Lurasidone
Lurasidone
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Lurasidone
Skeletal structure of lurasidone
Ball-and-stick model of the lurasidone molecule
3D representation of a lurasidone molecule
Clinical data
Pronunciation/ljʊəˈræsɪˌdoʊn/
Trade namesLatuda, others
Other namesSM-13496
AHFS/Drugs.comMonograph
MedlinePlusa611016
License data
Pregnancy
category
Routes of
administration		By mouth
Drug classAtypical antipsychotic[2]
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability9–19% (oral)[3]
Protein binding~99%[9]
MetabolismLiver (CYP3A4-mediated)[3]
Elimination half-life18–40 hours[3][9]
ExcretionFaecal (67–80%),
renal (9–19%)[3][9]
Identifiers
  • (3a''R'',4''S'',7''R'',7a''S'')-2-[((1''R'',2''R'')-2-{[4-(1,2-benzisothiazol-3-yl)piperazin-1-yl]methyl}cyclohexyl)methyl]-4,7-methano-1,3,3a,4,5,6,7,7a-octahydro-2''H''-isoindole-1,3-dione
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard100.225.187 Edit this at Wikidata
Chemical and physical data
FormulaC28H36N4O2S
Molar mass492.68 g·mol−1
3D model (JSmol)
Specific rotation[α]20D −59°
Melting point176 to 178 °C (349 to 352 °F)
Solubility in water0.224
  • O=C1[C@@H]2[C@H]3CC[C@H](C3)[C@@H]2C(=O)N1C[C@@H]1CCCC[C@H]1CN1CCN(c2nsc3ccccc23)CC1
  • InChI=1S/C28H36N4O2S/c33-27-24-18-9-10-19(15-18)25(24)28(34)32(27)17-21-6-2-1-5-20(21)16-30-11-13-31(14-12-30)26-22-7-3-4-8-23(22)35-29-26/h3-4,7-8,18-21,24-25H,1-2,5-6,9-17H2/t18-,19+,20-,21-,24+,25-/m0/s1
  • Key:PQXKDMSYBGKCJA-CVTJIBDQSA-N

Lurasidone, sold under the brand name Latuda among others, is an atypical antipsychotic medication used to treat schizophrenia and bipolar depression.[2] It is taken by mouth.

Common side effects include sedation, indigestion, nausea, and insomnia. At higher dosages, there is an increased risk for restlessness and movement problems.[2] Serious side effects are valid for all atypical antipsychotics and may include the potentially permanent movement disorder tardive dyskinesia, as well as neuroleptic malignant syndrome, angioedema, and high blood sugar levels.[10] Although lurasidone is less likely to cause high blood sugar levels in most patients, hyperosmolar hyperglycemic syndrome may occur.[2][11][12] In older people with psychosis as a result of dementia, it may increase the risk of dying.[2] Use during pregnancy is of unclear safety.[13][14]

Lurasidone was first approved for medical use in the United States in 2010, for treating schizophrenia.[2] In 2013, it was approved in Canada and by the U.S. Food and Drug Administration (FDA) to treat bipolar depression, either as monotherapy or adjunctively with lithium or valproate.[15][16] It is not FDA approved for treating manic symptoms associated with bipolar disorder despite its FDA approval for treating bipolar depression. Generic versions were approved in the United States in 2019, and became available in 2023.[17][18] In 2021, it was the 193rd most commonly prescribed medication in the United States, with more than 2 million prescriptions.[19][20]

Medical uses

[edit]

Lurasidone is used to treat schizophrenia and bipolar disorder.[2][21] In bipolar disorder, it has been studied both as a monotherapy and adjunctive treatment to lithium or valproate.[22]

The European Medicines Agency approved lurasidone for the treatment of schizophrenia for people aged 13 years and older.[23][8] Its use in Europe for bipolar disorder is considered off-label.[24] In the United States, it is used to treat schizophrenia for people aged 13 years and older. In July 2013, lurasidone received approval for bipolar I depression.[25][26][27][28] This includes depressive episodes of bipolar disorder age 10 and over as a monotherapy, and in conjunction with lithium or valproate in adults.[29]

In June 2020, lurasidone was approved in Japan, eight years after its first approval in the United States.[30] In Japan it is approved for bipolar depression and schizophrenia.[31][32][33] Lurasidone is not approved by the Food and Drug Administration (FDA) for the treatment of behavior disorders in older adults with dementia.[34]

Few available atypical antipsychotics are known to possess antidepressant efficacy in bipolar disorder (with the notable exceptions being cariprazine,[35] quetiapine,[36][37][38][39] olanzapine[40][41][42] and possibly asenapine[43]) as a monotherapy. The majority of atypical antipsychotics are known to possess significant antimanic activity,[44] however lurasidone is unusual as it was never studied for acute mania.[45]

In the early post approval period lurasidone-treated patients with bipolar disorder were retrospectively found to have more complex clinical profiles, comorbidities, and prior treatment history compared to patients initiated with other atypical antipsychotics. The study authors suggest this may be due to "the overall clinical profile of lurasidone, the role perceived for lurasidone in the therapeutic armamentarium by practitioners, and the recent introduction of lurasidone into clinical practice during the study period".[46]

Contraindications

[edit]

Lurasidone is contraindicated in individuals who are taking strong inhibitors of the liver enzyme CYP3A4 (ketoconazole, clarithromycin, ritonavir, levodropropizine, etc.) or inducers (carbamazepine, St. John's wort, phenytoin, rifampicin etc.).[47] The use of lurasidone in pregnant women has not been studied and is not recommended; in animal studies, no risks have been found.[48] Excretion in breast milk is also unknown; lurasidone is not recommended for breastfeeding women.[49] The enzyme CYP3A4 is involved in the digestion of drugs. Inhibitors such as grapefruit juice block its function, resulting in too much drug in the body.[50]

Side effects

[edit]
See also: List of adverse effects of lurasidone

Side effects are generally similar to other antipsychotics. The drug has a relatively well tolerated side effect profile, with low propensity for QTc interval changes,[51][52] weight gain and lipid-related adverse effects.[53] In a 2013 meta-analysis of the efficacy and tolerability of 15 antipsychotic drugs, it was found to produce the second least (after haloperidol) weight gain, the least QT interval prolongation, the fourth most extrapyramidal side effects (after haloperidol, zotepine and chlorpromazine), and the sixth least sedation (after paliperidone, sertindole, amisulpride, iloperidone and aripiprazole).[54]

