Lumateperone (Caplyta) is a second-generation antipsychotic.

It is used in the treatment of patients with schizophrenia.

Compared to other antipsychotic medications, it has a very low incidence of extrapyramidal symptoms and greater efficacy in treating the negative symptoms of schizophrenia.

Lumateperone (Caplyta) Uses:

• Schizophrenia:

  • Caplyta, also known as lumateperone, is used to treat schizophrenia in adults.

Lumateperone (Caplyta) Dose in Adults:

Schizophrenia:

• For adults with schizophrenia, the typical recommended dose of lumateperone (Caplyta) is 42 mg taken orally once a day.

Switching antipsychotics:

• There isn't a single best way to switch antipsychotic medications.

• One method is cross-titration, which involves gradually lowering the dose of the first antipsychotic while slowly increasing the new one.

• Another approach is a sudden transition, where the first antipsychotic is abruptly stopped, and the new one is either increased gradually or started at a therapeutic dose.

• Cross-titration is recommended for patients with schizophrenia at a high risk of relapse.

• Once the new medication reaches a therapeutic level, the first one is gradually reduced and withdrawn over one to two weeks.

• Some experts prefer cross-titration and overlap strategies over a sudden change based on clinical experience.

Dosage adjustment for concomitant therapy: 

• Certain medications can interact significantly, requiring adjustments in dosage, frequency, or avoidance altogether.

Discontinuation of therapy:

• • The American Psychiatric Association, Canadian Psychiatric Association, and World Federation of Societies of Biological Psychiatry recommend a careful tapering of antipsychotics to prevent physical withdrawal symptoms such as

  • anorexia

  • anxiety

  • diaphoresis

  • diarrhea

  • dizziness

  • dyskinesia

  • headache

  • myalgia

  • nausea

  • paresthesia

  • restlessness

  •  tremulousness

  •  vomiting

  • Abrupt discontinuation of anticholinergic or dopaminergic antipsychotics increases the risk of withdrawal symptoms.

  • Other factors influencing the risk include the medication's half-life, duration of use, and the reason for its prescription.

  • While there is no definitive sign of relapse in schizophrenia, studies indicate that 75% of patients who were well-stabilized on medication may experience a return of symptoms within 6–24 months after withdrawal.

  • Indefinite maintenance on antipsychotics is often recommended, especially for patients with a history of multiple prior episodes or two episodes in the previous five years.

Use in Children:

Not recommended for use in children.

Lumateperone Pregnancy Category: N

• Abnormal muscle movements, known as extrapyramidal signals, are more likely to occur in newborns shortly after delivery.

• These movements, along with withdrawal symptoms, can include agitation, feeding issues, both low and high muscle tone, tremors, difficulty breathing, and drowsiness.

• These symptoms may improve on their own, but in some cases, hospitalization may be necessary.

• There is a lack of safety data for atypical antipsychotics during pregnancy, and it is generally not recommended to use them routinely.

• If a mother was exposed to antipsychotics in a unique way during pregnancy, it might be more beneficial to continue the current therapy rather than switching to a new medication.

• It is advisable to avoid lumateperone if antipsychotics are considered during pregnancy, and other options should be preferred.

Use during breastfeeding

• The presence of lumateperone in breast milk is uncertain.

• However, if it is present, breastfeeding could expose infants to the medication, leading to problems like failure to thrive, jitteriness, extrapyramidal symptoms, and sedation.

• Due to the potential for significant adverse reactions in breastfed infants, the manufacturer does not recommend breastfeeding while using lumateperone.

• If a breastfeeding woman requires medication, alternatives other than lumateperone should be considered.

Dose in Kidney disease:

No adjustments to the dose are necessary for individuals with kidney disease.

Lumateperone (Caplyta) Dose in Liver Disease:

• For individuals with mild impairment (Child-Pugh class A), no dose adjustment is required.

• However, for those with moderate to severe impairment (Child-Pugh class B and C), it is advised to avoid the use of the medication.

Common Side Effects of Lumateperone (Caplyta):

• Central nervous system:

  • Sedated state
  • Drowsiness

Less Common Side Effects of Lumateperone (Caplyta):

• Central nervous system:

  • Dizziness
  • Fatigue
  • Extrapyramidal reaction

• Gastrointestinal:

  • Vomiting
  • Decreased appetite
  • Nausea Xerostomia

• Hepatic:

  • Increased serum transaminases

• Neuromuscular & skeletal:

  • Increased creatine phosphokinase in blood specimen

Frequency of Side effects not defined:

• Central nervous system:

  • Dystonia

• Endocrine & metabolic:

  • Increased serum cholesterol
  • Increased serum triglyceride
  • Increased LDL cholesterol

• Hematologic & oncologic:

  • Elevated glycosylated hemoglobin

Contraindications to Lumateperone (Caplyta):

• Lumateperone (Caplyta) should not be used in individuals who are hypersensitive or allergic to the medication.
• Additionally, there is a crucial warning stating that for patients with dementia-related psychosis, the use of lumateperone is not recommended, as it may increase the risk of death in such cases.

