Etifoxine

Summary

Etifoxine, sold under the trade name Stresam among others, is a nonbenzodiazepine anxiolytic agent, primarily indicated for short-term management of adjustment disorder, specifically instances of situational depression accompanied by anxiety, such as stress-induced anxiety.[2][6] Administration is by mouth.[7]Side effects associated with etifoxine use include slight drowsiness, headache, skin eruptions, and allergic reactions.[2][8][9] In rare cases, etifoxine has been linked to severe skin and liver toxicity, as well as menstrual bleeding between periods.[8][1] Unlike benzodiazepines, etifoxine does not cause sedation or lack of coordination.[10][3] Etifoxine acts as a GABAA receptor positive allosteric modulator and as a ligand for translocator proteins.[10] Both mechanisms are conjectured to contribute to its anxiolytic properties.[10][3]

Etifoxine
Clinical data
Trade namesStresam
Other namesÉtifoxine; Etifoxin; Etafenoxine; Etafenoxin; EFX; Hoe 36801; Hoe-36,801
AHFS/Drugs.comInternational Drug Names
Pregnancy
category
  • Not recommended[1]
Routes of
administration
Oral administration[2]
ATC code
Legal status
Legal status
  • In general: ℞ (Prescription only)
Pharmacokinetic data
Bioavailability90%[3]
Protein binding88–95%[4]
MetabolismLiver[5]
MetabolitesSeveral (including diethyletifoxine)[5]
Elimination half-lifeEtifoxine: 6 hours[5]
Diethyletifoxine: 20 hours[5]
ExcretionMainly urine, also bile[5][2]
Identifiers
  • 6-Chloro-N-ethyl-4-methyl-4-phenyl-4H-benzo[d][1,3]oxazin-2-amine
CAS Number
PubChem CID
  • 30768
IUPHAR/BPS
  • 5468
DrugBank
  • DB08986 checkY
ChemSpider
  • 28547 checkY
UNII
  • X24X82MX4X
KEGG
  • D07320 checkY
ChEMBL
  • ChEMBL2106227 checkY
ECHA InfoCard100.158.584 Edit this at Wikidata
Chemical and physical data
FormulaC17H17ClN2O
Molar mass300.79 g·mol−1
3D model (JSmol)
  • Interactive image
  • ClC1=CC=C2N=C(NCC)OC(C3=CC=CC=C3)(C)C2=C1
  • InChI=1S/C17H17ClN2O/c1-3-19-16-20-15-10-9-13(18)11-14(15)17(2,21-16)12-7-5-4-6-8-12/h4-11H,3H2,1-2H3,(H,19,20) checkY
  • Key:IBYCYJFUEJQSMK-UHFFFAOYSA-N checkY
  (verify)

Etifoxine was developed in the 1960s and was introduced for medical use in France in 1979.[11] Its marketed in 53 countries worldwide, although it remains unavailable in the United States.[7][11][12] Throughout the 2010s and early 2020s, the safety profile of etifoxine was scrutinized within France and the European Union, prompted by reports of toxicity.[13][8][7] The investigation revealed that instances of toxicity were infrequent, and etifoxine was allowed to remain on the market.[13][8][7]

Medical uses edit

Etifoxine has historically been used in the treatment of "psychosomatic manifestations of anxiety", for instance "autonomic dystonia, particularly with cardiovascular expression".[7][13][8][1] Subsequently, the indication for etifoxine has been more formalized as treatment of adjustment disorder (situational depression) with anxiety (ADWA) (e.g., stress-related anxiety).[7][14][3] Etifoxine has been found to reduce scores on the Hamilton Anxiety Rating Scale (HAM-A) in people with adjustment disorder with anxiety by approximately 50 to 75% after 4 weeks of treatment in clinical trials (e.g., AMETIS, ETILOR, ETIZAL, STRETI studies).[7] The medication is similarly effective or more effective than benzodiazepines like lorazepam, alprazolam, and clonazepam and more effective than buspirone for adjustment disorder with anxiety on the basis of directly comparative randomized controlled trials.[14][3][15][16][17][4] However, in the AMETIS study, both etifoxine and lorazepam failed to show greater effectiveness over placebo.[7]

The usual dosage of etifoxine (as the hydrochloride salt) is 150 to 200 mg per day in divided doses of 50 to 100 mg two to three times per day (e.g., 50 mg–50 mg–100 mg).[2][7][6][18][1][19][20] It is taken for a few days to a few weeks, but no longer than 12 weeks.[2][13][7][5]

