Buspirone

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Buspirone, sold under the name Buspar among others, is an anxiolytic medication primarily used for the treatment of generalized anxiety disorder. Unlike benzodiazepines, buspirone does not produce significant sedation, dependence, or withdrawal effects. Its principal mechanism of action involves partial agonism at postsynaptic serotonin 5-HT₁A receptors and full agonism at presynaptic 5-HT₁A autoreceptors, which initially reduces serotonergic neuron firing. Over time, autoreceptor desensitization occurs, leading to increased serotonin release and enhanced serotonergic tone, which may contribute to its clinical efficacy. Buspirone also has weak antagonistic effects at dopamine D2, D3, and D4 receptors and α1- and α2-adrenergic receptors.

Buspirone is approved for the management of generalized anxiety disorder. It is sometimes used off-label for other anxiety disorders, depression augmentation, and certain behavioral conditions. Buspirone is not effective as a sedative-hypnotic or muscle relaxant and does not have anticonvulsant properties.

Common side effects of buspirone include nausea, headaches, dizziness, and difficulty concentrating.<ref name="AHFS2019">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name=BNF76>Template:Cite book</ref> Serious side effects may include movement disorders, serotonin syndrome, and seizures.<ref name=BNF76/> Its use in pregnancy appears to be safe but has not been well studied, and use during breastfeeding has not been well studied either.<ref name=BNF76/><ref name=Preg2019>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Buspirone was developed in 1968 and approved for medical use in the United States in 1986.<ref name=AHFS2019/><ref name=Wil2018>Template:Cite journal</ref> It is available as a generic medication.<ref name=BNF76/> In 2023, it was the 40th most commonly prescribed medication in the United States, with more than 15Template:Nbspmillion prescriptions.<ref name="Top300Drugs">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Template:TOC limit

Medical uses

Anxiety

Buspirone is used for the short-term and long-term treatment of anxiety disorders or symptoms of anxiety.<ref name=DM>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name=TGA>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name=AMH>Template:Cite book</ref><ref name=EMC>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name=BNF>Template:Cite book</ref> It is generally preferred over benzodiazepines because it does not activate the receptors that make drugs like alprazolam addictive.<ref name=Wil2018/>

Buspirone has no immediate anxiolytic effects, and hence has a delayed onset of action; its full clinical effectiveness may require 2–4 weeks to manifest itself.<ref name="SadockSadock2014">Template:Cite book</ref> The drug is effective in the treatment of generalized anxiety disorder (GAD) similar to benzodiazepines including diazepam, alprazolam, lorazepam, and clorazepate.<ref name="pmid22608068" /> Buspirone is not known to be effective in the treatment of anxiety disorders other than GAD.<ref name="pmid26535760">Template:Cite journal</ref>

Other uses

Sexual dysfunction

There is some evidence that buspirone on its own may be useful in the treatment of hypoactive sexual desire disorder (HSDD) in women.<ref name="pmid27916394">Template:Cite journal</ref> Buspirone may also be effective in treating antidepressant-induced sexual dysfunction.<ref name=Wil2018/><ref name="pmid34247952">Template:Cite journal</ref><ref name="pmid31591339">Template:Cite journal</ref>

Miscellaneous

Buspirone is not effective as a treatment for benzodiazepine withdrawal, barbiturate withdrawal, or alcohol withdrawal.<ref>Template:Cite journal</ref>

SSRI and SNRI antidepressants such as paroxetine and venlafaxine, respectively, may cause jaw pain/jaw spasm reversible syndrome, although it is not common, and buspirone appears to be successful in treating antidepressant-induced bruxism.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>

Contraindications

Buspirone has these contraindications:<ref name=mono>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name="Gelder">Template:Cite book</ref>

• Hypersensitivity to buspirone
• Metabolic acidosis, as in diabetes
• Should not be used with MAO inhibitors
• Severely compromised liver or kidney function

Side effects

{{#invoke:Labelled list hatnote|labelledList|Main article|Main articles|Main page|Main pages}}

Known side effects associated with buspirone include dizziness, headaches, nausea, tinnitus, and paresthesia.<ref name="pmid22608068" /> Buspirone is relatively well tolerated and is not associated with sedation, cognitive and psychomotor impairment, muscle relaxation, physical dependence, or anticonvulsant effects.<ref name="pmid22608068" /> In addition, buspirone does not produce euphoria<ref name="SadockSadock2014" /> and is not a drug of abuse.<ref name=TGA/>