As with other atypical neuroleptics, lurasidone should be used with caution in the elderly because it puts them at an increased risk for a stroke or transient ischemic attack;[55][56] however, these risks are not likely to be greater than those associated with antipsychotics of other classes.[57] Similarly, lurasidone should not be used to treat dementia-related psychosis, as evidence has shown increased mortality with antipsychotic use.[58]

Weight gain is reported in up to 15 and 16 percent of users.[59][60] Other possible side effects include vomiting, akathisia, dystonia, parkinsonism, somnolence, dizziness, sedation and nausea.[61][62]

Discontinuation

[edit]

The British National Formulary recommends a gradual withdrawal when discontinuing antipsychotics to avoid acute withdrawal syndrome or rapid relapse.[63] Symptoms of withdrawal commonly include nausea, vomiting, and loss of appetite.[64] Other symptoms may include restlessness, increased sweating, and trouble sleeping.[64] Less commonly there may be a feeling of the world spinning, numbness, or muscle pains.[64] Symptoms generally resolve after a short period of time.[64]

There is tentative evidence that discontinuation of antipsychotics can result in psychosis.[65] It may also result in reoccurrence of the condition that is being treated.[66] Rarely tardive dyskinesia can occur when the medication is stopped.[64]

Interactions

[edit]

Blood plasma concentrations may be increased when combined with CYP3A4 inhibitors (e.g. ketoconazole, clarithromycin, ritonavir, and voriconazole) possibly leading to more side effects. This has been clinically verified for ketoconazole, which increases lurasidone exposure by a factor of 9, and is also expected for other 3A4 inhibitors such as grapefruit juice. Co-administration of CYP3A4 inducers like rifampicin, carbamazepine or St. John's wort can reduce plasma levels of lurasidone and its active metabolite, and consequently decrease the effects of the drug. For rifampicin, the reduction was sixfold in a study.[9]

Pharmacology

[edit]

Pharmacodynamics

[edit]
See also: Atypical antipsychotic § Pharmacodynamics, and Antipsychotic § Comparison of medications
Lurasidone[67]
Site Ki (nM) Action Species Ref
SERTTooltip Serotonin transporter >1,000 ND ND [68]
NETTooltip Norepinephrine transporter ND ND ND ND
DATTooltip Dopamine transporter >1,000 ND ND [68]
5-HT1A 6.7 Partial agonist Human [69]
5-HT2A 0.5-2 antagonist Rat [68]
5-HT2B 24 ND Human [70]
5-HT2C 415 ND Pig [68]
5-HT3 >1,000 ND ND [68]
5-HT4 >1,000 ND ND [68]
5-HT7 0.5 Inverse agonist Human [71][68]
α1 47.9 ND Rat [68]
α2A 41 Antagonist Human [68]
α2B ND ND ND ND
α2C 10.8 Antagonist Human [68]
β1 >1,000 ND ND [68]
β2 >1,000 ND ND [68]
D1 262 ND ND [68]
D2s 1.2-1.7 Antagonist Human [69]
D3S 15.7 Antagonist ND ND
D4.4L 30 Positive allosteric modulator ND ND
D5 ND ND ND ND
H1 >1,000 ND Guinea pig [68]
M1 >1,000 ND Human [68]
Values are Ki (nM). The smaller the value, the more strongly the drug binds to the site.

Lurasidone [(3aR,4S,7R,7aS)-2-{(1R,2R)-2-[4-(1,2-benzisothiazol-3-yl) piperazin-1-ylmethyl]-cyclohexylmethyl}-hexahydro-4,7-methano-2Hisoindole-1,3-dione hydrochloride] ][72] is an azapirone derivative[73] and acts as an antagonist of the dopamine D2 and D3 receptors,[74] and the serotonin 5-HT2A and 5-HT7 receptors, and the α2C-adrenergic receptor, and as a partial agonist of the serotonin 5-HT1A receptor. It has moderate-affinity antagonism at α2C-adrenergic receptors; low to very low-affinity antagonism at α1A-adrenergic α2A-adrenergic receptors.[75]

It has only low and likely clinically unimportant affinity for the serotonin 5-HT2C receptor, which may underlie its low propensity for appetite stimulation and weight gain.[68][76][77] The drug also has negligible affinity for the histamine H1 receptor and the muscarinic acetylcholine receptors, and hence has no antihistamine or anticholinergic effects.[78][79] Drowsiness (somnolence) side effect is not explained by its antagonist activity to histamine.[80][81]

The relationship between dose and D2 receptor occupancy levels were 41–43% for 10 mg, 51–55% for 20 mg, 63–67% for 40 mg, 77–84% for 60 mg, and 73–79% for 80 mg.[82]

Pharmacokinetics

[edit]
ID-14283, the main active metabolite. The hydroxylation of the norbornane ring is highlighted.[83] The other active metabolite, ID-14326, has the OH group in endo position.[84]
The main inactivation step by oxidative N-dealkylation produces the metabolites ID-11614 and ID-20219.[84][85]

Lurasidone is taken by mouth and should be taken with a meal of at least 350 calories to ensure maximum absorption.[86] It has an estimated absorption rate of 9 to 19%.[3] Studies have shown that when lurasidone is taken with food, absorption increases about twofold.[9]

Peak blood plasma concentrations are reached after one to three hours. About 99% of the circulating substance are bound to plasma proteins.[9] Efficacy data for lurasidone have been evaluated for doses of 20 mg to 120 mg daily.

