1a Recent Patets on Endocrine, Metabolle& Immune Drug Discovery 2007, 1, 82-184 Melatonin and Melatoninergic Drugs as Therapeutic Agents: g Melatonin Receptor Agonists Agomelatine, the Two Most Promi Ramelteon and Emilio J. Sanchez-Barcelo*, Carlos M. Martinez-Campa, Maria D, Mediavilla, Alicia Gonzalez, Carolina Alonso-Gonzalez and Samuel Cos Deparment of Physiology and Pharmacology, University of Camabria, 39011 Santander, Spain Received: March 18, 2007; Accepted: March 17,2007: Revised: April. 2007 Abstract: Melatonin is » pineal hormone which basically ac through membrane receptor, bata at « ee radical scavenger (equieng no receptors), and by binding to invacellulr sits (Calmodulin and mulear ecepors). Membrane recepirs (MT, MTs) a sociated to G proteins aked to inhibin of dens] eyclae and decease of cAMP, and are expressed by almost ll stuctues ofthe NS (especially hypotalamie suprachiasmatic auclews and pars tubers of the pity), as well ar ip pevpheal Uses (gastrointestinal tack, thymus, smooth muscle of blood vessels, adipocytes, Imptocytes, te), Amoog the actors abated tomestonin Sridepeseant, ete. This wie spectrum of ato those of antioxidant, controler of ciradianriytuns (special rte many posible therapeu appicsons fr reltonin. However, sure as 2 sleep-wake and core body temperature}, immunotedulatien, ‘rug presents Some limitations (eo optinise pharmaclogical responses of each subtype or receptor, is apd metabolic inactivation, tc.) ‘hat have caused many laboratories to develop analogues without the above meationed problems. Two ar te patented melaonmergi drugs with more interesting properties: onc is ramelteo (USEO34239; Rozerem™9, approved by the FDA for the long term teste oF Sleep disturbances characteriza by dificult wit sleep onset, the second, agomeltine(USS318984; VaMioxan™), which is completing the pace ll tal, wae designed forthe tectnent of symptors of major depreseve disorders, particularly anxie, sleep troubles nd ‘eeadiandaubances Keywords: Melatonin, agomelatine, valdoxan, ramelteon, rozerem, sleep troubles, depression, MT melatonin receptors, MT2 melatonin receptors. INTRODUCTION Melatonin: Synthesis, Circulation, Metabolism and Regulation of Secretion Melatonin is an indoleamine (N-acetylmethoxy-tryptamine) widely disabuted in nature, from plants, bacteria and unicellular Algae to humans [12] Although melaonin is symthesized in numerous organs (pineal, retina, Imphocytes, gastrointestinal rat, ttc) culating melatonin in marumals is maisy of pineal ongia {23}. Mammalian pinealocytes take tryptophan, the aminoacid ppecusor of melatonin, fiom blood, forming, frst S-hydroxy- feyptopban aad thea serotonin. This let is cciylatd to form N= scetylserotonin, a reaction catalyzed by the enzyme arylacylamine Neacetylransferase (ANAT), which, in est cases, represent he ratetimiting eazyme ia melanin syabesis. Neaeetyerotnin i finally converted t0 melatonin by the enzyme bydroxyindole-O- smetbylansteras [4] Once sythsize, melatonin, because ofits High Tiposolbiiy, difises ot into the capillary lod and cere>rospinal fiuid (CSP) In blood, melatonin escalates bound to proteins (70%) and free, rapidly reaching all tissues. Melatonin fsves atthe CSF through the pineal yess and its concenvaton in the third entice is up to 20 times higher Us ia blood (5) The IMIFLfe of melonin shows a biexponentil pater, with & fest distbuton halflife of 2 min, followed by a second of 20 min (6) Circulating melatonin is metabolized i te liver by hydroxylation, dependent| on. cytochrome P&S0. moao-oxygenaes, and. then conjugated ith sulphate (6-sulptstoxymeistonin) and, ta lescer extent, © glucuronide (6]-Intssus of neural origi, such asthe tens and: pineal_gland, melatonin can be deacaylated 5 rneforytptamine [7]. ln the brain, melatonin is metabolized to derivates of kynuramine (8). ‘The most siking feature of melatonin secretion is their thythmisty. The pineal prodacton of melatonin shows a circadian rythm with low cizeulating levels during the day, and high “TAdiiesscorespondence wo tis ahora the Departneat of Piysiology and Pharmacology. School of Medicine, Univeriy of Cantabria, 3901 Santander Spain E-mu barcsloguaicanes 1872-214407 $100,004.00 platmatic concentrations of hormone at night (4). This rhythmi Js controlled by an endogenous clock, the suprachiasmatic nuclei of hypothalamus (SCN), The activity of the SCN is synchronized by the light/dark cycle. Ligh, detected by photoreceptors located atthe retinal ganglion cells end containing the photopigmeat melanopsin, initiates the signals whieh, all along a neural pathway (the retino- hypothalamic tract) synchronizes the endogenous oscillator (SCN), to the dey/night period (4). Neurons from SCN project, through the paraventricular nucleus, medial forebrain bundle, reticular formation and intermediolaeral hom of the spinal cond, to the superior cervical ganglia (SCG). Posiganglionic noradrenergic SSbres from SCG innervate pinealocytes (conari nervi). In darkness, ‘he norpinephrine released by the conarii nerves binds to f- ‘adrenergic receptors on the pinealocytes, activates adenylate ‘yelase via the o-subunit of G, protein, increases the cAMP, and, ‘promotes the synthesis and activation of AANAT, thus triggering. the synthesis of melatonin [4]. During the light phase of the daily ‘le, the release of norepinephrine is low and, consequently, melatonin synthesis decreases ‘Melatonin Receptors ‘By using asa probe the agonist radioligand 21: iodomela- tonin {9} and though experiments of binding and autoradiography, Dinding ses for melatonin were characterized in diferent such Initially, two kinds of membrane receptors: MIL, (igh affinity, PM range) snd My (ow affinity, aM range), were desorbed. Thee Subypes of ML high afinty receptors were then characteriza and named Mele Mel and Mel, the last not being present in ‘manuals {10}, Now, in accordance with the enteria of the Inerstinal Union of Pharmacology (IUPHAR) the following melatonin membrane receptors are under consideration: MTT (the farmer Mel), MT; (the previously identified ss Mely), and MT, (the former ML). Both the MT; ad MT, receptors belong. 