Otsuka Pharmaceutical Co., Ltd. (Otsuka) and H. Lundbeck A/S (Lundbeck) announce positive results of the Phase 3 clinical trial of brexpiprazole in the treatment of agitation in patients with Alzheimer’s dementia (NCT03548584).
The analysis concluded that there is a statistically significant difference (p=0.0026) in the mean change from baseline to Week 12 in the Cohen-Mansfield Agitation Inventory (CMAI) total score between brexpiprazole and placebo.
Full study results are not yet available. Further prespecified and exploratory analyses of the data set will be conducted to determine the full potential of brexpiprazole in the treatment of agitation in patients with Alzheimer’s dementia.
Based on this outcome Otsuka and Lundbeck are planning a regulatory filing to the U. S. Food and Drug Administration (FDA) later in 2022. The Supplemental New Drug Application (sNDA) will be comprised of this study as well as two earlier trials.1 In February 2016, the FDA granted fast track designation for brexpiprazole for treatment of agitation in patients with Alzheimer’s dementia.
Otsuka and Lundbeck are incredibly grateful to all the patients with Alzheimer´s dementia, their families and the investigators who participated in the trials and contributed greatly to this research.
The trial results are planned to be submitted for scientific publication at a later date.
About the Study
Trial 331-14-213 (NCT03548584; Trial 213) was designed to assess the safety, tolerability and efficacy of two fixed doses of brexpiprazole (2 mg/day and 3 mg/day) in the treatment of patients with agitation in Alzheimer’s dementia. The trial consisted of a continuous 12-week double-blind treatment period with a 30-day follow-up. The randomized trial population included 345 male and female patients, aged 55–90 years (inclusive), with a diagnosis of probable Alzheimer’s disease, and meeting criteria of agitation as defined by the International Psychogeriatric Association (IPA). The primary outcome was the change in the CMAI total score at week 12 for all patients treated with brexpiprazole versus those treated with placebo. The key secondary outcome was the change in the Clinical Global Impression – Severity of Illness (CGI-S) score, as related to symptoms of agitation. Participating countries include Bulgaria, Hungary, Serbia, Slovakia, Spain, Ukraine, and USA. The study included both patients who were living at home and those living in institutionalized settings.
In the study, the improvements from baseline on the primary endpoint of CMAI for patients receiving brexpiprazole or 2 mg/day or 3 mg/day were statistically greater than for those receiving placebo (p=0.0026). This result was supported by a statistically superior improvement on the key secondary endpoint of CGI-S, as related to agitation (p=0.0055).
Brexpiprazole was generally well tolerated, and no new safety signals were observed. The only treatment emergent adverse event (TEAE) with more than 5% incidence in patients treated with brexpiprazole was headache (6.6% vs. 6.9% for placebo). The following TEAEs occurred at an incidence of at least 2% in the brexpiprazole treatment group and greater than that of placebo: somnolence, nasopharyngitis, dizziness, diarrhea, urinary tract infection, and asthenia. There was one death observed in the 3 mg/day treatment group, assessed as not related to treatment by the investigator.
