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继GLP-1药物掀起减肥与代谢疾病治疗革命之后,制药业正在寻找下一个潜在的“超级药物平台”。这一次,目标可能是食欲素(orexin)——一种帮助大脑维持清醒、调节注意力、动机和奖赏的神经递质。
目前,首批食欲素激动剂已经进入临床应用,用于治疗罕见的发作性嗜睡病。更令人期待的是,科学家发现,食欲素的作用远不止“让人保持清醒”:它还可能与缺陷多动障碍、睡眠呼吸暂停、抑郁症和成瘾等疾病有关。
如果说GLP-1药物改变了我们对“饥饿”的控制,那么食欲素药物或许正在尝试改变我们对“清醒”的控制。继减肥药之后,下一场改变制药业的“肽类药物革命”,会不会发生在大脑?
The brain may be about to have its Ozempic moment
大脑药物领域或将迎来属于自己的“司美格鲁肽时刻”
Pharma’s newest obsession involves mimicking the system that keeps people awake
制药行业最新的研发风口,是模拟维持人体清醒状态的生理系统
ONE PEPTIDE has recently transformed medicine. Drugs based on glucagon-like peptide-1 (GLP-1), a hormone released by the gut after a meal, began as treatments for diabetes before proving remarkably good at helping people shed weight. They have since shown benefits in the fields of heart disease, kidney disease, sleep apnoea and other ailments. Drugmakers are now betting that others, the orexins, could follow a similar path.
一种肽类物质近来重塑了医药行业格局。胰高糖素样肽-1(GLP-1)是人体进食后肠道分泌的激素;依托该靶点开发的药物最初用于治疗糖尿病,随后人们发现其减重效果十分突出。此后,这类药物又被证实对心脏病、肾病、睡眠呼吸暂停综合征等多种疾病具备疗效。如今各大药企押注另一类肽——食欲素,或将复刻GLP-1的成功之路。
Orexins are a pair of neurotransmitters—chemicals that carry messages between neurons. One of the main jobs of these particular neurotransmitters is to regulate wakefulness. And a new generation of drugs designed to mimic their effects is approaching the market.
食欲素是一对神经递质,也就是在神经元之间传递信号的化学物质。这类神经递质的核心功能之一是调控人的清醒状态。一批旨在模拟食欲素作用的新一代药物,即将登陆市场。
On August 5th America’s drug regulator approved oveporexton, made by Takeda, a Japanese pharmaceutical firm, as the first orexin agonist (ie, molecule that stimulates the same cell-surface receptors) for narcolepsy, a disorder that leaves patients excessively sleepy by day and prone to nod off without warning. Alkermes, an Irish biotech, is developing a competitor. Eli Lilly, whose fortunes GLP-1s have transformed, does not intend to miss another peptide boom: in June it bought Centessa, a biotech with an orexin drug in early trials, in a deal worth up to $7.8bn, depending on the trials’ success. Morgan Stanley, a bank, reckons orexin medicines could generate $16bn a year by 2035 from narcolepsy and related sleep disorders alone. The current crop of narcolepsy drugs, by contrast, have annual sales of $3bn.
8月5日,美国药品监管机构批准日本药企武田制药研发的奥维普雷克斯顿上市。这是全球首款食欲素激动剂(即能够激活细胞表面同源受体的分子),用于治疗发作性睡病。该病患者日间极度嗜睡,常常毫无征兆地骤然入睡。爱尔兰生物科技企业阿尔凯姆斯正在研发同类竞品。依靠GLP-1药物实现业绩腾飞的礼来制药不愿错过新一轮肽类药物热潮:今年6月,礼来收购生物科技公司森泰萨,后者拥有一款处于早期临床试验阶段的食欲素候选药物,这笔交易最高价值可达78亿美元,最终金额取决于临床试验结果。摩根士丹利测算,到2035年,仅发作性睡病及相关睡眠障碍适应症,食欲素类药物年销售额就有望达到160亿美元。与之相比,当前市面上所有发作性睡病药物年销售总额仅30亿美元。
And the excitement is not just about narcolepsy, which is estimated to afflict one person in 2,000 in America. Orexins help co-ordinate sleep, attention, motivation and the brain’s reward system. Drugmakers hope orexin medicines could eventually treat depression, attention deficit hyperactivity disorder (ADHD) and addiction, conditions that burden hundreds of millions of people.