In schizophrenia, lurasidone has a recommended dose range of 40-160 mg. In bipolar depression, lurasidone has a slightly lower recommended dose range of 20-120 mg.[87]

Lurasidone is extensively metabolised by CYP3A4 leading to contraindication of both strong inhibitors as well as strong inducers of this enzyme,[88] but has negligible affinity to other cytochrome P450 enzymes. It is transported by P-glycoprotein and ABCG2 and also inhibits these carrier proteins in vitro. It also inhibits the solute carrier protein SLC22A1, but no other relevant transporters.[9][55]

Main metabolism pathways are oxidative N-dealkylation between the piperazine and cyclohexane rings, hydroxylation of the norbornane ring, and S-oxidation.[9][85]:59 Other pathways are hydroxylation of the cyclohexane ring and reductive cleavage of the isothiazole ring followed by S-methylation.[84]

The two relevant active metabolites are the norbornane hydroxylation products called ID-14283 and ID-14326, the former reaching pharmacologically relevant blood plasma concentrations. The two major inactive metabolites are the N-dealkylation products (the carboxylic acid ID-20219 and the piperazine ID-11614[84]), and a norbornane hydroxylated derivative of ID-20219 (ID-20220). Of lurasidone and its metabolites circulating in the blood, the native drug makes up 11%, the main active metabolite 4%, and the inactive carboxylic acids 24% and 11%, respectively.[3][9] Several dozen metabolites have been identified altogether.[85]:59–61

Biological half-life is given as 18 hours or 20 to 40 hours in different sources. 80% or 67% of a radiolabelled dose was recovered from the feces, and 9% or 19% from the urine.[3][9]

History

[edit]

Lurasidone was first synthesised circa 2003.[89] Lurasidone is a structural analogue of ziprasidone.[84] Lurasidone shows a very close pharmacological profile and has been synthesized similarly to ziprasidone.[90] Lurasidone is chemically similar to perospirone (also a chemical analogue of ziprasidone), as well as risperidone, paliperidone and iloperidone.[91]

Lurasidone was developed by Sunovion Pharmaceuticals, a division of Dainippon Sumitomo Pharma Co. of Japan.[92] In 2009, Sunovion decided to develop lurasidone for the treatment of bipolar depression.[93]

Society and culture

[edit]
Latuda 40mg and 80mg bottles with 80mg tablets.
Latuda 40mg and 80mg bottles with 80mg tablets.

Regulatory approval

[edit]

Lurasidone was approved in the United States for the treatment of schizophrenia in October 2010[94][95] and for the treatment of depressive episodes associated with bipolar I disorder in June 2013.[25][27][28] In 2015, lurasidone was studied for major depressive disorder with mixed features in a randomized trial and had a positive result, however it did not receive an FDA indication for it.[45][96] In 2017, the FDA approved lurasidone for schizophrenia in adolescents age 13-17. In 2018, lurasidone was approved for bipolar depression in children and adolescents age 10-17.[87]

It received regulatory approval in the United Kingdom in September 2014. In October 2014, NHS Scotland advised use of lurasidone for schizophrenic adults who have not seen improvements with previous antipsychotics due to problems that arise from weight gain or changes in metabolic pathways when taking other medications.[97]

The Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA) issued a positive opinion for it in January 2014, and it was approved for medical use by the EMA in March 2014.[8] It was launched in Canada for the treatment of schizophrenia in September 2012, Health Canada giving their Summary Basis of Decision (SBD) as favourable on 15 October 2012.[98] The European Commission has granted a marketing authorization for once-daily oral lurasidone for the treatment of schizophrenia in adults.[99] It is approved for use in the EU.[8]

Generic versions of lurasidone were approved for use in the United States in January 2019 and became available in 2023.[100][17][18]

Brand names

[edit]

In India, this drug is available under the brand names of Atlura, Lurace, Lurafic, Luramax (Sun Pharma), Lurasid, Lurastar, Latuda, Lurata[101] and additionally as Alsiva, Emsidon, Lurakem, Luratrend, Tablura, and Unisidon.[102]

References

[edit]
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Lurasidone

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Lurasidone is an atypical antipsychotic medication of the benzisothiazole class, primarily used in the treatment of schizophrenia and depressive episodes associated with bipolar I disorder.[1] It acts as a full antagonist at dopamine D₂ and serotonin 5-HT₂A receptors, a partial agonist at 5-HT₁A receptors, and an antagonist at 5-HT₇ receptors, with minimal affinity for histamine H₁, muscarinic M₁, and alpha-adrenergic receptors, contributing to a relatively favorable side effect profile including lower risks of sedation, weight gain, and metabolic disturbances compared to some other antipsychotics.[2] Marketed under the brand name Latuda and available as a generic since 2023,[3] it is administered orally once daily with at least 350 calories of food to enhance bioavailability and is available in tablet strengths of 20 mg, 40 mg, 60 mg, 80 mg, and 120 mg.[4] Originally developed by Dainippon Sumitomo Pharma (now Sumitomo Pharma), lurasidone received initial U.S. Food and Drug Administration (FDA) approval on October 28, 2010, for the treatment of schizophrenia in adults.[4] Subsequent approvals expanded its indications: in June 2013 for monotherapy or adjunctive therapy with lithium or valproate in adults with bipolar depression; in January 2017 for schizophrenia in adolescents aged 13 to 17 years; and in March 2018 for bipolar depression in pediatric patients aged 10 to 17 years.[1] Clinical efficacy has been demonstrated in multiple randomized, placebo-controlled trials, showing significant improvements in positive and negative symptoms of schizophrenia as well as depressive symptoms in bipolar disorder, with recommended dosing ranges of 40–160 mg/day for adult schizophrenia and 20–120 mg/day for bipolar depression.[4] Lurasidone's pharmacological profile supports its role in modulating dopaminergic and serotonergic neurotransmission, potentially enhancing cognitive function and neuronal plasticity through downstream effects on gene expression and synaptic remodeling, though its exact mechanism in mood stabilization remains under investigation.[5] Common adverse effects include akathisia, nausea, somnolence, and extrapyramidal symptoms, with black box warnings for increased mortality in elderly patients with dementia-related psychosis and heightened risk of suicidal ideation in younger patients.[1] Contraindicated with strong CYP3A4 inhibitors or inducers due to significant pharmacokinetic interactions, it represents a key option in antipsychotic therapy for its balance of efficacy and tolerability.[4]