0 the superfamily of G-protein-coupled membrane receptos linked tothe inhibition of the adenyil cytase and the subsequent decease of cAMP [11]. The thied subtype of melatonin membrane receptors, MT;, with an affinity range 10 2M, has been described in hamsters as the homan homologue of the cytoplasmic enzyme quinone reductase 2 [12], which participates in the protection “ogaiet (© 2007 Bentham Science Publishers Li.Melton, Ramelicon ond Agomelatine oxidative stess by preventing the electron transfering reaction of {quinones [12]. They are expressed with the highest amounts in iver and kidney, modest amounts in brain, hear, brown adipose tissue, ‘nd low amounts in skeletal muscle and lung (12) ‘The human MT, and MT; melatonin receptor subtypes have a 55% overall identity in their aminoacid sequence and about 70% ‘within the transmembrane domains (11]. These receptors have been Aeseribed in almost all structures of te CNS, although the highest ‘density is found in the hypothalamic SCN and the pars tuberalis of ‘he pituitary {13}. This distribution explains the melatonin actions 5 a chronobiotic agent as well as ils modulatory effects on the neurcendocrine reproductive axis. MT, and MT; receptors are also present in the gastrointestinal tact, lungs, thyrnus, smooth muscle ff blood vessels, adipocytes, lymphocytes and neutophiles. The peripheral receptors could explain some of the melatonin effects on Cardiovascular, gastrointestinal or immune aystems [3], cDNAs and DNAs encoding high affinity melatonin receptors have been recently patented [14]. Nuclear receptors of the retinoic acid receptors superfamily (RZR/ROR) have also been proposed at selatonin binding sites, and would be especially related with the immunomodulatory role of melatonin (15), Melatonin also binds to moduln [16] and this binding is involved in the antieswogenic ‘esions of melatonin [17]. MELATONIN ACTIONS AND APPLICATIONS ‘The adjective “pleiotropic”, frequently used to design the actions of melatonin, defines the great number of functions tributed to this indoleamine. Let us briefly review some of the ‘best known actions ascribed to melatonin: Antioxidant Properties ‘Melatonin bas been shown to be a fee radical scavenger more efficient than most of the aaturally occurring antioxidants (7). Melatonin exer: its antioxidative effects by three different mechanisms 1 Direct imteraction with reactive oxygen species. A melatonin metabolite of nonhepatic tissues, the N'-acetyLN*-formyl-5- methoxykinuremine, isthe key to melatonia’s ability to neutralize fice radicals. In the formation process of this metabolite from melatonin, up to four ffee radicals are consumed. Furtbermore, another metabolite of the same family, the N'-acetyl-S-methony- Kinuramine, is a potent radical scavenger ot only for reactive ‘oxygen bu also with eactve nitrogen species [18] I) Indireeny, by up-regulating the expression of antioxidant ‘enzymes such ‘as superoxide dismutises, peroxidases and glutathione, and down-regulating pro-oxidant ones such as nitric ‘Oxide synthase and 5- and I2-lipo-oxigenases (19). I) By preventing the formation of oxidative radicals. This antionidant effect takes place at mitochondsal level. Mitochondria, are the main source of free radicals because of the reactions of the respiratory chain. Melatonin is capable of supporting the electron flux through the respiratory chain, of preventing the breakdown of | the mitochondrial membrane potential, and of Gecreasing clecton leakage, thus reducing the formation of superoxide anions [19]. The relafonin metabolite N'-acetyl-S-methoxykyauramine may also reduce the mitochondrial formation of oxidative radicals [20] Control of the Circadian System (Chronotropic Agent) ‘The robust circadian thythm of melatonin secretion, which is ‘ot disturbed by practically any situation or agent except light exposure, suggests a role as an endogenous eyachronizer (21). Melatonin is seereted under the contol of the SCN and, atthe same time, SCN itself has MT; melatonin reeeptos (22). Thus, the SCN ‘and the pineal gland integrate a feedback loop for the synchronization of many biological functions with the daily Recent Patents om Endocrine, Metabolic & Immune Drug Discovery 2007, Vol. Na? 1 lighudarkness cycles. Melatonin administration changes the timing of sleep, core body temperature, cortisol or melatonin rhythms [23] “The sense of these changes depends onthe time of administration of melatonin. Whea given during the evening othe frst alf period of ‘ight, melatonin induces © phase-advance, whereas during the second half of the night or in the morning it induces a phase-delay of the hye (23) Melatonin could be involved in the control of the circadian shythm of core body termperatare. Both, the circadian rhythms of melatonin and core body temperature are inversely coupled. It has ‘been demonstrated thet the hypothermic properties of melatonin are responsible for at least 40% of the amplitude of the circadian ‘hythm of body temperature (2), Sleep/Wake Rhythm Circulating levels of melatonin are highest during the night and the timing of highest urinary excretion of 6-sulphatoxymelatonin ‘overlaps with the greatest noctumal sleepiness (25]. This fact suggested a possible role of melatonin in the mechanism of seeping. Melatonin, at physiologic doses (0.1-0.3 mg) promotes sleep onset and maintenance, decreases sleep latency, increases