoms in patients with Alzheimer's disease. In addition, it is being tested in people with bipolar and post-traumatic stress disorder.
In July 2013, Otsuka and Lundbeck started a Phase 3 study in the U.S., Europe, and Russia, to evaluate brexpiprazole for the treatment of agitation in 560 patients with moderate to severe Alzheimer's dementia living in an institution or with a caregiver at home. The trial compared safety, efficacy, and tolerability of three months of 0.5, 1, and 2 mg of brexpiprazole or placebo once daily. The primary endpoint was change on the Cohen-Mansfield Agitation Inventory, but the trial also measures changes in aggression, global clinical status, and quality of life. In April 2015, this trial dropped the 0.5 mg dose and continued with a target enrollment of 420 patients. The trial offered a two-month safety follow-up study.
In September 2013, a second Phase 3 trial started enrolling an anticipated 230 patients. This trial explored brexpiprazole using a flexible dose titrated between 0.5 and 2 mg/day depending on efficacy and tolerability in a given patient, but is otherwise identical. In June 2014, Otsuka added a two-month follow-up study for participants in either of these two trials.
Top-line results of both trials were announced in May 2017 (see press release); more details were presented at the meeting of the American Association of Geriatric Psychiatry in March 2018 (press coverage). In the fixed-dose trial, patients on 2 mg daily were reported to have shown statistically significant improvement over placebo on the CMAI after three months. In the flexible-dose trial, the change in CMAI missed significance. A post hoc analysis of only the 2 mg/day group found a significant improvement in the CMAI compared to placebo. The full study group showed improvement on the Clinical Global Impression-Severity of Illness (CGI-S), a secondary measure of agitation.
Common adverse events were insomnia, residual agitation, and drowsiness in some patients. The investigators noted variability in data from different countries, which might be related to differences in standard of care. Patients in the U.S. responded well; patients from Russian sites did not.
Following discussions with the FDA, the sponsors started two new Phase 3 trials in 2018. In May, they initiated a three-month trial testing two unspecified doses of brexpiprazole or placebo in 225 Alzheimer's patients in the U.S. and Europe. In August, a similar trial started in Japan; it will treat 407 patients with 1 or 2 mg brexpiprazole per day or placebo for 10 weeks. For both, the primary endpoint is the change from baseline in CMAI at three months. The secondary endpoint is change in CGI-S. To monitor safety, the U.S. study will offer a 12-week extension, the Japanese study a 14-week extension. The trials will finish in 2020 and 2021.
For all trials of brexpiprazole, see clinicaltrials.gov.
Clinical Trial Timeline
- Phase 3
- Study completed / Planned end date
- Planned end date unavailable
- Study aborted
Last Updated: 01 Oct 2019
- Swainston Harrison T, Perry CM. Aripiprazole: a review of its use in schizophrenia and schizoaffective disorder. Drugs. 2004;64(15):1715-36. PubMed.
- Costentin J. [A new approach to antischizophrenic therapeutics: D2 dopamine receptor partial agonists]. Ann Pharm Fr. 2009 Sep;67(5):310-9. Epub 2009 Jul 18 PubMed.
- Citrome L. A review of the pharmacology, efficacy and tolerability of recently approved and upcoming oral antipsychotics: an evidence-based medicine approach. CNS Drugs. 2013 Nov;27(11):879-911. PubMed.
- Porsteinsson AP, Antonsdottir IM. An update on the advancements in the treatment of agitation in Alzheimer's disease. Expert Opin Pharmacother. 2017 Apr;18(6):611-620. Epub 2017 Mar 28 PubMed.