Therapeutic Use

Approved Indications

Lurasidone is approved by the U.S. Food and Drug Administration (FDA) for the treatment of schizophrenia in adults and adolescents aged 13 years and older.[6] The initial approval for schizophrenia in adults occurred in October 2010, based on evidence from four pivotal, 6-week, randomized, placebo-controlled phase 3 trials involving over 1,200 patients, which demonstrated significant improvements in Positive and Negative Syndrome Scale (PANSS) total scores compared to placebo, with mean reductions of 17-23 points for lurasidone versus 10-12 points for placebo across doses of 40-160 mg/day. In 2017, the indication was expanded to adolescents aged 13-17 years following a 6-week, placebo-controlled trial showing superior PANSS total score reductions (mean change of -17.4 for 40 mg/day lurasidone versus -11.7 for placebo).[7] Lurasidone is also approved as monotherapy for the treatment of depressive episodes associated with Bipolar I Disorder (bipolar depression) in adults and pediatric patients aged 10-17 years, as well as adjunctive therapy with lithium or valproate for the same indication in adults.[6] The adult indications were approved in June 2013, supported by two 6-week, placebo-controlled phase 3 trials: one monotherapy study (n=505) showing Montgomery-Åsberg Depression Rating Scale (MADRS) total score reductions of 15.4-17.1 points for lurasidone (20-60 mg/day) versus 6.6 points for placebo, and one adjunctive therapy study (n=340) with MADRS reductions of 17.1-17.7 points versus 13.5 points for placebo plus mood stabilizer.[8] The pediatric monotherapy approval followed in March 2018, based on a 6-week trial in patients aged 10-17 years demonstrating Children's Depression Rating Scale-Revised (CDRS-R) total score reductions of -21.0 points for lurasidone (20-80 mg/day) versus -15.3 points for placebo.[9] Lurasidone is not approved for the treatment of manic or mixed episodes associated with bipolar disorder, for maintenance treatment in bipolar disorder, or for patients with dementia-related psychosis.[6]

Dosage and Administration

Lurasidone is administered orally once daily in tablet form for the treatment of schizophrenia and depressive episodes associated with bipolar I disorder. The recommended starting dose for schizophrenia in adults is 40 mg once daily, with an effective dose range of 40 to 160 mg per day based on clinical response and tolerability; initial dose titration is not required.[6] For adults with bipolar depression, either as monotherapy or adjunctive therapy with lithium or valproate, the recommended starting dose is 20 mg once daily, with an effective dose range of 20 to 120 mg per day, also without initial titration.[6] For schizophrenia in adolescents aged 13-17 years, the recommended starting dose is 40 mg once daily, with an effective dose range of 40 to 80 mg per day; initial dose titration is not required.[6] For bipolar depression in pediatric patients aged 10-17 years as monotherapy, the recommended starting dose is 20 mg once daily, with an effective dose range of 20 to 80 mg per day, without initial titration.[6] To ensure adequate bioavailability, lurasidone must be taken with at least 350 calories of food, regardless of the meal type, as administration under fasting conditions substantially reduces absorption.[6] Tablets are available in strengths of 20 mg, 40 mg, 60 mg, 80 mg, and 120 mg, and should be swallowed whole with water at approximately the same time each day to maintain steady-state plasma levels.[6] Dose adjustments are necessary in certain scenarios to account for altered metabolism or clearance. When used concomitantly with moderate CYP3A4 inhibitors (e.g., diltiazem or verapamil), the starting dose should be reduced to 20 mg per day, with a maximum recommended dose of 80 mg per day; strong CYP3A4 inhibitors are contraindicated.[6] No dosage adjustment is required for patients with mild renal (creatinine clearance ≥50 mL/min) or mild hepatic (Child-Pugh A) impairment. However, for moderate to severe renal impairment (creatinine clearance <50 mL/min), the starting dose is 20 mg per day with a maximum of 80 mg per day; for moderate hepatic impairment (Child-Pugh B), the maximum dose is 80 mg per day; and for severe hepatic impairment (Child-Pugh C), the maximum dose is 40 mg per day.[6] These adjustments apply to both adult and pediatric patients. Following initial stabilization, long-term dosing typically remains within the established effective range without further adjustment, provided the patient continues to respond and tolerate the medication.[6] Clinicians should periodically reassess the need for continued treatment beyond 6 weeks, adjusting doses gradually if discontinuation is considered to minimize potential withdrawal effects.[6]

Safety Profile

Contraindications

Lurasidone is contraindicated in patients with known hypersensitivity to lurasidone hydrochloride or any components of the formulation. Serious hypersensitivity reactions, including angioedema, have been reported in postmarketing experience with the drug.[4] Concomitant use of lurasidone with strong CYP3A4 inhibitors, such as ketoconazole, clarithromycin, ritonavir, or voriconazole, is prohibited. These agents significantly increase lurasidone systemic exposure—up to ninefold in some cases—potentially leading to excessive pharmacodynamic effects and heightened risk of adverse reactions, including those related to cardiac conduction.[4] Similarly, strong CYP3A4 inducers like rifampin, phenytoin, carbamazepine, or St. John's wort are contraindicated due to their ability to decrease lurasidone concentrations by more than 95%, compromising therapeutic efficacy while based on pharmacokinetic interactions that alter drug metabolism.[4] Lurasidone carries a boxed warning against its use in elderly patients with dementia-related psychosis, where it is associated with increased mortality risk compared to placebo. This contraindication stems from analyses of 17 placebo-controlled trials with various atypical antipsychotics, showing a 1.6-1.7-fold higher death rate, primarily from cardiovascular or infectious causes.[4]

