Immediate switching of antidepressant therapy: results from a clinical trial of duloxetine

BACKGROUND

Approximately half of all treated depressed patients fail to show adequate response to their initially prescribed antidepressant medication. Switching to another medication represents one possible next-step approach for nonresponsive or partially responsive patients. However, specific techniques for switching between antidepressants have not been well studied. We examined the efficacy and tolerability associated with a switch from a selective serotonin reuptake inhibitor (SSRI) or venlafaxine to duloxetine.

METHODS

All patients met criteria for major depressive disorder as defined in DSM-IV. Patients (N = 88) exhibiting suboptimal response or poor tolerability to their current antidepressant medication (citalopram <or=40 mg/d, escitalopram <or=20 mg/d, fluvoxamine <or=150 mg/d, paroxetine <or=40 mg/d, sertraline <or=150 mg/d, or venlafaxine <or=150 mg/d) were switched to duloxetine 60 mg once-daily (QD) without intermediate tapering or titration ("switching" group). A comparator group (N = 67), comprising patients not currently receiving antidepressant medication, initiated duloxetine therapy at 60 mg QD ("initiating" group). Safety assessments included comparisons of discontinuation rates, treatment-emergent adverse events, and changes in vital signs. Efficacy measures included the HAMD(17), Hamilton Anxiety Scale (HAMA), and the Clinical Global Impression of Severity (CGI-S) scale.

RESULTS

The efficacy of duloxetine in switched patients did not differ significantly from that observed in untreated patients initiating duloxetine therapy (mean changes: HAMD(17) total score: -12.3 vs. -12.6; HAMA: -9.36 vs. -9.55, CGI-S: -1.94 vs. -2.12, respectively). However, the rate of discontinuation due to adverse events among patients switched to duloxetine was significantly lower than that in patients initiating duloxetine therapy (4.5% vs. 17.9%, p = .008). Treatment-emergent adverse events occurring in >or=10% of patients in both treatment groups were nausea, headache, dry mouth, insomnia, and diarrhea. Patients switched to duloxetine reported significantly lower rates of nausea and fatigue compared with patients initiating duloxetine.

CONCLUSIONS

In this study, the efficacy of duloxetine in switched patients was comparable to that observed in patients initiating duloxetine therapy. Immediate switching from an SSRI or venlafaxine to duloxetine (60 mg QD) was well tolerated.

A comparative study of the efficacy and safety profiles between fluvoxamine and nortriptyline in Japanese patients with major depression

OBJECTIVE

The aim of this study was to compare the efficacy and safety profiles between fluvoxamine and nortriptyline in Japanese patients with major depression.

METHODS

The efficacy and safety profiles of fluvoxamine, a selective serotonin-reuptake inhibitor, and nortriptyline were compared under a single-blind fashion in 74 Japanese patients with major depression. The efficacy was assessed using the 17-item Hamilton Rating Scale for Depression (HAM-D), Clinical Global Impression Scale (CGI) severity and improvement scores, while the safety profiles were assessed using the UKU Side Effect Rating Scale at baseline, and on days 7, 14, 28 and 56. Moreover, with the aim of determining the distinct efficacy profiles of each drug, the effects on each of the factor scores extracted by the principal component analysis performed for HAM-D scores were compared between drugs.

RESULTS

Both drug groups showed significant amelioration of depressive symptomatology over the trial period lasting for 8 weeks. Statistical analyses revealed no significant between-group differences regarding the efficacy assessed by either HAM-D or CGI scores; however, the efficacy of nortriptyline tended to appear earlier than that of fluvoxamine. Moreover, no significant differences were obtained for the factor scores, representing 'depressed mood', 'physical symptoms' or 'sleep disturbances', although 'sleep disturbances' appeared to improve earlier in the nortriptyline group than in the fluvoxamine group. As for the safety profiles, the nortriptyline group scored a significantly higher incidence of adverse events such as dysarthria or orthostatic dizziness, as well as increased heart rate.

CONCLUSIONS

These findings suggest that fluvoxamine is generally comparable to nortriptyline in its efficacy and superior in its safety profile, in accordance with findings obtained in previous comparative clinical trials conducted in Caucasian populations.