sleep efficiency and increases total sleep time (26,27). However, not al the results are similar, and the efficacy of melatonin 2 @ Lbypnotic agen is still controversial, Discrepancies could. be explained by the different dosage and time of administration of the indolearsine or the different way of assessing sleep quality (28) It, bas been suggested that melatonin hypnotic effects are secondary t0 its ability to indace a decrease in core body temperature [29]. A ‘g00d example of the role of melatonin inthe sleepiwake rhytim can be obiaied from patients of Smith-Mageais syndrome, originated by & partial deletion of chromosome 17. These patients show 2 characteristic inversion ofthe cteadian rhythm of melatonin, with a pase advance shift of 9.640.9 b with respect to control subjects Behavioural phenotype includes sleep disorders with eady sleep ‘onset, difficulty falling asleep, difficulty staying asleep, frequent avakening, early waking, reduced REM sleep and decreased sleep time (30]. The administration to these patients of a Pl-adrenergic antagonist in the moming (to abolish the diumal secretion of melatonin) associated with the administration of melatonin in the evening (to generate a noctumal peak, restoring the nonnal day'nightchythm of melatonin, induced a dramatic improvement in sleep quality (30,31), Melatonin synthesis declines with age and sleep troubles of elder people have been attributed to this low melatonin secretion, Consequently, melatonin, rather than the therapies based on ‘benzodiazepines [32], has been proposed as an elective treatment for insomnia in elderly pations, with positive results tis in those sleep disorders originated by a desynchronization of activity thythms with the dark-light eycle, such as sbif-work, Jetag or absolute blindness, where melatonin is more effective {33]- However, since in these situations circadian thytbms can also ‘be entrained by ight, the effects of melatonin can be obscure (28). Immunomodalation ‘The relationship berween melatonin and the immune system was demonstrated several years. ago [34]. Immunomodulatry properties of melatonin seem to be mediated via membrane and nuclear receptors [35], Both melatonin MT, membrane receptors and the putative nuclear RZR/RORa melatonin receptors have been described in various immune cells of humans (36). Melatonin ‘enhances the production of interleukins by cultured mononuclear cells (IL-2 and 11-6) and macrophages (HL-2 and IL-12)[37]. Furthermore, buman lymphocytes synthesize melatonin, which could stimulate the production of IL-2 as an autocrine or paracrine substance [38]M4 Recent Patents on Endocrine Metolic & Tnmane Drag Discovery 207, Vo 1, No.2 Mood Disorders ‘The cyclic nature of depressive ines, togeter with the divral changes in its symptoms well asthe toubles in he circadian fhythms of core body temperature and slexpwake, were the basis 0 consider that a dysfunction ofthe cicadian system could be among the ehiological factors of depression [39]. Because of is role a8 regulator of circadian syns, measurement of melatonin secretion im depression has gael atenion (39). Serum melatonin concentrations aze low in patients with majo depressive disorders aad, afer teatment with antdepresants, melatonin. sceetion (Beard by the urinary excretion ofits motbolte6-uphatoxy- sieatonin) inteases coinciding wih the improvement of the Symptoms (40,41) Not only the serum concenzaion of melatonin is altered in patients with bipolar affective disorder seasonal affective disorder (winter dopresion) but a phase delay of melatonin rhythm is characteristic ofthese mood disorders (39.40 Because ofthe ecadian component of depresive ins, eaten with phase-estting agents (bright light or melatonin) at critical timings was proposed several yeats ago (42). Recent, the description of dzpression-ike behaviour i melatonin MT receptor knockout mice [43] has caused interest o be rgained inthe role of| ‘melatonin in depression as well sin the development of melatonin ‘eeplor agonists a antidepressants Cardiovascular System thas been suggested that melatonin regulates biood pressure through ts control of the autonomic nervous system [44]. A roctufal serum concentration of melatonin lower tan normal bas ‘been described in subjects with coronary diseases [45]. Furher- ‘more, melatonin increases the vagal tone, decreases plasmatc levels of NE, and reduces blood pressure in Lypectensve paints {46}, Meletonin reeptors have bees ideatifed in the cardiac Yerticlar wall, coronary aeies, aorta and systemic ates (13] Although tee physiologieal meaning isnot completely understood, ‘Oncostatie Properties of Melatonin ‘The possible influence of melatonin on the growth and spread of different kinds of tumors as well asthe mechanisms involved in such oncostatic properties, have been widely studied in animal ‘models [47,48] and. also explored in human olinical trials (491 However, i is on hormone-dependent breast tumors where the ‘ncostatic actions of melatonin have been most studied [50]. ‘Melatonin inhibits the promotion, growth and invasiveness of estrogen-receptor positive mammary tumors by interacting with the cestrogen-signaling. pathway [17,51,52], and enhances the antes: twogenic action of tamoxifen by acting on a site other than this antesterogen [52]. Furthermore, melatonin exerts antsromatase actions in viro QMCF-7 cals) [53] as well 28 tn vivo (murine chemically induced mammary tumors) [54]. That is to say, melatonin shares properties of selective estrogen recepior ‘modulators (SERMs) such as tamoxifen and selective estrogen enzyme modulators (SEEMS) such as letozole or formestane, thus being a drug with potentiat interest in prevention and treatment of| human breast cancer. This property of melatonin reinforces