Available forms edit

Etifoxine is provided in the form of oral capsules containing 50 mg etifoxine hydrochloride.[2][1][21][22]

Contraindications edit

Etifoxine is contraindicated in people with circulatory shock, severe liver impairment, severe kidney impairment, myasthenia gravis, galactosemia (due to lactose in the drug formulation), severe respiratory failure, and hypersensitivity (allergy) to etifoxine.[2][5] The medication is not recommended in children or adolescents under the age of 18[5] and is not recommended during pregnancy and breastfeeding due to insufficient data.[2][1] Caution is warranted with regard to combining etifoxine and other central depressants such as benzodiazepines, central analgesics, antipsychotics, sedative antihistamines, and alcohol.[2][1]

Side effects edit

Side effects of etifoxine include slight drowsiness and headache.[2][9] Rarely, etifoxine can cause benign skin eruptions or rashes and allergic reactions such as hives and angioedema.[2][8][1] Etifoxine shows less adverse effects of anterograde amnesia, sedation, impaired psychomotor performance, and withdrawal syndromes than those of benzodiazepines.[5] No cases of misuse or dependence with etifoxine were identified in a French pharmacovigilance survey, which is also in contrast to benzodiazepines.[8]

Etifoxine has been associated rarely with cases of severe dermal toxicity and liver toxicity.[8][23] Skin and subcutaneous disorders are the most frequently reported, but these generally resolve after drug cessation.[3] A 2012 review of etifoxine by the French National Pharmacovigilance Committee determined that etifoxine was safe and continued to provide a favorable alternative to benzodiazepine anxiolytics. The committee found (for a ten-year pharmacovigilance period) that safety concerns were rare or very rare and that the incidence of idiosyncratic hepatic (liver) problems were very rare.[13]

Pharmacology edit

Pharmacodynamics edit

Unlike benzodiazepines, etifoxine may produce its anxiolytic effects through a dual mechanism, by directly binding to GABAA receptors and (purportedly, exact binding site undetermined) to the mitochondrial translocator protein (TSPO). This results in stimulation of the biosynthesis of endogenous neurosteroids, for instance allopregnanolone, a highly potent GABAA receptor positive allosteric modulator.[24]

At GABAA receptors etifoxine binds at the α+β− interface and preferentially potentiates α2β3γ2 and α3β3γ2 receptor types.[25] This direct allosteric potentiation can only be observed at relatively high concentrations (starting at >1 mM) and is perhaps not physiologically relevant at normal human doses.[26] This is different from benzodiazepines and etifoxine can be used alongside benzodiazepines to potentiate their effects without competing for binding sites;[27] however, it also means that the direct effects of etifoxine are not reversed by the benzodiazepine antagonist flumazenil.[28]

Pharmacokinetics edit

Etifoxine is taken via oral administration.[2][5] It is rapidly absorbed from the gastrointestinal tract.[5] It is well-absorbed, with a bioavailability of 90%.[2][3] The time to peak levels of etifoxine is 2 to 3 hours.[5] The plasma protein binding of etifoxine is 88 to 95%.[4] It does not bind to blood cells.[2] The drug is known to cross the placental barrier.[2] Etifoxine is metabolized in the liver into several metabolites.[5] One of these metabolites, diethyletifoxine, is pharmacologically active.[5] The elimination half-life of etifoxine is 6 hours and of diethyletifoxine is almost 20 hours.[5] Etifoxine is eliminated in three phases.[2] The drug is excreted mainly in urine in the form of metabolites.[5] It is also excreted in bile.[5] Only small amounts are excreted unchanged.[5]

Chemistry edit

Etifoxine is a nonbenzodiazepine—that is, it is similarly a GABAA receptor positive allosteric modulator but its chemical structure is distinct from that of benzodiazepines.[3][29] Instead, it is a benzoxazine derivative.[3]

Etifoxine is used pharmaceutically as the hydrochloride salt.[30][31]

(S)-Etifoxine, the (S) enantiomer of etifoxine, was under development by Anvyl Pharmaceuticals for the treatment of neuropathic pain, but development was discontinued.[32] A deuterated form of etifoxine with improved pharmacokinetics known as deuterated etifoxine (GRX-917) is under development by GABA Therapeutics for the treatment anxiety and mood disorders.[33][34][24][35]