Controlled clinical comparison of paroxetine and fluvoxamine considering the serotonin transporter promoter polymorphism

The present study aimed to compare the effects of two currently used selective serotonin reuptake inhibitors (SSRIs) in Japan taking the individual background in 5-HTT gene-linked polymorphic region (5HTTLPR) genotype into account. Clinical responses to paroxetine and fluvoxamine were evaluated by total and cluster depressive symptoms for 81 Japanese patients who were diagnosed with major depression. Patients with the l allele had a greater percentage reduction on the total score (P=0.059) and somatic anxiety items (P=0.026) of the 21-item Hamilton Depression Rating Scale (HAM-D) score compared to s/s genotype carriers. Paroxetine was significantly more effective than fluvoxamine in the s/s carriers, as evaluated on the percentage reduction in total score (P=0.012) and core (P=0.049) HAM-D after 4 weeks of medication, but not in the l/s carriers. These findings suggest that the genetic test may be useful in investigating the efficacy of the two SSRIs, and that normalization by the 5HTTLPR genotypes may lead to improvement of the precision of comparative analysis.

Sequential pharmacotherapy for children with comorbid attention-deficit/hyperactivity and anxiety disorders

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) is often accompanied by clinically significant anxiety, but few empirical data guide treatment of children meeting full DSM-IV criteria for ADHD and anxiety disorders (ADHD/ANX). This study examined the efficacy of sequential pharmacotherapy for ADHD/ANX children.

METHOD

Children, age 6 to 17 years, with ADHD/ANX were titrated to optimal methylphenidate dose and assessed along with children who entered the study on a previously optimized stimulant. Children with improved ADHD who remained anxious were randomly assigned to 8 weeks of double-blind stimulant + fluvoxamine (STIM/FLV) or stimulant + placebo (STIM/PL). Primary efficacy measures were the Swanson, Nolan, Atkins, and Pelham IV Parent and Teacher Rating Scale ADHD score and the Pediatric Anxiety Rating Scale total score. ADHD, ANX, and overall Clinical Global Impressions-Improvement scores were also obtained.

RESULTS

Of the 32 medication-naive children openly treated with methylphenidate, 26 (81%) improved as to ADHD. Twenty-five children entered the randomized trial. Intent-to-treat analysis indicated no differences between the STIM/FLV (n = 15) and STIM/PL groups on the Pediatric Anxiety Rating Scale or Clinical Global Impressions-Improvement-defined responder rate. Medications in both arms were well tolerated.

CONCLUSIONS

Children with ADHD/ANX have a response rate to stimulants for ADHD that is comparable with that of children with general ADHD. The benefit of adding FLV to stimulants for ANX remains unproven.

A double-blind randomized study comparing imipramine with fluvoxamine in depressed inpatients

OBJECTIVE

To compare the efficacy of imipramine and fluvoxamine in inpatients from two centers suffering from a depressive disorder according to DSM IV criteria.

METHODS

The study included 141 patients with a depressive disorder according to DSM IV criteria. After a drug-free and placebo run-in period of 1 week, patients were randomized to imipramine or fluvoxamine; doses of both drugs were adjusted to a predefined target blood level. Efficacy was evaluated 4 weeks after attaining predefined adequate plasma level.

RESULTS

The mean age of the study group (47 males, 94 females) was 51.8 (range 19-65) years. Of these 141 patients, 56 had episode duration longer than 1 year, 48 had mood congruent psychotic features, and 138 patients received medication. Seven patients did not complete the medication trial. The total number of patients using concurrent medication was 12/138 (8.6%). On the primary outcome criteria patients on imipramine improved significantly better on the change of illness severity score of the CGI (chi2 exact trend test=4.089, df=1, P=-0.048). There was no significant difference in 50% or more reduction on the HRSD, the other primary outcome criterion. On the secondary outcome criteria the mean reduction of the HRSD scores was significantly larger in the imipramine group than in the fluvoxamine group (mean difference=3.1, standard error (SE)=1.4, t=2.15, df=136, P=0.033). There was no significant difference in the number of patients with an HRSD < or =7 at the final evaluation.