th idea of the possible role of this hormone as an adjuvant therapy for prevention and treatment of cancer [52] Since oxidative sress has ‘been implicated in the initiation, promotion and progression of cateinogenesis [55], the anticarcinogenic actions of melatonin can be also attributed tits antioxidative properties (56), So fu, the highest clinical experience in te use of melatonin in treatment of cancer belongs tothe group of Lisson in Italy. They have used melatonin not only as an anticancer drug for different ‘kinds of neoplasias but also to reduce the adverse effects of other chemotherapeutic agents. The conclusion is that treatment with ‘melatonin ot an association of different pineal indoles, improves the efficacy of chemotherapy in terms of both survival and quality of| lie (57,58). Sanches-Barcelo eta Bone Metabolism Bone marrow cells express N-acetykransferase and hy droxy- indole-O-methylransfease, the two basic enzymes for melatonin ‘synthesis, and melatonin is present in these cells at concentrations Ihigher than in plasma (39,60), Bore marrow melatonin could play a tl as antioxidant or he involved in osteoblast ciffereatation (60, 61], Melatonin promotes osteogenesis and prevents bone deterio- ration (60,62]. These effects could be mediated by either: a) the suppression of osteoclasts activity, because of its free-zadicals’ scavenging properties or actions onthe receptor activator of NF-xB ligand (RANKL), b) by increasing the osteoblasts activity through specific receptors for melatonin [60-61,63] Energy Expenditure and Body Mass Regulation Melatonin. concentration in the gastrointestinal trast of vereeates is 10-100 times higher than in plasma [64]. The release (of gastrointestinal melatonin seems to be related with the periodicity of food intake (64, Thus, melatonin could play a role in the regulation of energy balance and body weight. The decline of, ‘melatonin secretion with aging has been related with the age~ dependent increase of visceral fat [68] although, in human adults, ‘obesity is not accompanied by significant changes in melatonin, secretion (66). However, obese pubertal boys (10-15 year-old) ‘how an increased excretion of 6-sulphatoxymelstonin (67). Human pathologies associated with desynchronization of cicadian rhythms ‘and melatonin seeretory pattems could lead to carbohydrate craving, ‘and overall weight gain (68). In rats rendered obese by being fed a hypercaloric diet, ‘melatonin reduces body weight gain [69] and daily administration of melatonin to middle age male rats feeding normocaloric food reverses visceral fat and citvalating levels of ghicose, leptin insulin and triglycerides to the youthful values [70], The presence of a ‘melatonin receptor in human adipocytes [71] could explain, atleast in par, these cffects. Recently, studies carted out on’ rabbits, demonstrated that melatonin improves metabolic and morpho- logical pathologies associated with obesity [72]. POTENTIAL INTEREST IN THE UTILIZATION OF MELATONIN AS A THERAPEUTIC DRUG From the reading of the above exposed wide catalogue of retatonia properties, it is reasonable 10 consider many possible therapeutic applications ofthis molecule. Table 1 summarizes some of the hundreds of patented opplications of melatonin. However, for different reasons, some of which will be described in the next Section, there is ite experience in therapeutic uses of melatonin, at Teast in controlled wials with criteria for any other drugs. This [paucity of “coniolled uses” contrasts with the extensive use of ‘melatonin without medical control What we are going now 10 ‘analyze are the pathologies for which melatonin could represeat a ‘therapeutic agent: Deficits of the Immune System ‘The role of melatonin as an immunoenhancer [34] opened up interest towards this substance in atleast two fields, One is the treatment of the HIV infection. Serum melatonin concentration seems to be decreased in HIV-infected pationts and ths fact could bbe related with the impsirment of the T-helper response [73] ‘Melatonin implants have recently demonstrated that they are able to ‘enhance the T-Helper immune response [74]. On the other band, some autoimmune diseases, such a¢ sheumatoid arthritis, develop with elevated serum melatonin. Th these cases the use of & melatonin receptor antagonist would be recommended. ~Breast Cancer ‘The properties of melatonin as an antiestogenic and antiaromatase drug (17, $2] with action mechanisms different (0 those of the drugs curently being used, open up interest for theMelatonin, Rameleon and Agomelatine ‘Table. ‘Recent Patents on Endocrine, Metabolic & Immune Drag Discovery 2001, Vol 1, No.2 148 Some Patents of Melatonin Uses or Melutoninergic Synthetic Drugs Uses for Melatonin or Melatoninerge Synthetic Drugs. Aleheimer disease weaanent US Patents Numbers 65986968, 274615 ‘Andogenie alopecia exei24i jessie Avene é 6552064, 6638966 ‘Asia 519665 Benign prostate hyperplasia 5730557, 5770610, 64868 Z Cardins Ania E ease Cerebral intuction weament 5700828, 675045 Contcption nd contol of menstrual ele 4555305, 27214 ‘Creadian shyt woubles 4600723, 4665086, 5247981, 5420152, 5591768, ‘707652 5716978, 6069164, 6180657, 623736, 6539963, 6794407 Dermocommetie 746674, 5691903, 5932608, 5959088, 985293, 6073409 Drv dependenries wesoneat 465044, 6853583 aa Taxnoculer pressure refuction Cresent of Guucom) 465061, 70707 Tmanomodon 5519087 Mignine prevention soa8s20 Premenstrual aypdome : 3945103 Rheunstoid artis 605877 —_ Skepwonbies ‘54496585, S641, 5654025, 6703412, 998112 Metaoninese drs "SOTIATs, sisia46, A968, 46u87, 5098403, | 5530012, 5881228, $596019, 677328, s103239, 5163471, 5780470, 5856529, 5808151, 5889031, 592771, 8948817, 5981571, 6028112, 6060506, 6000854, 6114373, 6140372, 6211225, 