而令制药公司兴奋的远不止发作性睡病。据估算,美国每2000人中就有一人罹患此病。食欲素能够协同调控睡眠、注意力、行动驱动力以及大脑奖赏系统。药企寄望,食欲素类药物未来可用于治疗抑郁症、注意缺陷多动障碍(ADHD)与成瘾性疾病,这些病症困扰着全球数亿人群。
Orexins were discovered nearly three decades ago by two teams working independently. In January 1998 Luis de Lecea and his colleagues at the Scripps Research Institute in La Jolla, California found the peptides and called them hypocretins. Weeks later a group led by Yanagisawa Masashi, of the University of Texas Southwestern Medical Centre in Dallas, reported that injecting the same peptides into rats’ brains made the animals eat more. They named the molecules orexins, from the Greek orexis, meaning appetite.
近三十年前,两支独立科研团队先后发现食欲素。1998年1月,加州拉霍亚斯克里普斯研究所的路易斯·德·莱塞亚团队发现这类肽,并将其命名为“下丘脑分泌素”(hypocretins)。数周后,达拉斯得克萨斯大学西南医学中心的柳泽正史团队发表研究:将同种肽注入大鼠大脑后,大鼠进食量显著上升。研究人员以希腊语中代表“食欲”的orexis为词根,将该物质命名为orexin(食欲素)。
Orexins’ true role emerged the following year. Emmanuel Mignot, of Stanford University, was studying hereditary narcolepsy in Doberman pinschers and Labrador retrievers, breeds of dog prone to sudden collapse mid-play. He showed that a mutation blocked the brain’s ability to respond to them. That same year, Dr Yanagisawa’s laboratory found that mice engineered to lack orexins repeatedly fell asleep and collapsed. Human confirmation followed: narcoleptic patients had lost the neurons that produce orexins.
次年,食欲素真正的生理功能得以揭晓。斯坦福大学的埃马纽埃尔·米尼奥研究杜宾犬与拉布拉多犬的遗传性发作性睡病,这两个品种的犬只经常在玩耍途中突然瘫倒。他证实,基因突变会阻断大脑对食欲素产生应答。同年,柳泽正史团队发现,经过基因改造、体内缺乏食欲素的小鼠会频繁犯困并突然倒下。后续人体研究进一步证实:发作性睡病患者体内合成食欲素的神经元大量丢失。
Orexins are made by a small number of neurons in the hypothalamus, a brain region tucked behind the eyes. Once released, these molecules lock, depending on their nature, onto one of two types of receptors, OXR1 and OXR2, in neighbouring neurons, switching them on. It is OX2R that is important for maintaining wakefulness. Its activation stimulates several wakefulness-promoting systems that rely on other neurotransmitters—norepinephrine, serotonin, dopamine and so on—and keeps them working together, rather like the conductor of an orchestra. OX1R, is more involved with reward and motivation.
食欲素由下丘脑内少量神经元合成,下丘脑是位于双眼后方的脑区。食欲素释放后,会结合邻近神经元上OX1R、OX2R两种受体中的一种并激活靶细胞,具体结合受体类型由自身特性决定。其中OX2R受体对维持清醒状态至关重要。它的激活能够刺激依赖甲肾上腺素、血清素、多巴胺等神经递质的促清醒系统,并统筹协调各个系统协同运转,如同乐队指挥。而OX1R更多参与大脑奖赏机制与动机调控。
You are feeling sleepy...
困意来袭……
Drugmakers first learned how to turn the OX2R conductor off. Orexin antagonists (which block the molecules’ actions rather than mimicking it, and thus promote sleep), have been available since 2014 as treatments for insomnia. They work differently from conventional sleeping pills, which enhance GABA, one of the brain’s main inhibitory neurotransmitters.
药企最先掌握的是“关闭”这位OX2R“指挥官”。食欲素拮抗剂并不模拟食欲素的作用,而是阻断其信号传导,以此诱导睡眠。自2014年起,这类药物已上市用于治疗失眠。它的作用机制和传统安眠药截然不同:传统安眠药主要增强γ-氨基丁酸(GABA)的活性,而GABA是大脑核心抑制性神经递质之一。
Birgitte Kornum, an expert on orexins at the University of Copenhagen, says such pills induce sedation rather than natural sleep and often lose effectiveness with continued use. Orexin antagonists instead turn down the brain’s wakefulness signal, letting its sleep-promoting systems take over. Evidence suggests this produces better sleep, with less risk of dependence and fewer long-term problems.
