Discovery of Procognitive Antipsychotics by Combining Muscarinic M₁ Receptor Structure-Activity Relationship with...

Current antipsychotic drugs are notably ineffective at addressing the cognitive deficits associated with schizophrenia. N-Desmethylclozapine (NDMC), the major metabolite of clozapine, displays muscarinic M₁ receptor (M₁) agonism, an activity associated with improvement in cognitive functioning. Preclinical and clinical data support that M₁ agonism may be a desired activity in antipsychotic drugs. However, NDMC failed clinical phase II studies in acute psychotic patients. NDMC analogues were synthesized to establish a structure-activity relationship (SAR) at the M₁ receptor as an indication of potential procognitive properties. In vitro evaluation revealed a narrow SAR in which M₁ agonist activity was established by functionalization in the 4- and 8-positions in the tricyclic core. In vivo behavioral response profiles were used to evaluate antipsychotic efficacy and exposure in zebrafish larvae and peripheral side effect related M₁ activity in adult zebrafish. The NDMC analogue 13f demonstrated antipsychotic activity similar to clozapine including M₁ agonist activity. Cotreatment with trospium chloride, an M1 peripheral acting antagonist, counteracted peripheral side effects. Thus, the NDMC analogue 13f, in combination with a peripherally acting anticholinergic compound, could be suitable for further development as an antipsychotic compound with potential procognitive activity.