CONCLUSIONS

In depressed inpatients imipramine is more efficacious than fluvoxamine. Both drugs were well tolerated by all patients.

Weight gain during long-term treatment of obsessive-compulsive disorder: a prospective comparison between serotonin reuptake inhibitors

BACKGROUND

The effect of extended anti-depressant treatment on weight has been poorly investigated. Also unknown is whether different compounds have differential effects. The aim of the present study was to assess changes in weight in obsessive-compulsive disorder (OCD) patients treated for 2.5 years with clomipramine or selective serotonin reuptake inhibitors.

METHOD

138 DSM-IV OCD patients who responded to 6-month acute treatment at the Mood and Anxiety Disorders Unit, Department of Neuroscience, University of Turin, Italy, were followed-up for 2 years while receiving open-label clomipramine, citalopram, fluoxetine, fluvoxamine, paroxetine, or sertraline. Patients were consecutively recruited and followed from May 1998 to March 2003. The mean percentage change in weight was compared for each group, as was the proportion of patients who had a > or = 7% weight increase from baseline.

RESULTS

At the end of the 2.5-year study period, patients had gained a mean of 2.5% of their body weight with respect to baseline (1.58 kg); 14.5% of the total sample experienced a significant (> or = 7%) weight increase. Within each but the fluoxetine treatment group, paired t tests showed a significant increase in weight from baseline to final visit. Analysis of variance showed a significant difference between treatment groups (p = .009), with clomipramine being associated with the highest weight increase and fluoxetine and sertraline with the lowest. A higher proportion of clomipramine-treated patients (34.8%) gained > or = 7% in weight as compared with sertraline and fluoxetine, which accounted for the lowest percentage of patients with a significant weight gain (4.5% and 8.7%, respectively), although this difference was not statistically significant.

CONCLUSION

Risk of weight gain during extended serotonin reuptake inhibitor treatment for OCD differs depending on which compound is used. The differences among antiobsessive drugs may affect compliance with medication and health risks.

Treating Functional Impairment of Autism with Selective Serotonin-Reuptake Inhibitors

OBJECTIVE:

To review literature describing use of selective serotonin-reuptake inhibitors (SSRIs) in the management of functional impairments associated with autistic disorder.

DATA SOURCES:

EMBASE (1980—3rd quarter of 2003), International Pharmaceutical Abstracts (1970–August 2003), and MEDLINE (1966–August 2003) were searched. Search terms included autism, autistic disorder, citalopram, fluoxetine, fluvoxamine, paroxetine, selective serotonin-reuptake inhibitors, and sertraline.

DATA SYNTHESIS:

Studies and case reports evaluating treatment outcomes associated with the use of SSRIs in managing impairments of autism were reviewed. Multiple SSRI dosing ranges were evaluated in autistic patients of different ages with various functional impairments. No specific SSRI or dose range has been shown to improve a specific autistic symptom although some patients have demonstrated improvements.

CONCLUSIONS:

Benefits with SSRIs in treating functional impairments in autism have been observed. Response to therapy and adverse effects are individualized. Current evidence does not support selection of one SSRI over another for any impairment associated with autism.

Effects of imipramine, fluvoxamine and depressive mood on autonomic cardiac functioning in major depressive disorder

OBJECTIVE

Diminished HR variability is considered to be associated with depression and the increased risk of cardiovascular disease. The pharmacological effects of antidepressants and depressive mood itself may contribute to alterations in autonomic cardiac functioning, but a limited amount of data is available. We studied the effects of two different types of antidepressant treatments (imipramine and fluvoxamine), in addition to the effect of depressive mood, on the cardiovascular system in depressed patients.

METHODS

Depressed inpatients were studied during a drug-free period and after 4 weeks of adequate treatment with imipramine (n = 17) or fluvoxamine (n = 24). Heart rate variability, blood pressure variability, and a baroreflex sensitivity index during supine rest and orthostatic challenge were analyzed by means of spectral techniques to obtain noninvasive parameters of sympathetic and parasympathetic activity.

RESULTS

Both imipramine and fluvoxamine reduced sympathetic and parasympathetic activity, although the effects of imipramine were much more pronounced. Severity of depression was positively related to mean levels of heart rate and blood pressure in the total patient group. There was no convincing evidence that these relationships differed between depressed patients treated with imipramine and those treated with fluvoxamine.