History edit

Etifoxine was developed by Hoechst in the 1960s.[11][36] It was introduced for medical use in France in 1979.[11] Since at least 2000, etifoxine has been marketed by the French pharmaceutical company Biocodex.[31][29][37][19] Following reports of post-marketing toxicity, the safety of etifoxine was reassessed by the French government[13][8] and the European Medicines Agency (EMA).[38][39] In January 2022, the EMA "finalized its review of Stresam and concluded that the medicine can continue to be used for the treatment of anxiety disorders, but it must not be used in patients who previously had severe skin reactions or severe liver problems after taking etifoxine."[38][39]

Society and culture edit

Names edit

Etifoxine is the generic name of the drug and its INNTooltip International Nonproprietary Name, BANTooltip British Approved Name, and DCFTooltip Dénomination Commune Française.[30][31] It is also known by the older and much-lesser-used synonym etafenoxine[40] and by its developmental code name Hoe 36801.[30][31] Etifoxine is marketed under the brand name Stresam.[30][31][19] It has also been marketed under the brand name Strezam, specifically in Russia.[19]

Availability edit

Etifoxine has been marketed in 53 countries as of 2022.[7][11] Some of the countries in which etifoxine has been marketed include Argentina, Bulgaria, Chile, France, Luxembourg, Malta, Romania, Russia, South Africa, Thailand, and Ukraine.[19][13][7][31] Etifoxine is not approved for use by the United States Food and Drug Administration (FDA) or the European Medicines Agency (EMA) of the European Union, and hence is not marketed in these regions.[11][7] However, etifoxine is marketed in five European Union member states (France, Bulgaria, Luxembourg, Malta, Romania).[13][7]

See also edit

References edit

  1. ^ a b c d e f g h Afect (1 May 2011). Traité de chimie thérapeutique Volume 7: Médicaments actifs sur le système nerveux central. Lavoisier. pp. 500–. ISBN 978-2-7430-1373-8. OCLC 758328876. 5.2. Propriétés pharmacologiques. [...] 5.2.2. Étifoxine. Utilisé dans les manifestations psychosomatiques de l'anxiété, telles que les dystonies neurovégétatives (Stresam, gélules à 50 mg). La posologie usuelle est de 150 à 200 mg/j. 5.4. Effets indésirables. [...] 5.4.2. Étifoxine. Légère somnolence en début de traitement, éruptions cutanées rares. 5.5. Contre-indications et précautions d'emploi. [...] 5.5.2. Étifoxine. Précaution lors d'association avec les dépresseurs centraux (benzodiazepines, analgesiques centraux, neuroleptiques, antihistaminiques H1 sédatifs, etc.). L'alcool potentialise l'effet sédatif de l'étifoxine. Ce produit est déconseillé pendant la grossesse et en cas d'allaitement.
  2. ^ a b c d e f g h i j k l m n o p q "STRESAM®, capsule Summary of Product Characteristics" (PDF). GABA Therapeutics, Inc. July 2010. Archived from the original (PDF) on 24 October 2021.
  3. ^ a b c d e f g h i Nuss P, Ferreri F, Bourin M (2019). "An update on the anxiolytic and neuroprotective properties of etifoxine: from brain GABA modulation to a whole-body mode of action". Neuropsychiatr Dis Treat. 15: 1781–1795. doi:10.2147/NDT.S200568. PMC 6615018. PMID 31308671.
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Further reading edit