Warnings and precautions

• Anticholinergic effects

  • It is possible to experience confusion, agitation, and constipation while using lumateperone.
  • Caution is advised in situations of decreased gastrointestinal motility, urinary retention, benign prostatic hyperplasia (BPH), and xerostomia (dry mouth).

• Blood dyscrasias:

  • Clinical trials and post-marketing reports have indicated that leukopenia and neutropenia may occur in combination with antipsychotics.

  • Pre-existing low white blood cell count (WBC) or absolute neutrophil count (ANC), as well as a history of drug-induced neutropenia or leukopenia, should be considered.

    If there are signs of a blood disorder or if the acute neutrophil count falls below 1,000/mm^3, it is recommended to discontinue the use of the medication.

• Effects on the cerebrovascular system:

  • In a placebo-controlled study involving certain atypical antipsychotics for dementia-related psychosis, there was an observed increase in cerebrovascular effects, such as strokes and transient ischemic attacks (TIAs).

  • This emphasizes the importance of cautious consideration and monitoring when using these medications in individuals with dementia-related psychosis.

• Depression in the CNS:

  • The use of this medication may lead to CNS depression, which can affect both mental and physical functioning.

  • It is advisable to avoid activities requiring mental alertness, such as operating machinery or driving a vehicle, if there are signs of CNS depression.

• Dyslipidemia:

  • Atypical antipsychotics, as opposed to typical ones, may lead to an elevation in total cholesterol or triglyceride levels.
  • The incidence rates of this effect can vary among different products within the class of atypical antipsychotics.

• Aspiration/ oesophageal dysmotility:

  • The use of antipsychotics may contribute to oesophageal dysmotility or aspiration, particularly in older individuals.

  • Conditions that elevate the risk of aspiration pneumonia, such as Alzheimer's disease, further increase the likelihood of these complications.

• Extrapyramidal symptoms

  • Antipsychotics can cause extrapyramidal symptoms (EPS), which encompass conditions like tardive dyskinesia, acute dystonic reactions, and pseudoparkinsonism.

  • It's important to note that the incidence of EPS is much lower with atypical antipsychotics compared to traditional ones.

  • Factors that increase vulnerability to tardive dyskinesia include old age, postmenopausal females, the presence of pseudoparkinsonism and Parkinson disease symptoms, affective disorders (especially major depressive disorder), diabetes, previous brain injuries, alcoholism, and inadequate healthcare.

  • Additionally, the use of conventional antipsychotics in younger men may heighten the risk of dystonia and other EPS.

  • It's crucial to consider these factors when prescribing antipsychotic medications.

• Falls

  • The use of this medication can result in motor or sensory instability, somnolence (excessive sleepiness), orthostatic hypertension (a drop in blood pressure upon standing), and an increased risk of falls.

  • It's important to be aware of these potential side effects and take precautions to ensure the safety of individuals taking the medication.

• Hyperglycemia

  • Antipsychotics, especially atypical ones, can lead to hyperglycemia, and in some cases, diabetes with hyperosmolar or ketoacidosis.

  • It is not advisable for use in individuals with diabetes or any other disorders related to glucose regulation.

  • Regular monitoring of blood sugar levels is recommended for those taking these medications to manage and detect any potential changes in glucose levels.

• Orthostatic hypotension

  • Orthostatic hypotension, a drop in blood pressure upon standing, can occur with the use of this medication.

  • Caution is advised, especially in patients at a higher risk, such as those taking medications that may lead to hypotension, bradycardia, or hypovolemia.

  • For individuals with a history of cardiovascular or cerebrovascular disease, including conditions like myocardial infarction, heart failure, conduction abnormalities, or a history of myocardial infarction, it is important to use the medication with caution.

  • Monitoring for potential cardiovascular effects is recommended in these cases.

• Neuroleptic malignant Syndrome:

  • The use of this medication can lead to neuroleptic malignant syndrome (NMS), characterized by signs and symptoms such as mental state changes, fever, muscle rigidity, and/or instability.
  • It is important to monitor for the development of NMS and take appropriate actions if these symptoms arise.
  • Neuroleptic malignant syndrome is a serious condition that requires prompt medical attention.