Overdose

Buspirone appears to be relatively benign in cases of single-drug overdose, although no definitive data on this subject appear to be available.<ref name="FultonBrogden1997">Template:Cite journal</ref> In one clinical trial, buspirone was administered to healthy male volunteers at a dosage of 375 mg/day, and produced side effects including nausea, vomiting, dizziness, drowsiness, miosis, and gastric distress.<ref name=DM/><ref name=TGA/><ref name=EMC/> In early clinical trials, buspirone was given at dosages even as high as 2,400 mg/day, with akathisia, tremor, and muscle rigidity observed.<ref name="Dart2004">Template:Cite book</ref> Deliberate overdoses with 250 mg and up to 300 mg buspirone have resulted in drowsiness in about 50% of individuals.<ref name="Dart2004" /> One death has been reported in a co-ingestion of 450 mg buspirone with alprazolam, diltiazem, alcohol, and cocaine.<ref name="Dart2004" />

Interactions

Buspirone has been shown in vitro to be metabolized by the enzyme CYP3A4.<ref name="pmid15640381" /> This finding is consistent with the in vivo interactions observed between buspirone and these inhibitors or inducers of cytochrome P450 3A4 (CYP3A4), among others:<ref name=mono/>

• Itraconazole: Increased plasma level of buspirone
• Rifampicin: Decreased plasma levels of buspirone
• Nefazodone: Increased plasma levels of buspirone
• Haloperidol: Increased plasma levels of buspirone
• Carbamazepine: Decreased plasma levels of buspirone
• Grapefruit: Significantly increases the plasma levels of buspirone.<ref>Template:Cite journal</ref> See grapefruit–drug interactions.
• Fluvoxamine: Moderately increased plasma levels of buspirone.<ref>Template:Cite journal</ref>

Elevated blood pressure has been reported when buspirone has been administered to patients taking monoamine oxidase inhibitors (MAOIs).<ref name=mono/>

Buspirone has been found to markedly reduce the hallucinogenic effects of the serotonergic psychedelic psilocybin in humans.<ref name="HalmanKongSarris2024">Template:Cite journal</ref><ref name="BrandtKavanaghTwamley2018">Template:Cite journal</ref><ref name="PokornyPrellerKraehenmann2016">Template:Cite journal</ref> This parallels findings in which serotonin 5-HT_1A receptor agonists like 8-OH-DPAT attenuate the head-twitch response, a behavioral proxy of psychedelic effects, induced by serotonergic psychedelics in rodents.<ref name="HalberstadtNichols2020">Template:Cite book</ref> Paradoxically however, buspirone enhances the head-twitch response, a behavioral proxy of psychedelic effects, induced by 5-hydroxytryptophan (5-HTP) plus pargyline in rodents.<ref name="HaberzettlBertFink2013">Template:Cite journal</ref><ref name="KitamuraNagataniWatanabe1994">Template:Cite journal</ref>

Pharmacology

Pharmacodynamics

citation

CitationClass=web }}</ref>
Site	Ki (nM)	Action	Species	Ref
5-HT1A	3.98–214 21 (median)	Agonist	Human	<ref name="PDSP" /><ref name="pmid7984267">Template:Cite journal</ref>
5-HT1B	>100,000	Agonist ?<ref name="Sato_2010">Template:Cite journal</ref>	Rat	<ref name="pmid1974152">Template:Cite journal</ref>
5-HT1D	22,000–42,700	Agonist ?<ref name="Sato_2010" />	Human	<ref name="pmid2521959">Template:Cite journal</ref><ref name="pmid2975354">Template:Cite journal</ref>
5-HT2A	138–3,240	Antagonist	Human
5-HT2B	214	?	Human
5-HT2C	490	Antagonist ?<ref name="Sato_2010" />	Human
5-HT7	375–381 840	Antagonist ?<ref name="Sato_2010" />	Rat Human	<ref name="pmid8398139">Template:Cite journal</ref><ref name="pmid8397408">Template:Cite journal</ref> <ref name="pmid31882369">Template:Cite journal</ref>
α1	1,000	Antagonist	Rat	<ref name="pmid1974152" />
α2	6,000	Antagonist	Rat	<ref name="pmid1681447">Template:Cite journal</ref>
α2A	7.3 (Template:Abbrlink)	Antagonist	Human	<ref name="pmid1974152" />
β	8,800	Antagonist	Rat	<ref name="pmid1974152" />
D1	33,000	Antagonist	Rat	<ref name="pmid1974152" />
D2	484 240	Antagonist	Human Rat	<ref name="pmid22827916">Template:Cite journal</ref> <ref name="pmid1974152" />
D3	98	Antagonist	Human	<ref name="pmid22827916" />
D4	29	Antagonist	Human	<ref name="pmid22827916" />
Template:Abbrlink	38,000	?	Rat	<ref name="pmid1974152" />
[[GABAA receptor#Benzodiazepine site|GABAA (Template:Abbr)]]	>100,000	-	Rat	<ref name="pmid1974152" />
Values are Ki (nM). The smaller the value, the more strongly the drug interacts with the site.

