Sulpiride

Sulpiride

Systematic (IUPAC) name
(±)-5-(aminosulfonyl)-N-[(1-ethylpyrrolidin-2-yl)methyl]-2-methoxybenzamide
Clinical data
AHFS/Drugs.com	International Drug Names
Pregnancy cat.	?
Legal status	℞ Prescription only
Routes	Oral
Pharmacokinetic data
Bioavailability	25–35%
Half-life	7 hours
Identifiers
CAS number	15676-16-1 Y
ATC code	N05AL01
PubChem	CID 5355
IUPHAR ligand	5501
DrugBank	DB00391
ChemSpider	5162 Y
UNII	7MNE9M8287 Y
KEGG	D01226 Y
ChEMBL	CHEMBL26 Y
Chemical data
Formula	C15H23N3O4S
Mol. mass	341.427 g/mol
SMILES O=S(=O)(N)c1cc(c(OC)cc1)C(=O)NCC2N(CC)CCC2
InChI InChI=1S/C15H23N3O4S/c1-3-18-8-4-5-11(18)10-17-15(19)13-9-12(23(16,20)21)6-7-14(13)22-2/h6-7,9,11H,3-5,8,10H2,1-2H3,(H,17,19)(H2,16,20,21) Y Key:BGRJTUBHPOOWDU-UHFFFAOYSA-N Y
Y (what is this?)  (verify)

Sulpiride (sold as Meresa, Bosnyl, Dogmatil, Dolmatil, Eglonyl, Modal; as Espiride in South Africa) is an atypical antipsychotic drug of the benzamide class used mainly in the treatment of psychosis associated with schizophrenia and major depressive disorder. Sulpiride is more commonly used in Europe and Japan. Levosulpiride is its purified levo- isomer and is sold in India for similar purpose. So far it has not been approved in the United States and Canada. The drug has strong chemical and clinical similarities to the related antipsychotic amisulpride.

Uses and dosage

• Productive psychosis: treatment with rather high doses—in excess of 600 mg daily
• Long-term treatment of negative (unproductive) psychosis: in moderate doses (approx. 600 mg daily)
• Treatment of depression and vertigo: in low to moderate doses (50 to 200 mg daily)
• Levosulpiride has also been promoted as a gastroprokinetic agent

Pharmacology

Pharmacokinetics

Sulpiride is absorbed slowly from the gastrointestinal tract. Its oral bioavailability is only 25 to 35% with marked interindividual differences. The peak plasma concentration is reached 4.5 hours after oral dosing. The usual half-life is 6 to 8 hours. Ninety-two percent is excreted unchanged in the urine. Sulpiride is usually given in 2 or 3 divided doses.

Pharmacodynamics

Sulpiride is a selective antagonist at dopamine D₂ and D₃ receptors. This action dominates in doses exceeding 600 mg daily. In doses of 600 to 1,600 mg sulpiride shows mild sedating and antipsychotic activity. Its antipsychotic potency compared to chlorpromazine is only 0.2 (1/5). In low doses (in particular 50 to 200 mg daily) its prominent feature is antagonism of presynaptic inhibitory dopamine receptors accounting for some antidepressant activity and a stimulating effect. Therefore, it is in these doses used as a second line antidepressant. Additionally, it alleviates vertigo.

The benzamide neuroleptics (including sulpiride, amisulpride, and sultopride) have been shown to activate the endogenous gamma-hydroxybutyrate receptor in vivo at therapeutic concentrations. Sulpiride was found in one study in rats to upregulate GHB receptors. GHB has neuroleptic properties and it is believed binding to this receptor may contribute to the effects of these neuroleptics.

Side effects

Sulpiride has fewer extrapyramidal side effects (dystonia, parkinsonism, and akathisia) than many of the older antipsychotic medications.

Sulpiride can occasionally increase motor agitation and can cause or worsen aggressive, agitated or excitation symptomatology; therefore caution is required in individuals who have mania or hypomania as these side effects are more likely in this population of people. Other adverse effects include delirium/confusion, catatonia, depression, somnolence, lassitude and insomnia and other sleep disturbances, overstimulation and agitation may occur. Also possible is the development of extrapyramidal effects, such as akathisia, acute dystonia and parkinsonism; tardive dyskinesia develops rarely. Patients with no history of convulsions have experienced convulsions as a result of sulpiride therapy. Sulpiride can cause withdrawal symptoms if the drug is withdrawn too quickly. Some of these withdrawal symptoms include nausea, vomiting, sweating and insomnia; psychotic symptoms may also reoccur, as well as involuntary movement disorders, including akathisia, dystonia and dyskinesia. Gradual reduction when discontinuing therapy is therefore advised by experts to reduce the incidence and severity of any possible withdrawal symptoms.

Most of these do not seem to occur in a dose related manner. Other side effects occur infrequently (hypotension, rarely long-QT syndrome, dry mouth, sweating, nausea, activation or sedation, insomnia, allergic rash or pruritus). Isolated cases of the potentially life-threatening NMS (neuroleptic malignant syndrome) have been reported. Sulpiride should not be taken after 4 p.m. in order to avoid insomnia. The foremost problem with sulpiride is a strong stimulation of prolactin-secretion; whether this may contribute to the development of breast-cancer in women is currently not known.

• Levodopa : Sulpiride and levodopa have antagonistic effects.
• Alcohol : Sedation and hypotension may be potentiated.
• Antihypertensive agents : Hypotension may be potentiated (risk of postural collapse).
• Other central depressants : Increased sedation with negative impact on the capacity to drive or operate machinery.

Overdose

Sulpiride has a relatively low order of acute toxicity. Substantial amounts may cause severe but reversible dystonic crises with torticollis, protrusion of the tongue, and/or trismus. In some cases all the classical symptoms typical of severe Parkinson's Disease may be noted; in others, over-sedation/coma may occur. The treatment is largely symptomatic. Some or all extrapyramidal reactions may respond to the application of anticholinergic drugs such as biperiden or benztropine. All patients should be closely monitored for signs of long-QT syndrome and severe arrhythmias.

Contraindications and cautions

• Hypersensitivity to sulpiride
• Pre-existing breast cancer or other prolactin-dependent tumors
• Phaeochromocytoma
• Intoxication with other centrally active drugs
• Concomitant use of levodopa
• Caution : Pre-existing Parkinson's Disease
• Caution : Patients below 18 years of age (insufficient clinical data)
• Caution : Pre-existing severe heart disease/bradycardia, or hypokalemia (predisposing to long QT syndrome and severe arrhythmias)
• Caution : Patients with pre-existing epilepsy. Anticonvulsant therapy should be maintained.

Pregnancy and lactation

• Pregnancy: Animal studies did not reveal any embryotoxicity or fetotoxicity, nor did limited human experience. Due to insufficient human data, pregnant women should be treated with sulpiride only if strictly indicated. Additionally, the newborns of treated women should be monitored, because isolated cases of extrapyramidal side effects have been reported.
• Lactation: Sulpiride is found in the milk of lactating women. Since the consequences are unclear, women should not breastfeed during treatment.

Chemistry

Sulpiride can be synthesized from 5-aminosulfosalicylic acid. Methylating this with dimethylsulfate gives 2-methoxy-5-aminosulfonylbenzoic acid, which is transformed into an amide using 2-aminomethyl-1-ethylpyrrolidine as the amine component and carbonyldiimidazole (CDI) as a condensing agent.

See also

• Atypical antipsychotic
• Benzamide