6214869, 6136044, 6195543, 6569, 6620809, 6737431, 6844445, 6908931 study of the possbie utility of melatonin in the prevention and ‘westment of bormone-dependent mammary cancer, at least af an adjuvant ofthe consolidated therapies. = Other Neoplasias [Not only mammary tumors but other neoplasas expressing estrogen receptors (glioma, melanoma, etc) are susceptible to ‘weatment with melatonin and some experimental resus support this possibility [75,76]. Furthermore, oncostatic properties of rmelatonin are possibly not exclsively dependent on its antistro- genic properties. Immunoenhancing [3437.38] and antioxidant 17.18.20) ‘etions of melatonin are also’ useful in antincoplasic ‘reatments, as has been assessed in experimental studies [4, 47,48]. ~Cireadian Rhythm Disturbances. ‘This is, without doubt, the field of highest incerest up 10 date, ‘The chroncbiotic effects of melatonin [21] make its use viable in diferent kinds of alterations of the circadian system such as: a) Desynchroniztions because of shif-work or tansmeridian fights (et-lag). b) Sleep toubles of circadian origin (delayed or advanced sleep onset syndromes), c) General desynchronization in elderly people in which endogenous melatonin secretion is very low. The {reament of sleep troubles of circadian origin is probubly the most successful application of melatonin [25-29] and one ofthe reasons forthe interest in the development of melatonin receptor agonists for this purpose. One example is ramelteon, the drug we will ‘comment on in greater detail inthe next section, ~‘Treatment of Mood Disorders Depression is oe ofthe most common mental health problems. (One in five women and one in tea men wil suffer from depression at some point in ther lives, these dats explaining the interest in development of antidepressant drugs. Essential features of a major depression include sleep distarbances [77], which could be related with changes in melatonin secretory pattems. Furthermore, some forms of depression show seasonal components (SAD), and light, the principal zitgeber of melatonin circadian thythins of secretion, is being used as a tool for its treatment. All these-data reinforce the145 Recent Patents on Endocrine, Metabele & Immune Drug Discovery 2007, Vol J, Ne.2 role of the circadian system in the pathophysiology of depression [42] and, consequently, the interest in the development of ant depressant drugs, such as melatonin receptor agonists, with incidence in the circadian rhythmicity. «Treatment of Neurodegenerative Diseases ‘The antioxidant effects of melatonin protect neurons against amyloid-B-induced effects in Alzheimer's disease 78]. Similar postive effets of melatonin have been described for Parkinson's ‘isease, Huntington's Corea and other neurodegenerative diseases [79-81]. This is afield of melatonin therapeutic uses with great future prospects -Controlof Food Ingestion and Body Mass Although the role of melatonin in the control of food intake and ‘body mass is sill controversial (64-72) there is evidence that melatoninerpic drugs could, in te future, be used in the prevention ‘of obesity. Some laboratories such as Servier, inteosted in development of melatonin analogues, have been studying, in animal models, the effects of a melatonin agonist (S20304) and an antagonist ($30982) in body weight contol (82), PROBLEMS REGARDS THE THERAPEUTIC USE OF MELATONIN As sated inthe previous section, the description ofthe multiple sction of melatonin suggests a possible usefulness in the treatment (of pathological sinations such as depression, je-lag, work-shit syndrome, sleep disorders, some disorders aasociated with reproduction, some kinds of hormone-dependent cancer, immune disorders, aging, ete. However, the Use of the natural molecule a8 a ‘drug presents some limitations. The first isthe difficaly to obtain selective pharmacological responses" mediated by each kind ot subrype of receptors. The second isis rapid metabolic inactivation (hort hal life) which signifies alow orl bioavailability as well as 4 great interindividual variation. Other reasons which limit the pharmacological (medically controlled) use of native melatonin are not of scientific nature, The use of melatonin for human consump- tion is differently regulated in many counties. Thus, whereas in USA melatonin is considered as a “dietary supplement” which can be obtained without prescription, in some countries of the EU melatonin is @ medicine available only under prescription but in others its use is illegal. The consequence of this lack of an intermational regulation is that people interested in using melatonin can obtained it by intemet, in preparations with doses which gives plasiatic concentrations ‘hundreds of times higher than the Physiological ones, with potential side effects. Furthermore, 10 Pharmaceutical company has requested regulatory approval (0 market it as a drug, perhaps because itis anon patentable molecule Sonchet- Barcelo etal ‘These reasons have led many laboratories to look for melatonin analogues able to mimic the effects ofthe native hormone without the above mentioned problems. BASIS FOR THE DEVELOPMENT OF MELATONINERGIC SYNTHETIC DRUGS ‘The relatively simple siucture of melatonin (Fig. 1) and the ‘well known relationships between structure and function offer ‘many possibilities for development of synthetic analogues (82). Both, the ethyl amide side chain and the methoxy group of melatonin, are critical forthe affinity t receptors. Thus, whereas the removal of the methoxy group reduces the affinity, the incresse in the length of the alkyl substituent atached tothe cattonyl group fiom CH; to CsHly has the contrary effect [83]. The indole ring is rot necessary for melatonin binding to the receptor and even its replacement by