Adverse Effects

Lurasidone is associated with a range of adverse effects, primarily extrapyramidal symptoms (EPS) and sedation, though its overall tolerability profile is favorable compared to other atypical antipsychotics. In placebo-controlled clinical trials for schizophrenia in adults, the most common adverse reactions (incidence ≥5% and at least twice that of placebo) included somnolence (17.0% vs. 7.9% placebo), akathisia (13.0% vs. 4.8% placebo), EPS (excluding akathisia and restlessness, 14.0% vs. 5.8% placebo), and nausea (10.0% vs. 5% placebo).[6] Similar patterns were observed in trials for bipolar depression, with akathisia (9.4% vs. 2.6% placebo), EPS (6.9% vs. 2.7% placebo), and somnolence/sedation (11.0% vs. 5.4% placebo) being prominent. Akathisia incidence can be dose-dependent, reaching up to 22.9% at higher doses (120 mg/day) in schizophrenia trials compared to 4.3% with placebo.[10] Parkinsonism, a subset of EPS, occurred at rates of 5-10% across studies, often manifesting as tremor or rigidity. Serious adverse effects with lurasidone are less frequent but include EPS-related complications, tardive dyskinesia (incidence <1%), and neuroleptic malignant syndrome (NMS, very rare, <0.1%). Tardive dyskinesia involves potentially irreversible involuntary movements and requires discontinuation if diagnosed. NMS, characterized by hyperthermia, muscle rigidity, and altered mental status, demands immediate withdrawal and supportive care. Regarding metabolic changes, lurasidone shows minimal impact, with weight gain typically limited to 0.1-0.5 kg over short-term trials (vs. 0.2 kg placebo) and lower risks of hyperglycemia or diabetes compared to agents like olanzapine; shifts to fasting glucose ≥126 mg/dL occurred in 5.6-12.7% of patients vs. 8.3% placebo.[11] Long-term studies confirm a low odds ratio for developing metabolic syndrome (OR 1.05-1.12).[12] Management of adverse effects focuses on monitoring and dose adjustment. For EPS and akathisia, reducing the dose or adding anticholinergic agents like benztropine can alleviate symptoms, with incidence decreasing at lower doses (e.g., 11.8% akathisia at 40 mg/day).[10] Metabolic parameters, including weight, glucose, and lipids, should be monitored at baseline and periodically, particularly in patients with risk factors. Lurasidone exhibits a lower sedation profile than olanzapine, with somnolence rates of 17% vs. up to 26% for olanzapine in comparative trials.[10] If severe effects lead to discontinuation, gradual tapering may mitigate withdrawal risks.

Discontinuation Effects

Discontinuation of lurasidone, an atypical antipsychotic, can lead to withdrawal symptoms such as rebound psychosis, insomnia, nausea, anxiety, and hyperkinesia, though these are generally milder compared to those observed with typical antipsychotics.[13] Unlike selective serotonin reuptake inhibitors (SSRIs), lurasidone does not typically cause a severe discontinuation syndrome, but monitoring for extrapyramidal symptom (EPS) rebound, including akathisia or parkinsonism, is recommended due to its partial dopamine D2 receptor antagonism.[1] To minimize risks, gradual tapering of lurasidone over 1-4 weeks is advised rather than abrupt cessation, as sudden discontinuation increases the risk of schizophrenia relapse by approximately five-fold within one year.[14] Evidence from long-term studies supports this approach; for instance, a double-blind, placebo-controlled randomized withdrawal trial in patients with schizophrenia demonstrated that continuing lurasidone (40-80 mg/day) delayed time to relapse and reduced relapse risk by 33.7% compared to placebo, with relapse probabilities of 42.2% versus 51.2% at 28 weeks.[15] These findings underscore the importance of supervised tapering to prevent symptom exacerbation and support ongoing therapeutic monitoring.[16]

Use in Special Populations

Lurasidone's use during pregnancy is considered appropriate when the potential benefits to the mother outweigh the potential risks to the fetus, as there are no adequate and well-controlled studies in pregnant women. Animal reproduction studies conducted at doses up to 12 times the maximum recommended human dose (MRHD) of 160 mg/day revealed no evidence of teratogenicity or adverse effects on embryo-fetal development. However, neonates exposed to antipsychotics like lurasidone during the third trimester may experience extrapyramidal symptoms (EPS) or withdrawal symptoms, including agitation, hypertonia, hypotonia, tremor, somnolence, and respiratory distress. Limited human data from pregnancy registries and observational studies have not identified a clear pattern of major birth defects, though ongoing monitoring is recommended via the National Pregnancy Registry for Atypical Antipsychotics.[6][17] Regarding lactation, the presence of lurasidone in human breast milk remains unknown, though it is excreted in the milk of lactating rats. Due to its high plasma protein binding (>99%), clinically significant transfer into breast milk is unlikely, and case reports of maternal use have shown no adverse effects in breastfed infants. A 2025 pharmacokinetic study reported a relative infant dose of 1.16%, below the 10% safety threshold, with no observed adverse effects.[6][18][19] Nonetheless, clinicians should weigh the importance of the drug to the mother against potential risks to the infant, such as sedation or developmental effects, and consider monitoring the infant for drowsiness or poor feeding if breastfeeding continues. Discontinuation of nursing or the drug may be advisable in some cases. In pediatric populations, lurasidone is approved for the treatment of schizophrenia in adolescents aged 13 to 17 years at doses of 40 to 80 mg/day and for depressive episodes associated with bipolar I disorder in children and adolescents aged 10 to 17 years at doses of 20 to 80 mg/day, with efficacy similar to that observed in adults. A 2025 FDA postmarketing review confirmed no new safety signals in pediatric use. Safety and effectiveness have not been established in children younger than 13 years for schizophrenia or younger than 10 years for bipolar depression. Youth treated with lurasidone may experience a higher incidence of EPS compared to adults, consistent with the general profile of atypical antipsychotics in this age group, though long-term studies indicate overall tolerability with minimal impact on weight, lipids, or prolactin levels.[6][20][21] For geriatric patients, lurasidone is not approved for the treatment of dementia-related psychosis, as elderly individuals with this condition treated with atypical antipsychotics have an increased risk of mortality, primarily due to cardiovascular or infectious causes. Limited pharmacokinetic data show comparable drug exposure in elderly patients (aged 65-85 years) to younger adults at a 20 mg dose, with no routine dose adjustment required based on age alone. However, older adults may exhibit greater sensitivity to sedative effects, leading to orthostatic hypotension, dizziness, and an elevated risk of falls; initiation at lower doses and careful monitoring for somnolence and mobility issues are recommended.[6][22] In patients with renal or hepatic impairment, dose adjustments are necessary to account for increased drug exposure. For moderate to severe renal impairment (creatinine clearance <50 mL/min), the recommended starting dose is 20 mg/day, with a maximum of 80 mg/day. In moderate hepatic impairment (Child-Pugh class B), the starting dose is also 20 mg/day, up to a maximum of 80 mg/day, while severe hepatic impairment (Child-Pugh class C) requires a starting dose of 20 mg/day and a maximum of 40 mg/day; lurasidone is not recommended in severe cases without close monitoring. No specific dose adjustments are needed based on ethnicity, sex, or smoking status.[6]