Buspirone acts primarily on the serotonin 5-HT_1A receptor. It behaves as a full agonist at presynaptic 5-HT_1A autoreceptors in the dorsal raphe, reducing the firing of serotonin-producing neurons, and as a partial agonist at postsynaptic 5-HT_1A receptors in forebrain regions. This difference in activity between presynaptic and postsynaptic sites is thought to result from variations in receptor density and coupling efficiency.<ref name="Smith1986">Smith LM, Peroutka SJ. Differential effects of 5-HT₁A–selective compounds on [³H]8-OH-DPAT binding and 5-HT behavioral syndrome in rat. Eur J Pharmacol. 1986;128(1-2):73-80.</ref><ref name="IUPHAR">IUPHAR/BPS Guide to Pharmacology. Ligand: buspirone (ID: 36), "Ligand Activity Charts".</ref><ref name="Savitz2009">Savitz J, Lucki I, Drevets WC. 5-HT₁A receptor function in major depressive disorder. Prog Neurobiol. 2009;88(1):17-31.</ref><ref name="VanderMaelen1986">VanderMaelen CP, Aghajanian GK. Electrophysiological and pharmacological characterization of 5-HT₁A autoreceptors in dorsal raphe. Neuropharmacology. 1986;25(8):857-862.</ref><ref name="Haleem2019">Haleem DJ. Targeting 5-HT₁A receptors for treating chronic pain and depression. CNS Neurosci Ther. 2019;25(10):1105-1114.</ref><ref name="Valdizan2010">Valdizán EM, Castro E, Pazos A. Agonist-dependent desensitization of 5-HT₁A autoreceptors: implications for antidepressant action. Int J Neuropsychopharmacol. 2010;13(6):813-828.</ref>

Buspirone also has lower affinity for other serotonin receptors, including 5-HT_2A, 5-HT_2B, 5-HT_2C, 5-HT₆, and 5-HT₇, where it is thought to act primarily as an antagonist.<ref>Sato, et al., 2010</ref> In addition, buspirone has weak antagonistic activity at dopamine D₂, D₃, and D₄ receptors, with preferential blockade of presynaptic D₂ autoreceptors at low doses and postsynaptic D₂ receptors only at higher doses.<ref name="LoanePolitis2012">Template:Cite journal</ref>

A major metabolite of buspirone, 1-(2-pyrimidinyl)piperazine (1-PP), circulates at higher levels than buspirone itself and is a potent α₂-adrenergic receptor antagonist, which may contribute to some of buspirone's noradrenergic and dopaminergic effects.<ref>PMID 1681447</ref><ref>PMID 1796057</ref><ref>PMID 12438536</ref> Buspirone has very weak affinity for α₁-adrenergic receptors, and does not interact with the GABA_A receptor complex, unlike benzodiazepines.<ref>PMID 22608068</ref><ref>PMID NuttBallenger2008</ref>