naphthalene ring increases the affinity. The evelopment of receptoc ligands is based on modifications of different regions or the melatonin molecale, according to different strategies. The authors recommend an excellent review from Zlotos [83], which describes the main symthetic melatonin analogues grouped by their chemical structure: indoles, tetralines, napfialenes, indanes, benzoxazoles, beavofuranes, and others. From the melatonin derivates patented as melaoninergic drugs (see Table 1) ‘we have selected the two most successful patents ‘THE TWO MOST PROMISING MELATONIN AGONISTS Among the hundreds of patents for melatoninergic drugs, there ‘are two that show the most interesting properties. One of them, ramelteon (US6034239) [84] has already been approved by the FDA and commercialized by Takeda Pharmaceuticals North America under the name of Rozerem™. The second, agomelatine ((U85318994) [85] is completing the phase II trial and will be soon, available from Servier and Novans, under tbe commercial rame of Valdoxaa™. RAMELTEON Structure and Nomenclature Rameltcon (TAK-375); systematic (TUPAC) name: {()-NS(2- (,6,7,8-tetranydro- 217 ndeno {5,4 bfuraa-8-yDethyl}propions- side]; MW 259,34; forma: (CiHaiNO,); CAS mumber:(196597- 26.3), PubChem: 208902; marketed as Rozerem™ by. Takeda Pharmaceuticals Nort America. Stage of Development of the Patent Ramelieon (US6034739) was approved (uly, 2005) by the FDA (Food aad Drug Administration) for long-term use for ‘ueatment of sleep disturbances characterized by difficulty with sleep onset AR aoe AGOMELATINE Fig (1), Seactr f meltonin and two melatonin ceptor agonists.Melatonin, Rameltcon and Agomelatine Properties ‘Ramelteon is an indenofuran derivative of melatonin, the frst ia 1 new class of sleep agents that selectively binds to the MT; and MT; melatonin receptors (86) in the hypothalamic suprechiasmatic nucleus . Rameteon inhibits forskolin-stmulated cAMP production in neonatal pituitary rats, with an ICsp value of 20.8 pM, indicating a strong MI; agonistic activity [83,86]. Is binding activity to the IMT, receptors in Chinese hamster ovarian cells (Ki = 45 pM) i 3- fold lower than forthe MT, receptors (Ki=14 pM) and 4-fld higher than the MT affinity of melatonin (Ki=195 pM) [83]. The affinity of ramelieon for hamster brain MT, receptor binding sites is exiremely weak (KI=14 pM) compared 1o that of melatonin (Ki= 240M) [83.87]. Ramelieon affinity for other ligand binding sites such a5 receptors for benzodiazepines, dopamine, opiates, ion channels and transporters, isnot measurable [83,87,88]. Ramelteon also does not interfere with the activity of a number of selected enzymes in a standard panel (83) ‘Among the pharmacokinetic properties of ramelteon it is remarkable that its half Life in humans is longer than that of ‘melatonin {89,90} and is moze poteat than the indoleamine as a sleep promoter. Its chronobiotic properties have been demonstrated in ras. Like melatonin, ramelteon aeeclerates the re-entrainment of| running whee! capabilities (91), ‘The major metabolite of ramelteon, designed MLM, is also ‘active and has approximately one tenth and one fith the binding. affinity of the parent molecule for the human MT, and MT: receptoss, respectively, and is 17 to 25-fold less potent than ramelteon on fn vitro functional assays. Although the potency of M- TatMT, and MT, receptors is lower than the parent drug, after oral simian of mehcon, Mil aus, cmenatins Digher than those of ramelteon, resulting i a systemic exposure th i520 to 100-fid greater thn the parent compound (92) Mal has weak affinity forthe serotonin S-HTy receptor, but no appreciable affinity for other receptors or enzymes and, sinilar to ramelteon, oes not interfere with the activity of a number of endogenous enzymes [89 ‘Specific Applications Insomnia is one of the most common causes of medical consulting. The pharmacological options available forthe weatmaent of insomnia included benzodiazepines and non-benzodiazepine hbypnotics, which have the potential to induce addiction, cause withdrawal symptoms, or tigger rebound insomnia [93], Since melatonin had been demonstrated to have sopontic effects (26,27), the design of a melatonin receptor agonist for veatment of insomnia was a reasonable hypothesis. Thus, rameligon, a MT, and MT ‘melatonin receptor agonist, was conceived for the treatment of ‘patients with insomnia and circadian rhythm ‘roubles; especially for long-term teatmeat of sleep disturbances characterized by difficulty with sleep onset [88,92,93]. Compared with melatonin, ramelteon selectivity for MT, receptors it more than 1000-fold higher than for MT; ones, this data suggesting that ramelteon may target sleep onset more specifically than melatonin, and may be ‘more suitable for insomnia characterized by difficulty in falling asleep [88,92]. Ramelteon promotes sleep by regulating the normal sleep-wake cycle rather than having generalized depressant effects ‘on the central nervous system [88,92-95} ‘An excellent review of the randomized controlled tials published up 1o July 2006 examining the efficacy and tolerability of| Fameltoa is that of Borja and Danie [92], Ramelteon i currently the only non-scheduled prescription drug for the treatment of insomnia available in USA. It has not exhibited potential for abuse ‘or dependency’ in laboratory tess {96}, and the withdrawal and rebound insomnia typical with other GABA modulators is not present in ramelicon, Which has few sie effects [96]. In a double- bind crossover study on fourteen adults with histories of sedative abuse, ramelteon demonstrated no significant effects indicative of ‘Recent Patents on Endocrine, Metabolic & Immune Drug Discovery 2007, Vol. 1, No.2 147 Potential for abuse or motor and cognitive