Drug Interactions

Pharmacokinetic Interactions

Lurasidone is primarily metabolized by the cytochrome P450 3A4 (CYP3A4) enzyme, making it susceptible to pharmacokinetic interactions with CYP3A4 modulators.[6] Concomitant administration with strong CYP3A4 inhibitors, such as ketoconazole, substantially increases lurasidone exposure, with a 9.3-fold increase in area under the curve (AUC) and a 6.8-fold increase in maximum concentration (Cmax), leading to contraindication of their combined use to avoid toxicity.[23] Similarly, strong CYP3A4 inducers like rifampin markedly reduce lurasidone levels, decreasing AUC to approximately one-fifth (an 80% reduction) and Cmax to one-seventh of values observed with lurasidone alone, necessitating avoidance of such combinations due to potential loss of efficacy.[23] For moderate CYP3A4 inhibitors, such as diltiazem, exposure increases more modestly (approximately 2-fold for AUC), requiring dose adjustments: the maximum recommended dose of lurasidone is reduced to 80 mg/day, with initiation at half the usual starting dose if necessary.[6][23] Moderate inducers may also warrant monitoring and potential dose escalation after at least 7 days of concurrent therapy to maintain therapeutic levels.[6] The bioavailability of lurasidone is significantly enhanced by food, with administration alongside a meal containing at least 350 calories approximately doubling AUC and tripling Cmax compared to fasting conditions; therefore, lurasidone must always be taken with food to ensure consistent absorption.[6] As a substrate for P-glycoprotein (P-gp), lurasidone exhibits minimal interaction potential with P-gp modulators, with no dose adjustments required for coadministration with P-gp substrates like digoxin.[23] Lurasidone undergoes negligible renal clearance (less than 1% excreted unchanged in urine), resulting in no significant pharmacokinetic interactions via renal pathways with other drugs.[6] These interactions underscore the need for careful review of concomitant medications and adherence to dosing guidelines to optimize safety and efficacy.[6]

Pharmacodynamic and Other Interactions

Lurasidone, an atypical antipsychotic with antagonist activity at dopamine D2 and serotonin 5-HT2A receptors, as well as alpha-1 adrenergic receptors, can interact pharmacodynamically with central nervous system (CNS) depressants, leading to additive sedative effects. Concomitant use with alcohol or benzodiazepines may enhance CNS depression, increasing risks of drowsiness, impaired psychomotor performance, and respiratory depression. Caution is advised due to potential orthostatic hypotension from combined effects.[24][25] The alpha-1 adrenergic blockade by lurasidone can potentiate the hypotensive effects of antihypertensives, resulting in enhanced orthostatic hypotension, particularly in patients with cardiovascular comorbidities. Monitoring of blood pressure is recommended when lurasidone is co-administered with agents such as beta-blockers or other antihypertensives.[26][27] Although lurasidone has a low risk of QT interval prolongation on its own, additive effects with other QT-prolonging drugs may increase the risk of arrhythmias, such as torsades de pointes. Caution is warranted with concomitant use of antipsychotics like ziprasidone or antiarrhythmics (e.g., quinidine), and ECG monitoring may be considered in at-risk patients.[6][28] Lurasidone's dopamine D2 receptor antagonism can reduce the therapeutic efficacy of levodopa in patients with Parkinson's disease, potentially exacerbating parkinsonian symptoms. Antipsychotics like lurasidone are generally avoided in this population due to heightened sensitivity. No major pharmacodynamic interactions with herbal supplements have been identified, though overall caution with unstudied herbals is advised.[25][29]

Pharmacology

Pharmacodynamics

Lurasidone is classified as an atypical antipsychotic agent whose primary mechanism of action involves antagonism at dopamine D2 and serotonin 5-HT2A receptors, which modulates dopaminergic and serotonergic neurotransmission to alleviate positive symptoms of schizophrenia and depressive episodes in bipolar disorder.[30] This dual receptor blockade contributes to its efficacy while reducing the risk of extrapyramidal side effects compared to typical antipsychotics.[30] Additionally, lurasidone acts as a partial agonist at serotonin 5-HT1A receptors, potentially enhancing its antidepressant effects in bipolar depression by promoting serotonin release and reducing anxiety-related symptoms.[30] The drug exhibits high binding affinity at key receptors, with Ki values of approximately 1.0 nM at D2 receptors, 0.5 nM at 5-HT2A receptors, 6.4 nM at 5-HT1A receptors (as a partial agonist), and 0.5 nM at 5-HT7 receptors (as an antagonist).[30] In contrast, lurasidone demonstrates low affinity at histamine H1 (Ki >1000 nM) and muscarinic M1 (Ki >1000 nM) receptors, which underlies its favorable profile with minimal sedation, weight gain, and anticholinergic effects.[30] The antagonism at 5-HT7 receptors may further support cognitive improvements, as preclinical studies indicate it ameliorates deficits induced by NMDA receptor antagonists like MK-801.[31] Lurasidone's balanced D2 receptor blockade, combined with its serotonergic actions, results in minimal extrapyramidal symptoms (EPS) at therapeutic doses, distinguishing it from agents with more pronounced D2 occupancy.[32] Its pharmacodynamic profile is atypical, sharing similarities with aripiprazole in terms of dopamine-serotonin modulation and partial agonism at 5-HT1A, but lurasidone displays stronger 5-HT2A antagonism (Ki ≈ 0.5 nM versus 3.4 nM for aripiprazole).[33]

Pharmacokinetics

Lurasidone exhibits low oral bioavailability of approximately 9-19%, which increases twofold in terms of area under the curve (AUC) and threefold in terms of maximum concentration (Cmax) when administered with food containing at least 350 calories, regardless of fat content.[4] Peak serum concentrations are reached within 1-3 hours post-dose (Tmax), and the pharmacokinetics demonstrate dose proportionality and linearity over the therapeutic dose range of 20-160 mg daily.[4][34] Following absorption, lurasidone is widely distributed throughout the body, including crossing the blood-brain barrier to exert central effects, with an apparent volume of distribution of approximately 6173 L after a 40 mg dose.[4] It is highly bound to serum proteins, with approximately 99% binding, primarily to albumin and α1-acid glycoprotein.[4][34] Lurasidone undergoes extensive hepatic metabolism primarily via the cytochrome P450 3A4 (CYP3A4) enzyme, involving oxidative N-dealkylation, hydroxylation of the norbornane ring, and S-oxidation, resulting in two major inactive metabolites (ID-20219 and ID-20220) that account for over 10% of the dose each.[4][34] Minor active metabolites, such as ID-14283, are produced but contribute less to overall exposure (about 25% of parent drug levels).[34] The mean elimination half-life is approximately 18 hours following a 40 mg dose.[4] Excretion occurs predominantly via feces (about 80% of the dose) and to a lesser extent via urine (about 9%), with less than 1% of the unchanged drug recovered in urine and approximately 9% in feces.[4][34] Steady-state concentrations are achieved within 7 days of daily dosing, with no significant accumulation observed due to the linear pharmacokinetics.[4] This half-life supports once-daily dosing in clinical practice.[4]