• Temperature regulation

  • The use of antipsychotic medication may result in impaired regulation of core body temperature.
  • It is important to exercise caution in situations involving heat exposure, strenuous exercise, dehydration, and the use of concurrent anticholinergic medications.
  • Monitoring for signs of overheating or difficulty regulating body temperature is advised, and appropriate measures should be taken to avoid potential complications in such situations.

• Weight loss

  • The use of an antipsychotic medication may lead to weight gain.

  • It is important to monitor both waist circumference and Body Mass Index (BMI) regularly.

  • Keeping track of these measures helps in assessing and managing potential changes in weight associated with the use of the medication.

  • If significant weight gain occurs, discussions with healthcare professionals about potential adjustments or alternatives may be considered.

• Dementia:[US Boxed Warning]

  • Antipsychotics, when used to treat dementia-related psychosis in the elderly, have been associated with a higher death rate compared to a placebo.

  • It is not recommended to use lumateperone in individuals with either severe or mild hepatic (liver) impairment.

  • Patients with Lewy body dementia and Parkinson's disease are more vulnerable to adverse effects.

  • There is an increased sensitivity to extrapyramidal side effects, which can result in irreversible cognitive decline or even death.

  • It's crucial to note that lumateperone is not approved for the treatment of dementia-related psychosis. Therefore, its use for this condition is not endorsed.

• Hepatic impairment

  • Patients who are at a high risk for seizures should receive careful and cautious medical attention when using lumateperone or any similar medications.
  • Seizure-prone individuals may require additional monitoring and adjustments to their treatment plan to minimize the risk of seizures associated with the medication.

• Seizures

  • Patients who are over the age of 65 may be more vulnerable to the effects of lumateperone.

  • Careful consideration and monitoring are recommended for this age group due to potential age-related factors that can impact how the medication is tolerated and its overall effectiveness.

Lumateperone: Drug Interaction

Monitoring Parameters:

• Mental Health:

• For mental health considerations, it is crucial to monitor vital signs as needed and clinically indicated.

• Regular assessment of vital signs, including parameters like heart rate, blood pressure, and respiratory rate, is an important aspect of managing mental health and ensuring the well-being of individuals receiving treatment.

• The frequency of monitoring may vary based on the specific needs and conditions of the patient.

• BP:

  •  

    Blood pressure (BP) should be monitored by repeating the procedure three months after starting antipsychotic medication at baseline, and then it should be checked every year thereafter.

  • This routine monitoring helps in assessing the impact of antipsychotic treatment on blood pressure over time.

• Weighing, height, BMI and waist circumference

  • Regular monitoring of weight, height, BMI, and waist circumference is important.

  • It is recommended to repeat these measurements at baseline, 4 weeks, 8 weeks, and 12 weeks after starting or modifying therapy, and then once a year thereafter.

  • If there is a weight gain of greater than 5% from the starting weight, it is advisable to consider switching to another antipsychotic.

  • This proactive approach to monitoring helps in managing potential side effects and making informed decisions about the course of treatment.

• CBC:
  • Complete Blood Count (CBC) monitoring is advised based on clinical indications.
  • For the initial months of treatment, patients with a low White Blood Cell (WBC) count or a history of drug-induced neutropenia or leukopenia should be closely monitored.
  • Regular assessments of the CBC help in detecting any potential abnormalities and ensuring the well-being of the patient during the course of treatment.

• Liver function and electrolytes:
  • Liver function and electrolyte levels should be monitored annually and as clinically indicated.
  • Regular assessments of liver function and electrolytes are important for identifying any potential abnormalities and ensuring the overall health of the patient, especially during long-term use of medications.

• HbA 1c fasting blood sugar levels

  • Monitoring HbA1c and fasting blood sugar levels is recommended at baseline, followed by a three-month follow-up after starting an antipsychotic, and then annually thereafter.

  • Regular assessments of these parameters are essential to detect and manage any changes in blood sugar levels associated with antipsychotic medication use.

  • This monitoring helps in addressing potential metabolic effects and ensuring the overall health of the individual.

• Fasting lipid profile
  • For fasting lipid profile monitoring, it is recommended to conduct the test at baseline, repeat it after three months, and subsequently, if low-density lipoprotein (LDL) levels are normal, repeat the test as often as every two to five years or more frequently as clinically necessary.
  • Regular assessments of lipid levels are important for managing cardiovascular health and determining the need for any adjustments in the treatment plan.

• Changes in menstruation and libido

  • Monitoring changes in menstruation and libido is recommended on an annual basis.

  • Regular assessments in these areas can help identify any potential side effects or changes related to medication and allow for appropriate adjustments or interventions as needed.

  • It is important to address any concerns or issues related to sexual health during these routine check-ups.