impairment at up to 20 times the recommended therapeutic dose [97]. In individuals with milé to moderate obstructive slesp apnea (OSA), ramelteon was ‘well-tolerated and, as expected, because of its lack of depressant, effects on the central nervous system, did not worsen OSA when administered wo subjects with mild Wo moderate symptoms (98) The clinical efficacy of ramelteon was evaluated in clinical tals which have been analyzed in the above mentioned review [92], The tial involving a highest number of cases has been a ‘multicentric randomized, double-blind, placebo-contolled 35-night ‘outpatient tial caried out on 829 older people © 65 years) with chronie insomnia, The conclusion was that ramelteon, at doses of 4 for 8 mg, takeo nightly for five weeks, significantly reduced sleep latency with no significant rebound insomnia or withdrawal effects {94} In a previous tial, the efficacy of ramelteon was checked not {in chronic insomniacs but in patients with transient insomnia (375 volunteer aged 35-60 yours). Ramelteon at doses 16 or 24 mg ‘administered a half hour before scheduled bedtime significantly ecreased sleep latency compared with placebo [95]. Result from other tials [99-101] show similar results of decrease of sleep latency, although the effect of ramelteon in sleep efficiency and tox sleep at night i less pronounced (92) Doses ‘Although dotes used in clinical tals ranged from 4 to 64 g, the recommended dosage for treatment of insomnia in adults is 8 mg ‘orally administered within 30 minutes of bed time (92), Side effects Ramelton is generally wel (olested in clinical tis, with mos adverse event lasified ar mild or moderate [99] Theze ae headache (9), somnolence (5), zines (5%), fatigue 6) and nausea (3%) [99]. Following the adminisaton of rametcon, tents id nt report rebound insomnia or withdrawal effets (9) Compared with tazoin, ranelcon was found not to. have Significant effect om behavioural and cognitive performance or ‘Dive poten! [102], Since CYPIA2 is the mayor ‘soenzyme ‘eapeosible for hepatic metablim of ramelton, the inhibitor of ‘his enzyme, auch a emiodarne, ciprofloxacin and fisvoxamine, increase he effects of this og 93), ‘Shorteomings ‘The absence, up to date, of published ils comparing rameltgon with other hypnotic agents (including native melatonin) ‘make it difficult to assess its efficacy relative to other treatments of insomnia. The usual dosage of rameltcon approved for treatment of ‘insomnia is 8 mg. However, except a report on a two-day treatment in insomniac subjects (99], there are no comparative shidis of the efficiency and toxicity of this new melatoninergic drug. with melatonin, active ata much lower dose (0:3 mg). AGOMELATINE, Structure and Nomenclature ‘Agomelatine ($20098); systematic (LAUPAC) name: (NI27- ‘methoxy-I-naphthy)ethyl}-acetamide), MW 243.3; formula. Cs Hyp NOs, CAS number 138112-762; PubChem 82148; marketed as ‘Valdoxan™ by Servier and Novartis. ‘Stage of Development of the Patent Agomelatine (US5318994) is being developed by Servier and [Novarts under the name of Valdoxan™. In March 2006, Novartis aequired she exchusive rights to further develop aad market agomelatine in the United States. Servier retains the rights to develop and market the product in the rest ofthe world, Currently, agomelatine has completed the phase INI clinical trials for treatment ‘of symptoms of major depressive disorders, particularly anxiety,148 Recent Potents on Endocrine, Metaboli & I sleep troubles and eireadian disturbances, and a registration dossier for an indication in major depressive disorder has been recently submitted tothe European Regulatory Agency (103) Properties ‘The replacement of the indole soaffold of melatonin by the saphihalene ring system yields agomelaine (83), which is @ potent agonist a melatonin receptors (MT; and MT) [104] and antagonist at serotonin 2C (5HTac) and seotonin-2B (SHIT) reeepors {104}, The affinity of agomelatine for cloned human rectors MTT and MTz subtypes OKr6.15 x 10" and 268 x 10” Mf respectively) ig, comparable to that of melatonin (K-8.52 x 10" and 263 x 10" M, respectively). On the other hand, agomelatine behaves 28a compeitive antagonist forthe -HTac receptor with a, C4g-2.7 x 16° Mon human cloned 5-H receptors (83,104, 105}. Specific Applications ‘This drug was developed basically s once-caily treatment for major depressive disorder and its symptoms, particularly anxiety and sleep and circadian disturbances (103), Its efficacy was assessed on experiments caried out on different animal (rats or mice) models of depression (forced swimming test, olfacary Dulbectomy, ete) as well as in trinsgenic murine models [82]. Ix these different animal tests, agomelatine, at an average dose of 10 mgKe, was as effective as imipramine or fuoxetine (the two antidepressant molecule of reference at identical doses. The range of currently available antidepressant treatments inchudes selective serotonin reuptake inhibitors (SSRIS) and serotonin and noradrenaline euptake inhibitors (SNR). Both are effective in the treatment of major depressive disorders and have a beter safety and tolerability profile than the older mieyclic antidepressants and monoamine oxidase inhibitors. However, the SSRIs and the SNRI are associated with side-effects of their own, such as gastrointestinal problems, weight ea, sexual dysfunction, drowsiness and sedation, and discontinuation symptoms, all. of Which contribute to @ reduction in compliance and may lead to premature cessation of treatment [106,107]. In addition, some ‘concems about increased suicide rates in patients receiving SSRIs have recently been described (108) and thore have been also cconcems shout the toxicity of SNRIs in overdose [106]. The antidepressant action of agomelatine