Development and History

Discovery and Preclinical Studies

Lurasidone was developed by Dainippon Sumitomo Pharma in the early 2000s as a novel atypical antipsychotic agent targeted at treating schizophrenia. The compound emerged from a research program exploring benzisothiazole derivatives, selected for its multifaceted receptor binding profile that included potent antagonism at dopamine D₂ and serotonin 5-HT₂A receptors, alongside activity at 5-HT₇ and 5-HT₁A sites, aiming to balance efficacy against positive and negative symptoms while minimizing side effects associated with earlier antipsychotics.[35][2][36] Preclinical evaluations in animal models confirmed lurasidone's antipsychotic potential through dose-dependent inhibition of amphetamine-induced hyperactivity in rats, reflecting D₂ receptor antagonism relevant to positive symptoms of schizophrenia. Unlike typical antipsychotics, it exhibited minimal catalepsy induction in rodents, indicating a low risk of extrapyramidal symptoms (EPS), while maintaining efficacy in conditioned avoidance response models. Toxicology assessments across species, including rats, dogs, and monkeys, identified no significant target organ toxicities beyond prolactin-related effects, and genotoxicity studies—encompassing the Ames bacterial reverse mutation assay, chromosomal aberration tests in Chinese hamster lung cells, and in vivo micronucleus assays in mice—yielded negative results, supporting a favorable safety profile for advancement.[30][32][30] Notable preclinical insights highlighted lurasidone's advantages in cognitive function models, where it outperformed haloperidol in reversing phencyclidine- or scopolamine-induced impairments in rat novel object recognition and passive avoidance tasks, an effect mediated by 5-HT₇ receptor blockade that enhanced glutamatergic transmission without the cognitive deficits seen with D₂-selective agents. These findings, combined with completed IND-enabling toxicology, pharmacokinetic, and efficacy studies in multiple species, paved the way for the Investigational New Drug application, effective December 19, 2000. The compound patent for lurasidone (US 5,532,372) was filed on July 6, 1994. A later method-of-use patent (US 9,815,827 B2) claims priority to August 22, 2002.[37][30][38][39]

Clinical Development and Trials

The clinical development of lurasidone advanced through several phase 3 trials for schizophrenia conducted between 2006 and 2008, involving over 1,200 patients across four randomized, double-blind, placebo-controlled studies. These pivotal trials evaluated doses ranging from 40 mg to 160 mg daily, demonstrating significant improvements in Positive and Negative Syndrome Scale (PANSS) total scores compared to placebo, with effect sizes indicating robust efficacy in acute symptoms of schizophrenia.[10][40][41] For bipolar I depression, two key phase 3 trials from 2009 to 2011 enrolled more than 800 patients, assessing lurasidone as monotherapy (20-120 mg/day) and adjunctive therapy (with lithium or valproate). In the monotherapy study (n=505), lurasidone significantly reduced Montgomery-Åsberg Depression Rating Scale (MADRS) scores versus placebo, while the adjunctive trial (n=340) showed similar benefits in combination regimens, establishing efficacy for depressive episodes without inducing mania.[42][43][44] Long-term extension trials, including 12-month open-label studies following acute phase 3 trials, confirmed sustained efficacy and tolerability in over 600 patients with schizophrenia, with improvements maintained in PANSS scores and low relapse rates. A 12-month randomized withdrawal study (PEARL 3) further demonstrated that lurasidone (40-80 mg/day) delayed time to relapse by 33.7% compared to placebo, reducing risk in stable patients. Additionally, a 22-month open-label extension reported minimal impacts on weight, lipids, glucose, and prolactin levels, supporting long-term use.[45][46][47][48] Recent developments include trials from 2023 to 2025 exploring higher doses (up to 160-240 mg/day) for treatment-resistant schizophrenia, such as a double-blind study comparing 80 mg to flexible higher dosing after initial stabilization, which suggested improved efficacy in refractory cases without proportional increases in adverse events. A 2025 phase 3 study in Chinese patients confirmed that initial doses of 40-80 mg were noninferior to risperidone for acute symptoms, with potential for dose escalation in resistant subgroups.[49][50][51] The NRX-101 combination (D-cycloserine plus lurasidone) underwent phase 2b/3 evaluation for suicidal bipolar depression, with 2024 results from a randomized, double-blind trial (n=81) showing superior maintenance of remission in depression and suicidality compared to lurasidone alone, particularly after ketamine stabilization, with fewer movement-related side effects.[52][53] Ongoing European Union trials, registered in the Clinical Trials Information System, are investigating lurasidone for expanded indications such as bipolar disorder maintenance and potential adjunctive use in major depressive disorder, though results remain pending as of 2025.[54][55] Limited off-label exploration includes small studies for irritability in autism spectrum disorder, where lurasidone (20-80 mg/day) reduced symptoms in open-label and placebo-controlled trials involving children and adolescents, but without regulatory approval. Data for major depression are sparse, primarily from adjunctive use in treatment-resistant cases, showing modest MADRS improvements but lacking large-scale validation.[56][57][58]