Pharmacokinetics

Buspirone has a low oral bioavailability of 3.9% relative to intravenous injection due to extensive first-pass metabolism.<ref name="pmid22608068" /> The time to peak plasma levels following ingestion is 0.9 to 1.5 hours.<ref name="pmid22608068" /> It is reported to have an elimination half-life of 2.8 hours,<ref name="pmid22608068" /> although a review of 14 studies found that the mean terminal half-life ranged between 2 and 11 hours, and one study even reported a terminal half-life of 33 hours.<ref name="pmid3515929">Template:Cite journal</ref> Buspirone is metabolized primarily by CYP3A4, and prominent drug interactions with inhibitors and inducers of this enzyme have been observed.<ref name="pmid10320950" /><ref name="pmid15640381" /> Major metabolites of buspirone include 5-hydroxybuspirone, 6-hydroxybuspirone, 8-hydroxybuspirone, and 1-PP.<ref>Template:Cite journal</ref><ref name="pmid3515929" /><ref name="SchatzbergNemeroff2009" /><ref name="pmid17494642">Template:Cite journal</ref> 6-Hydroxybuspirone has been identified as the predominant hepatic metabolite of buspirone, with plasma levels that are 40-fold greater than those of buspirone after oral administration of buspirone to humans.<ref name="SchatzbergNemeroff2009">Template:Cite book</ref> The metabolite is a high-affinity partial agonist of the 5-HT_1A receptor (K_i=25 nM) similarly to buspirone, and has demonstrated occupancy of the 5-HT_1A receptor in vivo.<ref name="SchatzbergNemeroff2009" /> As such, it is likely to play an important role in the therapeutic effects of buspirone.<ref name="SchatzbergNemeroff2009" /> 1-PP has also been found to circulate at higher levels than those of buspirone itself and may similarly play a significant role in the clinical effects of buspirone.<ref name="pmid1796057">Template:Cite journal</ref><ref name="pmid17700052">Template:Cite journal</ref>

File:Buspirone metabolism.png

Phase I Metabolism of buspirone in humans<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name="pmid15640381"/>

Chemistry

Buspirone is a member of the azapirone chemical class, and consists of azaspirodecanedione and pyrimidinylpiperazine components linked together by a butyl chain.

Analogues

Structural analogues of buspirone include other azapirones like gepirone, ipsapirone, perospirone, and tandospirone.<ref name="pmid1679210">Template:Cite journal</ref>

A number of analogues are recorded.<ref>Template:Cite journal</ref>

Synthesis

A number of methods of synthesis have also been reported.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> One method begins with alkylation of 1-(2-pyrimidyl)piperazine (1) with 3-chloro-1-cyanopropane (4-chlorobutyronitrile) (2) to give (3). Next, reduction of the nitrile group is performed either by catalytic hydrogenation or with lithium aluminium hydride (LAH) giving (4). The primary amine is then reacted with 3,3-tetramethyleneglutaric anhydride (5) in order to yield buspirone (6).<ref name="Psychosedative agents. 2. 8-4-Subs">Template:Cite journal</ref><ref>DE2057845 idem Y Wu, J Rayburn, Template:US patent (1973 to Mead Johnson).</ref><ref>Template:Cite patent</ref><ref>Template:Cite patent</ref><ref>Template:Cite patent</ref>

File:Buspirone-synthesis.svg

Synthesis of buspirone

History

Buspirone was first synthesized by a team at Mead Johnson in 1968<ref name="pmid26535760" /> but was not patented until 1980.<ref>Template:Cite patent</ref><ref name="Psychosedative agents. 2. 8-4-Subs"/><ref>Template:Cite patent</ref> It was initially developed as an antipsychotic acting on the D₂ receptor but was found to be ineffective in the treatment of psychosis; it was then used as an anxiolytic.<ref name="pmid22608068" /> In 1986, Bristol-Myers Squibb gained FDA approval for buspirone in the treatment of GAD.<ref name="pmid26535760" /><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The patent expired in 2001, and buspirone is available as a generic drug.

Society and culture

File:Buspar.jpg

Buspar (buspirone) 10-mg tablets

Generic names

Buspirone is the Template:Abbrlink, Template:Abbrlink, Template:Abbrlink, and Template:Abbrlink of buspirone, while buspirone hydrochloride is its Template:Abbrlink, Template:Abbrlink, and Template:Abbrlink.<ref name="Elks2014">Template:Cite book</ref><ref name="IndexNominum2000">Template:Cite book</ref><ref name="MortonHall2012">Template:Cite book</ref><ref name="Drugs.com">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Brand names

Buspirone was primarily sold under the brand name Buspar.<ref name="IndexNominum2000" /><ref name="Drugs.com" /> Buspar is currently listed as discontinued by the U.S. Food and Drug Administration (FDA).<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> In 2010, in response to a citizen petition, the FDA determined that Buspar was not withdrawn from sale for reasons of safety or effectiveness.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

External links

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