is not mediated through the sane mechanisms ap selective serotonin reuptake inhibitors oF tricyclics [109]. ‘The current therapeutic strategies for major depressive disor- ders are, therefore, lacking in agents that combine antidepressant cffcacy witha favourable tolerability profile Agomelatine isa new antidepressant with an ianovative pharmacological profil: i is the first melatoninergic antidepressant (82]. Several large, multicenter, ‘multinational, placebo controlled studies and several double-blind, placebo-contolled tials of agomelatine have demonstrated that i is ‘clinically effective and well wlerated antidepressant in acute trials (107,110,111). The antidepressant efficacy of agomelatine has been emonstraed in comparison with placebo at various levels of severity of depression, Indeed, it seems that the treatment effect of sgomelatine tends to increase with the severity of the depression (107). The results also indicate an carly improvement of depressive Symptoms and good response rates. Agomeatine has also been shown to have a comparable efficacy profile o the SSRIs, such as paroxetine, and the SNRIS, such as venlafaxine [112], but lacks ‘typical antidepressant side effects. In rats, agomelatine potentiates the anxiolytic effects of diazopam [113]. ‘The novel mode of action of agomelatine, involving melato- siergicagonism and 5-HT;cand 5-HT7p antagonism, has interesting ‘consequences in terms of clinical benefits, The low rate of adverse vents observed with this new drug contrasts with the SSRIS and NRIs for which the release of serotonin and noradrenaline can ‘ase gastrointestinal, central nervous system and cardiovascular ane Drag Disconery 2007, Val. 1, No.2 Sanches Barcelo ea, side-effects [107,109,110]. Furthermore, agomelatine prevents ‘weatment-elated sexual dysfunction and has positive effects on the relief of sleep disturbances in depression (110}. Indeed, ago- imelatine isthe only antidepressant to have a specific action om circadian rhythms, which are often imbalanced in depressed patients [82], being capable of phase-shifting circadian caythms in folder men [114]. Furthermore, sleep elecroencephalographic changes consistent with desirable sleep architecture improvements, ‘as well as improved subjective sleep quality within the first week of administration of agomelatine, are accompanied by an improvement in daytime aleroess [115] In addition, 2 placebo-controlled, double-blind study comparing agomelatine with paroxetine showed that, after one week of treatment discontinuation, 20 signs of discontinuation symptoms wore seen in the agomelstine group compared to significant discon- ‘imuation symptoms inthe paroxetine group (112) Doses ‘The antidepressant efficacy of agomelatine has been shown at a standard dose of 25 mg, once daily in the evening, in a dos ‘ranging study performed in major depressive disorder {116}. Side-Effects ‘Agomelatine, whatever the dose, has been shown to have a remarkable tolerability and safety profile, showing good sccepta- bility with side-effects profile close to that of the placebo [107,116]. The most common adverse events are reported to be headache, nausea and fatigue. The number of events remains very low and generally resolved within wo weeks. The rates of iscontinuation due 1 adverse events are low (8%) and similar 10 ‘those forthe placebo [107,116] ‘of sgomelatine derives from its mecha nism of action which gives this molecule anidepressant properties together with the ability to regulate sleep-wake rhytim without affecting daytime vigilance. (CURRENT & FUTURE DEVELOPMENTS. Remeitcon and agomelatine are two melatoninergic drugs which share its affinity for MT and MT molatain receptors and consequently bave some hypnotic and chronobiotc actions in ‘common. Only the antagonism at S-HTac recepiors seems to be i to agomelsine [105]. Both drags have been patented as Specialized for sleep dzone (ramelcon or as atieprestant (gomelatine). Sleep dysfunction and psychiatric disorders are ‘commonly associated. When insomnia is comorbid with depression, ‘agomelatine therapy could be prefered whereas chronic insomnia ‘im nonpsychiatic patents could be treated with ramclicon. Thi «drug bas not yet been studied in psychiatric patients [117]. Another ‘substance developed for treatment of sleep troubles is LY 156735 (eveloped by Eli Lilly; USA patent 2005016498741) [118], a B- substitu analogue of melatoeia with higher hypnotic potency and a better pharmacokinetic profile than the native indoleamine (119), ike the other melatoninergie drugs, it has a chronabiotc effect: it improves the adaptation to a phase-advance inthe light-dark cycle (120), yet_not lowering the core body temperature when administered during daytime (28]. LY 156735 isin the early stages oflinical studies, [No comparative studies have been carried out on the efficacy and side eflects of both drugs for its common actions. Probably they are likely to be made in the future, especially ater the commercialzstion of agomelatine. From the knowledge of the distribution and properties of MT, and MT: melatonin rezeptors it seems logical t expect that the potential peripheral effects (cardiovascular effects, oncostatc actions, ete) of rameltean and ‘agomelatine willbe investigated hy further studiesMelatonin, Rameleon and Agomelatine ACKNOWLEDGEMENTS Supported, i part, by a grant from the Spanish Health Instiute Carlos I (71042603) REFERENCES o a a 1 @ Pl m o 8 oo oa 1 1a us) us, on on 9 ea) en a) es 4) es 6, pn en 0) po, py ered R Fue 8. Ube melon. Presence and efi a nicl anand snarl Tends Cp totes Pil 1962254. eter HD Pal icin call Nology of #2 ayhexs me 9 i Pyselape ieroona Endo Rev 1991 121180. Flint R. PusdePenal SR Cal DP. 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