Regulatory Approvals and Milestones

Lurasidone, marketed as Latuda in the United States, received initial approval from the U.S. Food and Drug Administration (FDA) on October 28, 2010, for the treatment of schizophrenia in adults. Sumitomo Dainippon licensed commercialization rights in the US to its subsidiary Sunovion Pharmaceuticals Inc., which submitted the NDA in December 2009.[59][60] In June 2013, the FDA expanded its approval to include the treatment of depressive episodes associated with bipolar I disorder as adjunctive therapy with lithium or valproate in adults. Further expansions occurred on January 28, 2017, for schizophrenia in adolescents aged 13 to 17 years, and on March 6, 2018, for bipolar depression in pediatric patients aged 10 to 17 years. Internationally, the European Medicines Agency (EMA) granted marketing authorization for lurasidone on March 21, 2014, for the treatment of schizophrenia in adults and adolescents aged 13 years and older.[61] In Japan, the Ministry of Health, Labour and Welfare approved lurasidone on March 25, 2020, for both schizophrenia and bipolar depression in adults.[62] Generic versions of lurasidone became available in the United States following the expiration of key patents, with launches beginning in February 2023 by manufacturers including Lupin Limited. Other companies, such as Accord Healthcare and Amneal Pharmaceuticals, also introduced generics around this time, increasing accessibility.[63] Key milestones in lurasidone's regulatory history include post-marketing commitments established by the FDA upon initial approval, focusing on long-term safety evaluations such as carcinogenicity studies and assessments of potential effects on prolactin levels and metabolic parameters.[59] These commitments were progressively fulfilled, with several completed by 2019 as confirmed in FDA correspondence.[64] No major label changes have occurred since 2020 beyond updates related to generic entry. Ongoing regulatory reviews include evaluations of combination therapies, such as NRX-101 (a fixed-dose combination of D-cycloserine and lurasidone), which has received FDA Fast Track and Breakthrough Therapy designations for bipolar depression with acute suicidal ideation but remains under investigation in pivotal trials as of 2025.[65] No notable denials or withdrawals have been reported in lurasidone's approval history.

Society and Culture

Brand Names and Formulations

Lurasidone is primarily marketed under the brand name Latuda in the United States, European Union, Canada, Japan, China, Australia, and over 50 other countries.[62][66][67] In these regions, Latuda is produced by Sumitomo Pharma Co., Ltd., the original developer of the compound.[68] In India, lurasidone is available under multiple brand names from local manufacturers, including Luramax by Sun Pharmaceutical Industries Ltd., Lurasid by Intas Pharmaceuticals Ltd., and Atlura by Torrent Pharmaceuticals Ltd.[69][70] Generic versions of lurasidone hydrochloride entered the U.S. market in February 2023 following FDA approval of abbreviated new drug applications.[63] These generics are manufactured by several companies, such as Accord Healthcare, Inc., Amneal Pharmaceuticals LLC, Dr. Reddy's Laboratories Ltd., and Lupin Pharmaceuticals, Inc.[71][72] Lurasidone is available exclusively in oral tablet formulations, with strengths of 20 mg, 40 mg, 60 mg, 80 mg, and 120 mg; no injectable, liquid, or extended-release options have been developed or approved.[25][73]

Cost and Accessibility

In the United States, the brand-name version of lurasidone, marketed as Latuda, typically costs between $1,200 and $1,500 per month for a standard 30-day supply prior to the availability of generics, based on average retail prices without insurance.[74] Following the entry of generic lurasidone in February 2023, prices dropped significantly, with monthly costs for generics ranging from $8 to $50 as of November 2025, depending on dosage, pharmacy, and discounts.[75][63] This substantial reduction, often exceeding 99%, was driven by the expiration of key patents protecting Latuda, enabling multiple manufacturers such as Lupin, Amneal, and Dr. Reddy's to launch generic versions.[76] Additionally, Sumitomo Pharma America offers a patient assistance program that provides eligible uninsured or underinsured patients with free medication to address financial barriers.[77] Globally, lurasidone is more affordable in markets with robust generic competition, such as India, where a 30-day supply of generic equivalents like Lurasid can cost as little as $5 to $20 as of 2025.[78][79] However, access remains limited in low- and middle-income countries due to higher relative costs of second-generation antipsychotics, inconsistent availability, and inadequate healthcare infrastructure, as evidenced by sparse clinical intervention studies in these regions.[80] In such settings, older first-generation antipsychotics are often preferred for affordability, though they may carry higher risks of side effects. In the US, lurasidone is widely covered by private insurance plans and Medicare Part D, with approximately 99% of Medicare prescription drug plans including it on their formularies.[81] Coverage for bipolar depression often requires prior authorization, where insurers may mandate documentation of inadequate response to alternative therapies or preferred generics to ensure medical necessity.[82] This step-therapy approach helps manage costs but can delay access for patients needing prompt treatment.[83]

Legal and Regulatory Status

Lurasidone is not designated as a controlled substance by the U.S. Drug Enforcement Administration (DEA), carrying no schedule classification, and is available exclusively by prescription in the United States. Internationally, it is also prescription-only (Rx-only) in approved markets, with classifications such as Schedule H in India, which mandates a prescription from a registered medical practitioner and restricts retail sales without one.[84][85][86][87] Lurasidone has no known abuse potential and is not associated with recreational use, euphoria, or dependency. The FDA prescribing information notes that it is not a controlled substance and has not been systematically studied for abuse liability, but clinical studies revealed no tendency for drug-seeking behavior. Poison center reports on intentional overdoses (up to 4000 mg) indicate common effects include drowsiness/lethargy, agitation, nausea, vomiting, and tachycardia, with most cases resulting in no serious outcomes and no reports of pleasurable or intoxicating effects.[6][88] The U.S. Food and Drug Administration (FDA) requires black-box warnings on lurasidone labeling for the increased risk of mortality in elderly patients with dementia-related psychosis and for suicidal thoughts and behaviors in children, adolescents, and young adults taking antidepressants, a class-wide warning applicable here. Lurasidone does not require a Risk Evaluation and Mitigation Strategies (REMS) program, distinguishing it from certain other antipsychotics with more stringent post-marketing requirements.[27][22][1] No major regulatory controversies have arisen regarding lurasidone's approval or use, though pre-approval concerns focused on off-label pediatric applications, such as for irritability in children with autism spectrum disorder, prompting FDA requests for further pediatric studies. Ongoing scrutiny applies to investigational combination therapies like NRX-101, a fixed-dose pairing of lurasidone with D-cycloserine for bipolar depression and suicidality, which holds FDA Breakthrough Therapy Designation but faces review for efficacy and safety in this context.[89][90] Globally, lurasidone requires a prescription for distribution, with pregnancy categories varying by jurisdiction: Category B in the United States, based on animal reproduction studies showing no fetal risk but limited human data, and Category B1 in Australia, indicating no evidence of harm in animal studies with inadequate human information.[91][27][92][93]

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