• Parkinsonian signs or abnormal involuntary movements

  • Monitoring for Parkinsonian signs or abnormal involuntary movements should be conducted at baseline, weekly for at least two weeks after the introduction of the medication, and for no more than two weeks after any significant dose increases.

  • This close monitoring is essential until dose stabilization is achieved, helping to promptly detect and manage any potential extrapyramidal side effects associated with the medication.

• Tardive dyskinesia

  • Monitoring for tardive dyskinesia should be conducted annually for most individuals.

  • However, for high-risk patients, assessments should be done more frequently, every 6 months.

  • This routine monitoring helps in early detection and management of tardive dyskinesia, a potential side effect associated with the use of antipsychotic medications.

• Ocular examination
  • Ocular examinations are recommended at different frequencies based on age.
  • Younger patients may attend ocular examinations once every two years, while individuals over the age of 40 are advised to have annual visits.
  • Regular eye examinations help in detecting and addressing any potential ocular side effects associated with the use of medications.
• Fall risk
  • Assessment of fall risk is recommended at baseline and regularly during therapy, especially if there are any pre-existing conditions or concurrent medications that could increase the likelihood of falls.
  • Regular monitoring helps in identifying potential risk factors and implementing appropriate measures to prevent falls and ensure patient safety.

How to administer Lumateperone (Caplyta)?

Lumateperone (Caplyta) is administered orally, and it is recommended to take it with food.

The specific requirements for calorie or fat content are not specified, so it can be taken with a meal. Following the prescribed administration instructions is important for the optimal effectiveness of the medication.

Lumateperone (Caplyta) Mechanism of action:

• Lumateperone (Caplyta) is a second-generation antipsychotic with a mechanism of action that involves blocking both the central serotonin 5-HT2A receptors and dopamine D2 receptors.

• It acts as a variable binding agent, demonstrating high binding affinity for serotonin 5-HT2A receptors and moderate binding affinity for dopamine D2 receptors.

• While lumateperone has low affinity for muscarinic or histaminergic receptors, it exhibits significant affinity for dopamine D1 and D4 receptors, as well as adrenergic beta1A and alpha1B receptors.

• This diverse binding profile contributes to its therapeutic effects in the treatment of certain mental health conditions.

Absorption

• The absorption of lumateperone is influenced by food. High-fat meals can increase the Area Under the Curve (AUC) by 9%, but they also decrease the mean maximum concentration (Cmax) by 33%.
• When taken with food, there is a median delay of 1 hour in the time it takes to reach maximum concentration (Tmax) compared to taking it in a fasted state (from 1 to 2 hours fasted).

Protein binding

• Lumateperone exhibits high protein binding in the plasma, with approximately 97.4% of the drug binding to proteins in the bloodstream.

• This high degree of protein binding can influence the distribution, metabolism, and elimination of the medication within the body.

Metabolism

• Lumateperone undergoes extensive metabolism in the body and can be converted by more than 20 enzymes to various metabolites.
• Some of the key enzymes involved in its metabolism include cytochrome P450 enzymes such as 3A4, 2C8, and 1A2.
• Additionally, uridine 5-diphosphoglucuronosyl-transferases (UDP-glucuronosyltransferases) including 1A1, U4, and 2B15, aldoketoreductases 1C1 and 1B10, and several others play a role in the metabolic processes of lumateperone.
• The involvement of multiple enzymes reflects the complexity of its metabolic pathways.

Bioavailability:

• The bioavailability of lumateperone is 4.4%, indicating that only a small percentage of the administered dose reaches the systemic circulation in its unchanged form.
• The low bioavailability suggests that a significant portion of the drug undergoes extensive metabolism or other processes before reaching the bloodstream.

Half-life elimination:

• The elimination half-life of lumateperone is approximately 18 hours after intravenous administration.
• With the oral route, it takes approximately 5 days to reach steady-state concentrations, indicating the time required for the drug to achieve a consistent level in the bloodstream when taken orally on a regular basis.

Time to peak:

• The time it takes for lumateperone to reach peak concentration (Tmax) is approximately 1 to 2 hours.
• This indicates that after oral administration, the drug is absorbed and reaches its highest concentration in the bloodstream within this time frame.

Excretion:

• Lumateperone is primarily excreted from the body through urine and feces.
• Approximately 58% of the administered dose is eliminated in the urine, with less than 1% present in its unchanged form.
• Additionally, around 29% of the dose is excreted in the feces.
• This information provides insights into the routes and percentages of lumateperone elimination from the body.

International Brand Names of Lumateperone:

• Caplyta

Lumateperone Brand Names in Pakistan:

No Brands Available in Pakistan.