The Cohen-Mansfield Agitation Inventory (CMAI) is a caregiver rated questionnaire that measures the frequency of manifestations of 29 agitated behaviors in elderly persons, such as pacing, restlessness, yelling, and hitting.2 It has been used extensively for assessing agitation and has been adapted and validated for different patient settings.2-5
About Agitation in Alzheimer’s Dementia
Neuropsychiatric symptoms (NPS) of Alzheimer’s dementia, such as agitation are associated with poor caregiver outcomes, including reduced quality of life and poorer health.6-9
Agitation is a common neuropsychiatric symptom of Alzheimer’s dementia. It is reported in approximately 45% of patients with Alzheimer’s dementia and has a large impact on quality of life for the patients and their loved ones.10-11 Agitation covers a large group of behaviors occurring in patients with Alzheimer’s dementia, and it is an excessive/inappropriate manifestation of “normal” human emotions and behaviors. Such behaviors include pacing, gesturing, profanity, shouting, shoving, and hitting.12
Symptoms of agitation are also a consistent predictor of nursing home admission in patients with dementia.13-15
Agitation in Alzheimer’s dementia is thought to be associated with underlying pathophysiological circuit level dysfunctions in noradrenergic, serotonergic, and dopaminergic neurotransmission.16
Brexpiprazole was approved in the U.S. on July 10, 2015, as an adjunctive therapy to antidepressants in adults with major depressive disorder and as a treatment in adults with schizophrenia. Brexpiprazole was also approved in 2017 in Health Canada and by the EMA in Europe in 2018 for the treatment of schizophrenia. In addition, brexpiprazole has been approved in several other countries across the world. Brexpiprazole is distributed and marketed under the brand name Rexulti®. In Europe, brexpiprazole is distributed and marketed under the brand name Rxulti®
Brexpiprazole was discovered by Otsuka and is being co-developed by Otsuka and Lundbeck. The efficacy of brexpiprazole may be mediated through a combination of antagonism at noradrenaline alpha1B/2C receptors and serotonin 5-HT2A receptors and partial agonist activity at serotonin5-HT1A and dopamine D2 receptors.17-18
About H. Lundbeck A/S
Lundbeck is a global pharmaceutical company specialized in brain diseases. For more than 70 years, we have been at the forefront of neuroscience research. We are tirelessly dedicated to restoring brain health, so every person can be their best. We are committed to fighting stigma and discrimination against people living with brain diseases and advocating for broader social acceptance of people with brain health conditions. Our research programs tackle some of the most complex challenges in neuroscience, and our pipeline is focused on bringing forward transformative treatments for brain diseases for which there are few, if any therapeutic options.
- Grossberg GT et al. Efficacy and Safety of Brexpiprazole for the Treatment of Agitation in Alzheimer’s Dementia: Two 12-Week, Randomized, Double-Blind, Placebo-Controlled Trials. Am J Geriatr Psychiatry. 2020;28(4):383-400
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- Kupeli N et al. Psychometric evaluation of the Cohen-Mansfield Agitation Inventory in an acute general hospital setting. Int J Geriatr Psychiatry 2018; 33: e158–e165
- de Jonghe JF, Kat MG. Factor structure and validity of the Dutch version of the Cohen-Mansfield Agitation Inventory (CMAI-D). J Am Geriatr Soc 1996; 44: 888–889
- Griffiths AW et al. Validation of the Cohen-Mansfield Agitation Inventory Observational (CMAI-O) tool. Int Psychogeriatr 2020; 32: 75–85
- Brodaty H, Hadzi-Pavlovic D. Psychosocial effects on carers of living with persons with dementia. Aust NZ J Psychiatry 1990; 24: 351–361
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- Karttunen K et al. Neuropsychiatric symptoms and quality of life in patients with very mild and mild Alzheimer’s disease. Int J Geriatr Psychiatry 2011; 26: 473–482
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- Fillit H et al. Impact of agitation in long-term care residents with dementia in the United States. Int J Geriatr Psychiatry 2021; 36: 1959–1969
- Cummings J et al. Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition.
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- Gaugler JE et al. Predictors of nursing home admission for persons with dementia. Med Care 2009; 47: 191–198
- Kales HC et al. Rates of clinical depression diagnosis, functional impairment, and nursing home placement in coexisting dementia and depression. Am J Geriatr Psychiatry 2005;13:441-449
- Yaffe K et al. Patient and caregiver characteristics and nursing home placement in patients with dementia. JAMA 2002;287:2090 -2097
- Liu, K. Y. et al. The neurochemistry of agitation in Alzheimer’s disease: a systematic review. Ageing Research Reviews. 2018;43:99–107
- Maeda K, Sugino H, Akazawa H, et al. Brexpiprazole I: in vitro and in vivo characterization of a novel serotonin–dopamine activity modulator. J Pharmacol Exp Ther. 2014a;350(3):589–604.
- Maeda K, Lerdrup L, Sugino H, et al. Brexpiprazole II: antipsychotic-like and procognitive effects of a novel serotonin–dopamine activity modulator. J Pharmacol Exp Ther. 2014b;350(3):605–614.