# Zuclopenthixol

Zuclopenthixol (brand names Cisordinol, Clopixol and others), also known as zuclopentixol, is a medication used to treat schizophrenia and other psychoses. It is classed, pharmacologically, as a typical antipsychotic. Chemically it is a thioxanthene. It is the cis-isomer of clopenthixol (Sordinol, Ciatyl). Clopenthixol was introduced in 1961, while zuclopenthixol was introduced in 1978.
Zuclopenthixol is a D$_1$ and D$_2$ antagonist, α$_1$-adrenergic and 5-HT$_2$ antagonist. While it is approved for use in Australia, Canada, Ireland, India, New Zealand, Singapore, South Africa and the UK, it is not approved for use in the United States.

## Medical uses
### Available forms

Zuclopenthixol is available in three major preparations:
* As zuclopenthixol decanoate (Clopixol Depot, Cisordinol Depot), it is a long-acting intramuscular injection. Its main use is as a long-acting injection given every two or three weeks to people with schizophrenia who have a poor compliance with medication and suffer frequent relapses of illness. There is some evidence it may be more helpful in managing aggressive behaviour.
* As zuclopenthixol acetate (Clopixol-Acuphase, Cisordinol-Acutard), it is a shorter-acting intramuscular injection used in the acute sedation of psychotic inpatients. The effect peaks at 48–72 hours providing 2–3 days of sedation.
* As zuclopenthixol dihydrochloride (Clopixol, Cisordinol), it is a tablet used in the treatment of schizophrenia in those who are compliant with oral medication.
It is also used in the treatment of acute bipolar mania.

### Dosing

As a long-acting injection, zuclopenthixol decanoate comes in a 200 mg and 500 mg ampoule. Doses can vary from 50 mg weekly to the maximum licensed dose of 600 mg weekly. In general, the lowest effective dose to prevent relapse is preferred. The interval may be shorter as a patient starts on the medication before extending to 3 weekly intervals subsequently. The dose should be reviewed and reduced if side effects occur, though in the short-term an anticholinergic medication benztropine may be helpful for tremor and stiffness, while diazepam may be helpful for akathisia. 100 mg of zuclopenthixol decanoate is roughly equivalent to 20 mg of flupentixol decanoate or 12.5 mg of fluphenazine decanoate.
In oral form zuclopenthixol is available in 2, 10, 25 and 40 mg tablets, with a dose range of 20–60 mg daily.

## Side effects

Chronic administration of zuclopenthixol (30 mg/kg/day for two years) in rats resulted in small, but significant, increases in the incidence of thyroid parafollicular carcinomas and, in females, of mammary adenocarcinomas and of pancreatic islet cell adenomas and carcinomas. An increase in the incidence of mammary adenocarcinomas is a common finding for D$_2$ antagonists which increase prolactin secretion when administered to rats. An increase in the incidence of pancreatic islet cell tumours has been observed for some other D$_2$ antagonists. The physiological differences between rats and humans with regard to prolactin make the clinical significance of these findings unclear.
Withdrawal syndrome: Abrupt cessation of therapy may cause acute withdrawal symptoms (eg, nausea, vomiting, or insomnia). Symptoms usually begin in 1 to 4 days of withdrawal and subside within 1 to 2 weeks.
Other permanent side effects are similar to many other typical antipsychotics, namely extrapyramidal symptoms as a result of dopamine blockade in subcortical areas of the brain. This may result in symptoms similar to those seen in Parkinson's disease and include a restlessness and inability to sit still known as akathisia, a slow tremor and stiffness of the limbs. Zuclopenthixol is thought to be more sedating than the related flupentixol, though possibly less likely to induce extrapyramidal symptoms than other typical depots. As with other dopamine antagonists, zuclopenthixol may sometimes elevate prolactin levels; this may occasionally result in amenorrhoea or galactorrhoea in severe cases. Neuroleptic malignant syndrome is a rare but potentially fatal side effect. Any unexpected deterioration in mental state with confusion and muscle stiffness should be seen by a physician.
Zuclopenthixol decanoate induces a transient dose-dependent sedation. However, if the patient is switched to maintenance treatment with zuclopenthixol decanoate from oral zuclopenthixol or from i.m. zuclopenthixol acetate the sedation will be no problem. Tolerance to the unspecific sedative effect develops rapidly.

### Very common Adverse Effects (≥10% incidence)

* Hypersalivation
* Somnolence
* Akathisia
* Hyperkinesia
* Hypokinesia

### Common (1–10%)

* Tachycardia
* Heart palpitations
* Vertigo
* Accommodation disorder
* Abnormal vision
* Salivary hypersecretion
* Constipation
* Vomiting
* Dyspepsia
* Diarrhoea
* Asthenia
* Fatigue
* Malaise
* Pain (at the injection site)
* Increased appetite
* Weight gain
* Myalgia
* Tremor
* Dystonia
* Hypertonia
* Dizziness
* Headache
* Paraesthesia
* Disturbance in attention
* Amnesia
* Abnormal gait
* Insomnia
* Depression
* Anxiety
* Abnormal dreams
* Agitation
* Decreased libido
* Nasal congestion
* Dyspnoea
* Hyperhidrosis
* Pruritus

### Uncommon (0.1–1%)

* Hyperacusis
* Tinnitus
* Mydriasis
* Abdominal pain
* Nausea
* Flatulence
* Thirst
* Injection site reaction
* Hypothermia
* Pyrexia
* Abnormal liver function tests
* Decreased appetite
* Weight loss
* Muscle rigidity
* Trismus
* Torticollis
* Tardive dyskinesia
* Hyperreflexia
* Dyskinesia
* Parkinsonism
* Syncope
* Ataxia
* Speech disorder
* Hypotonia
* Convulsion
* Migraine
* Apathy
* Nightmares
* Libido increased
* Confused state
* Ejaculation failure
* Erectile dysfunction
* Female orgasmic disorder
* Vulvovaginal
* Dryness
* Rash
* Photosensitivity
* Pigmentation disorder
* Seborrhoea
* Dermatitis
* Purpura
* Hypotension
* Hot flush