哥本哈根大学食欲素领域专家比尔吉特·科尔纳姆表示,传统安眠药带来的只是镇静麻醉效果,并非自然睡眠,而且随着持续使用,药效往往会逐渐减弱。与之不同,食欲素拮抗剂能够下调大脑的清醒信号,让促睡眠系统占据主导。现有证据表明,这类药物可以带来更高质量的睡眠,成瘾风险更低,长期不良反应也更少。
The bigger prize lies not in blocking orexin’s signal, but restoring it—for many sleep disorders stem from faulty orexin signalling. The immediate application is for narcolepsy type 1 (NT1), in which excessive daytime sleepiness is accompanied by cataplexy, a sudden loss of muscle control typically triggered by strong emotion.
真正更具价值的目标并不是阻断食欲信号,而是恢复这一信号——大量睡眠障碍都源于食欲素信号传导异常。最先落地的适应症是1型发作性睡病(NT1),患者除日间重度嗜睡外,还会出现猝倒;这类肌肉失控的突发状况,通常由强烈情绪诱发。
NT1 is caused by abnormally low levels of the orexin that binds to OX2R. During REM (rapid eye movement) sleep, the phase when dreams are most intense, the brain paralyses the body to stop it actually acting out movements involved in such dreams. When someone is awake, this paralysis is held in check by norepinephrine and serotonin—two neurotransmitters that orexin sustains. With insufficient orexin, the paralysis circuit may fire even if a person is fully conscious. They might be wide awake, in the middle of a burst of laughter for example, and then lose muscle control and crumple to the floor.
1型发作性睡病的成因,是能够结合OX2R受体的食欲素水平异常偏低。快速眼动睡眠(REM)是梦境最鲜活的睡眠阶段,此时大脑会抑制躯体运动,以防止人体在现实中做出梦境里的动作。人清醒时,这套躯体抑制通路会被去甲肾上腺素与血清素限制,而这两种神经递质的分泌依靠食欲素维持。一旦食欲素不足,即便患者意识完全清醒,躯体抑制通路也可能异常启动。比如患者开怀大笑时,意识依旧清晰,却突然丧失肌肉控制力,瘫倒在地。
Turning orexins back on is, however, harder than switching them off. An antagonist need only fit into a receptor to prevent an orexin from binding. An agonist must actually reproduce the effect of a peptide many times the drug’s own size. It must also cross the blood-brain barrier, which keeps potentially harmful molecules out of that organ.
然而,激活食欲素通路远比阻断它更加困难。拮抗剂只需占据受体位点,就能阻止食欲素结合;激动剂却要复刻一种分子量远大于自身的肽类物质的生理效应,同时还必须穿透血脑屏障——这道屏障会阻挡潜在有害物质进入大脑。
Takeda’s first attempt to do this, an agonist called firazorexton, showed early promise, but the firm discontinued it in 2021 after it caused liver damage in several patients. But results published in May 2025 on oveporexton, their follow-up OX2R agonist, created a stir. In its trial, patients sat in a darkened room to see how long they could stay awake—a procedure called the Maintenance of Wakefulness test. Without oveporexton many fell asleep almost instantly. On it, they managed to stay awake 12.5 to 25 minutes longer, depending on the dose, pushing many into the normal range. Cataplexy attacks were roughly a third as frequent in those taking the drug, compared with participants on placebo. Side-effects included insomnia and, in about a third of patients, an uncomfortable need to urinate.
武田制药的首次尝试是一款名为剂菲拉佐雷克斯顿的激动剂,初期数据亮眼,但因多名受试者出现肝损伤,企业在2021年终止研发。而2025年5月公布的二代OX2R激动剂奥维普雷克斯顿临床试验结果引发行业热议。试验中,受试者在昏暗房间内接受维持清醒试验,观测能够保持清醒的时长。未用药时,许多受试者几乎立刻入睡;服药后,根据剂量不同,清醒时长可延长12.5至25分钟,大量受试者指标回归正常区间。相比安慰剂组,用药受试者的猝倒发作频率下降约三分之二。该药不良反应包括失眠,约三分之一受试者会出现尿频不适。
What makes oveporexton different is not just its effect, but how that effect is achieved. Existing treatments, including stimulants such as methylphenidate and wakefulness-promoting agents such as modafinil, manage symptoms rather than the disease itself. They increase the activity of neurotransmitters such as dopamine and norepinephrine in many parts of the brain. That can improve alertness but may also cause anxiety, elevated blood pressure and poor sleep. Some drugs also carry a risk of addiction.