  • Verleye M (January 2008). "Étifoxine : pharmacologie comportementale" [Etifoxine: behavioral pharmacology]. L'Encéphale (in French). 34 (Suppl 1 (Etifoxine : un nouveau regard sur le récepteur GABA et l'anxiété)): S15–S19. doi:10.1016/S0013-7006(08)71387-3. ISSN 0013-7006.
  • Dumas S, Vujasinovic T (January 2008). "Étifoxine et circuits des émotions" [Etifoxine and emotional circuits]. L'Encéphale (in French). 34 (Suppl 1 (Etifoxine : un nouveau regard sur le récepteur GABA et l'anxiété)): S21–S27. doi:10.1016/S0013-7006(08)71388-5. ISSN 0013-7006.
  • Hamon A (January 2008). "Étifoxine et récepteurs GABA" [Etifoxine and GABA receptors]. L'Encéphale (in French). 34 (Suppl 1 (Etifoxine : un nouveau regard sur le récepteur GABA et l'anxiété)): S29–S34. doi:10.1016/S0013-7006(08)71389-7. ISSN 0013-7006.
  • Schlichter R (January 2008). "Étifoxine, neurostéroïdes et anxiété" [Etifoxine, neurosteroids and anxiety]. L'Encéphale (in French). 34 (Suppl 1 (Etifoxine : un nouveau regard sur le récepteur GABA et l'anxiété)): S35–S43. doi:10.1016/S0013-7006(08)71390-3. ISSN 0013-7006.
  • Spadone C, Glikman M (April 2008). "L'étifoxine: un nouveau regard sur le récepteur GABA et l'anxiété" [Etifoxine: a new look at the GABA receptor and anxiety]. Encephale (in French). 34 Spec No 1: 1–11. doi:10.1016/S0013-7006(08)70553-0. ISSN 0013-7006. PMID 18826172.
  • Nothdurfter C, Rammes G, Baghai TC, Schüle C, Schumacher M, Papadopoulos V, Rupprecht R (January 2012). "Translocator protein (18 kDa) as a target for novel anxiolytics with a favourable side-effect profile". J Neuroendocrinol. 24 (1): 82–92. doi:10.1111/j.1365-2826.2011.02166.x. PMID 21609361. S2CID 21476596.
  • Girard C, Liu S, Adams D, Lacroix C, Sinéus M, Boucher C, Papadopoulos V, Rupprecht R, Schumacher M, Groyer G (January 2012). "Axonal regeneration and neuroinflammation: roles for the translocator protein 18 kDa". J Neuroendocrinol. 24 (1): 71–81. doi:10.1111/j.1365-2826.2011.02215.x. PMID 21951109. S2CID 21312172.
  • Poisbeau P, Keller AF, Aouad M, Kamoun N, Groyer G, Schumacher M (2014). "Analgesic strategies aimed at stimulating the endogenous production of allopregnanolone". Front Cell Neurosci. 8: 174. doi:10.3389/fncel.2014.00174. PMC 4060572. PMID 24987335.
  • Choi YM, Kim KH (January 2015). "Etifoxine for pain patients with anxiety". Korean J Pain. 28 (1): 4–10. doi:10.3344/kjp.2015.28.1.4. PMC 4293506. PMID 25589941.
  • Cottin J, Gouraud A, Jean-Pastor MJ, Dautriche AD, Boulay C, Geniaux H, Auffret M, Bernard N, Descotes J, Vial T (April 2016). "Safety profile of etifoxine: A French pharmacovigilance survey". Fundam Clin Pharmacol. 30 (2): 147–52. doi:10.1111/fcp.12169. PMID 26588183. S2CID 7599622.
  • Poisbeau P, Gazzo G, Calvel L (2018). "Anxiolytics targeting GABAA receptors: Insights on etifoxine". World J Biol Psychiatry. 19 (sup1): S36–S45. doi:10.1080/15622975.2018.1468030. PMID 30204559. S2CID 52191153.
  • Stein DJ (2018). "Pharmacotherapy of adjustment disorder: A review". World J Biol Psychiatry. 19 (sup1): S46–S52. doi:10.1080/15622975.2018.1492736. PMID 30204560. S2CID 52187107.
  • Nuss P, Ferreri F, Bourin M (2019). "An update on the anxiolytic and neuroprotective properties of etifoxine: from brain GABA modulation to a whole-body mode of action". Neuropsychiatr Dis Treat. 15: 1781–1795. doi:10.2147/NDT.S200568. PMC 6615018. PMID 31308671.
  • Dimitrova-Shumkovska J, Krstanoski L, Veenman L (April 2020). "Diagnostic and Therapeutic Potential of TSPO Studies Regarding Neurodegenerative Diseases, Psychiatric Disorders, Alcohol Use Disorders, Traumatic Brain Injury, and Stroke: An Update". Cells. 9 (4): 870. doi:10.3390/cells9040870. PMC 7226777. PMID 32252470.
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External links edit

  • Stesam (etifoxine hydrochloride) Summary of Product Characteristics (SPC)
  • Stresam (etifoxine hydrochloride) Patient Leaflet
  • Stresam (etifoxine hydrochloride) Package Insert
  • Etifoxine French Commission Nationale de Pharmacovigilance Review (Original French)
  • Etifoxine French Commission Nationale de Pharmacovigilance Review (English Translation)
  • Etifoxine European Medicines Agency Assessment Report