### Rare (0.01–0.1%)

* Thrombocytopenia
* Neutropenia
* Leukopenia
* Agranulocytosis
* QT prolongation
* Hyperprolactinaemia
* Hypersensitivity
* Anaphylactic reaction
* Hyperglycaemia
* Glucose tolerance impaired
* Hyperlipidaemia
* Gynaecomastia
* Galactorrhoea
* Amenorrhoea
* Priapism
* Withdrawal symptoms

### Very rare (<0.01%)

* Cholestatic hepatitis
* Jaundice
* Neuroleptic malignant syndrome
* Venous thromboembolism

## Pharmacology
### Pharmacodynamics

Zuclopenthixol antagonises both dopamine D$_1$ and D$_2$ receptors, α$_1$-adrenoceptors and 5-HT$_2$ receptors with a high affinity, but has no affinity for muscarinic acetylcholine receptors. It weakly antagonises the histamine (H$_1$) receptor but has no α$_2$-adrenoceptor blocking activity.
Evidence from in vitro work and clinical sources (i.e. therapeutic drug monitoring databases) suggests that both CYP2D6 and CYP3A4 play important roles in zuclopenthixol metabolism.

### Pharmacokinetics

vte Pharmacokinetics of long-acting injectable antipsychotics :
| Medication | Brand name | Class | Vehicle | Dosage | T$_{max}$ | t$_{1/2}$ single | t$_{1/2}$ multiple | logP$^c$ |
| Aripiprazole lauroxil | Aristada | Atypical | Water$^a$ | 441–1064 mg/4–8 weeks | 24–35 days | ? | 54–57 days | 7.9–10.0 |
| Aripiprazole monohydrate | Abilify Maintena | Atypical | Water$^a$ | 300–400 mg/4 weeks | 7 days | ? | 30–47 days | 4.9–5.2 |
| Bromperidol decanoate | Impromen Decanoas | Typical | Sesame oil | 40–300 mg/4 weeks | 3–9 days | ? | 21–25 days | 7.9 |
| Clopentixol decanoate | Sordinol Depot | Typical | Viscoleo$^b$ | 50–600 mg/1–4 weeks | 4–7 days | ? | 19 days | 9.0 |
| Flupentixol decanoate | Depixol | Typical | Viscoleo$^b$ | 10–200 mg/2–4 weeks | 4–10 days | 8 days | 17 days | 7.2–9.2 |
| Fluphenazine decanoate | Prolixin Decanoate | Typical | Sesame oil | 12.5–100 mg/2–5 weeks | 1–2 days | 1–10 days | 14–100 days | 7.2–9.0 |
| Fluphenazine enanthate | Prolixin Enanthate | Typical | Sesame oil | 12.5–100 mg/1–4 weeks | 2–3 days | 4 days | ? | 6.4–7.4 |
| Fluspirilene | Imap, Redeptin | Typical | Water$^a$ | 2–12 mg/1 week | 1–8 days | 7 days | ? | 5.2–5.8 |
| Haloperidol decanoate | Haldol Decanoate | Typical | Sesame oil | 20–400 mg/2–4 weeks | 3–9 days | 18–21 days | 18–21 days | 7.2–7.9 |
| Olanzapine pamoate | Zyprexa Relprevv | Atypical | Water$^a$ | 150–405 mg/2–4 weeks | 7 days | ? | 30 days | – |
| Oxyprothepin decanoate | Meclopin | Typical | ? | ? | ? | ? | ? | 8.5–8.7 |
| Paliperidone palmitate | Invega Sustenna | Atypical | Water$^a$ | 39–819 mg/4–12 weeks | 13–33 days | 25–139 days | ? | 8.1–10.1 |
| Perphenazine decanoate | Trilafon Dekanoat | Typical | Sesame oil | 50–200 mg/2–4 weeks | ? | ? | 27 days | 8.9 |
| Perphenazine enanthate | Trilafon Enanthate | Typical | Sesame oil | 25–200 mg/2 weeks | 2–3 days | ? | 4–7 days | 6.4–7.2 |
| Pipotiazine palmitate | Piportil Longum | Typical | Viscoleo$^b$ | 25–400 mg/4 weeks | 9–10 days | ? | 14–21 days | 8.5–11.6 |
| Pipotiazine undecylenate | Piportil Medium | Typical | Sesame oil | 100–200 mg/2 weeks | ? | ? | ? | 8.4 |
| Risperidone | Risperdal Consta | Atypical | Microspheres | 12.5–75 mg/2 weeks | 21 days | ? | 3–6 days | – |
| Zuclopentixol acetate | Clopixol Acuphase | Typical | Viscoleo$^b$ | 50–200 mg/1–3 days | 1–2 days | 1–2 days | 1–2 days | 4.7–4.9 |
| Zuclopentixol decanoate | Clopixol Depot | Typical | Viscoleo$^b$ | 50–800 mg/2–4 weeks | 4–9 days | ? | 11–21 days | 7.5–9.0 |
| Note: All by intramuscular injection. Footnotes: $^a$ = Microcrystalline or nanocrystalline aqueous suspension. $^b$ = Low-viscosity vegetable oil (specifically fractionated coconut oil with medium-chain triglycerides). $^c$ = Predicted, from PubChem and DrugBank. Sources: Main: See template. ||||||||||

## History

Zuclopenthixol was introduced by Lundbeck in 1978.