奥维普雷克斯顿的独特之处不只体现在疗效,更在于作用机制。现有治疗方案包括哌甲酯等中枢兴奋剂、莫达非尼等促醒药物,只能缓解症状,无法针对病因治疗。这类药物会在大脑多处区域提升多巴胺、去甲肾上腺素等神经递质活性,虽然能够提升警觉度,却可能引发焦虑、血压升高、夜间睡眠紊乱,部分药物还存在成瘾风险。
Orexins work farther upstream. Rather than stimulating individual parts of the alertness system, they help bring them into line. Dr Yanagisawa says orexin agonists should produce more natural and stable wakefulness, with fewer side-effects and less potential for abuse than stimulants.
食欲素作用点处于更上游。它并非单独刺激警觉系统的各个分支,而是统筹协调整套系统有序运转。柳泽正史认为,相较于中枢兴奋剂,食欲素激动剂能够带来更加自然、平稳的清醒状态,副作用更少,滥用风险也更低。
Drugmakers believe the same molecule could also help with conditions besides NT1. One is narcolepsy type 2 (NT2), which lacks cataplexy. Another is idiopathic hypersomnia, a related type of excessive daytime sleepiness. Lilly’s orexin agonist, acquired through Centessa, is being tested against all three, making it one of the broadest bets in the field. Early data are encouraging. In a small trial the drug improved wakefulness by more than 20 minutes in people with NT1 and by more than ten minutes in those with NT2.
药企认为,这类药物除治疗1型发作性睡病外,还可用于其他病症:一是不伴随猝倒症状的2型发作性睡病;二是特发性嗜睡症,同为日间过度嗜睡相关疾病。礼来通过收购森泰萨获得的食欲素激动剂,正在针对这三类适应症开展临床试验,是该领域布局适应症最广的候选药物之一。早期数据令人振奋:一项小型试验显示,该药让1型发作性睡病患者清醒时长提升20分钟以上,2型患者清醒时长提升超10分钟。
Dreaming big
远大前景
Beyond these rarer sleep diseases, drugmakers are studying orexin agonists’ effects on more prevalent conditions. Alkermes is testing one in adults for the treatment of ADHD, based on the observation that an added benefit in narcolepsy patients is sharpened attention, suggesting they might help with ADHD as well. Others are exploring their use for treating sleep apnoea, a far more common disorder.
除上述相对罕见的睡眠疾病外,药企正在研究食欲素激动剂对高发疾病的作用。阿尔凯姆斯正在开展成人ADHD临床试验,研究依据是药物能够改善发作性睡病患者注意力,推测其对多动症同样有效。还有企业探索将其用于治疗患病率更高的睡眠呼吸暂停综合征。
There are more tantalising ideas, too, about the reward-and-motivation role of the other orexin receptor, OX1R—though the science is far less developed. Dr Yanagisawa says blocking OX1R shows promise curbing addictive cravings. Activating the same receptor, rather than blocking it, is a more speculative approach, but he believes boosting the orexin signal into the brain’s reward circuitry could help treat depression and even enhance motivation.
学界对于另一类食欲素受体OX1R在奖赏与动机调控中的作用,还有诸多极具吸引力的猜想,不过相关研究尚处于早期。柳泽正史表示,阻断OX1R受体有望抑制成瘾渴求。与之相反,激活该受体尚属于前沿设想,但他认为,增强大脑奖赏环路的食欲素信号,或许能够帮助治疗抑郁症,甚至提升人的行动动力。
These are hints, not proof, and will need robust tests before any drug reaches the market. Lilly believes the potential is vast. Hunger and sleep, argues Dan Skovronsky, the firm’s chief scientific officer, are both “master homeostasis mechanisms”—systems that keep the body in balance. When they misbehave, illness follows. That, he says, helps explain why incretins, the hormone family behind GLP-1, proved so broadly useful. Hence why orexins could be just as important. ■
目前这些结论还只是线索,尚未形成定论,相关药物上市前仍需大量严谨试验验证。礼来制药首席科学官丹·斯科夫龙斯基认为,食欲素赛道蕴藏巨大潜力。饥饿调控与睡眠调控同属“核心稳态调节机制”——即维持机体平衡;一旦机制失衡,疾病便会随之而来。这也能够解释,GLP-1所属的肠促胰素家族为何拥有极为广泛的治疗价值,而食欲素很可能拥有同等重要的地位。■
思维导图
From: The Economist | Science & technology | Wide awake
Date:Aug 11th, 2026
⚠️重要提示:本文节选自英文外刊,译文仅供外语学习交流。文中提及的药物、生理机制、临床试验信息仅为科普资讯,不能替代执业医师的专业诊疗意见,不提供任何用药、治疗指导。请勿仅凭本文内容自行判断病情或购药。
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