CONCLUSION

Our findings suggest that alterations in mean heart rate and blood pressure in depressed patients after antidepressant treatment are the result of a combined effect of pharmacological actions of antidepressants and improvement of depressive mood state. The present study did not confirm the relationship between clinical state and cardiovascular variability or baroreflex sensitivity.

Olanzapine plus fluvoxamine and olanzapine alone for the treatment of an acute exacerbation of schizophrenia

The objective of the present study was to compare the efficacy and adverse effects of olanzapine plus fluvoxamine and those of olanzapine alone, in schizophrenic patients with acute exacerbation. A randomized, placebo-controlled, 6-week trial was carried out at a University Hospital in Bangkok, Thailand. The efficacy and adverse effects were assessed biweekly by using the Brief Psychiatric Rating Scale (BPRS) and the Udvalg for Kliniske Undersogelser side-effect scale, respectively. Twenty schizophrenic patients with acute exacerbation were randomly assigned to receive olanzapine plus fluvoxamine or olanzapine alone. The study found that the means of BPRS total and BPRS general psychopathology score changes were significantly larger in olanzapine plus fluvoxamine group (P = 0.037 and P = 0.045, respectively). The incidence of treatment adverse effects is comparable. In conclusion, the study findings suggest that fluvoxamine augmentation to olanzapine is well tolerated and more effective than olanzapine alone for short-term (6-week) treatment of an acute exacerbation of schizophrenia. Due to a number of limitations, further studies are warranted to confirm.

Fluvoxamine for fatigue in primary biliary cirrhosis and primary sclerosing cholangitis: a randomised controlled trial [ISRCTN88246634]

Background

Fatigue is a major clinical problem in many patients with primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC). An effective treatment has not been defined. Recently, a large proportion of patients with these diseases was found to have symptoms of depression. Because fatigue is a frequent symptom of depression and there is some evidence that treatment with an antidepressant improves fatigue in patients with fibromyalgia, we hypothesised that the antidepressant fluvoxamine might improve fatigue related to PBC and PSC.

Methods

Fatigued patients were randomised to receive fluvoxamine (75 mg BID) or placebo for a six-week period. Fatigue and quality of life were quantified using a visual analogue scale, the Fisk Fatigue Severity Scale, the Multidimensional Fatigue Inventory and the SF-36.

Results

Seventeen and 16 patients were allocated to fluvoxamine and placebo, respectively. There was no statistically significant beneficial effect of fluvoxamine on fatigue or quality of life. The median VAS scores in the fluvoxamine and placebo groups were 7.40 and 7.45 at day 0, 6.9 and 7.15 at day 14, 7.45 and 7.65 at day 42 and 7.8 and 8.0 four weeks after treatment discontinuation.

Conclusion

We found no evidence for a beneficial effect of fluvoxamine on fatigue in these patients with cholestatic liver disease and severe chronic fatigue.

Analysis and Its Application for Prevention of Side-Effects of Drugs and for Evaluation of Drug Responsiveness

The response of patients to drugs can be affected by genetic polymorphisms/defects in drug metabolizing enzymes, transporters, and receptors. Genetic polymorphisms/defects are generated by mutation of coding regions and/or noncoding regions of target genes, such as single-point mutations, deletions/insertions, variation in the number of tandem repeats, etc. If a genetic defect in a patient which affects drug response were known, it would be possible to optimize medications individually. The author developed two improved methods for detecting CYP2C19(*)2 and CYP2C19(*)3. Using the methods, the type of CYP2C19 gene was examined in 80 inpatients, and the medication status of patients with the mutation was examined focusing on dosage and side effects. The author also examined polymorphisms of the serotonin transporter/biosynthetic or metabolizing enzymes in depressive patients treated with fluvoxamine, a selective serotonin reuptake inhibitor, and the relationship between clinical efficacy and polymorphisms was investigated. As a result, patients with the S/S genotype of 5-HTTLPR were found to experience better clinical efficacy.

Neonatal complications after intrauterine exposure to SSRI antidepressants

(1) Newborns exposed to selective serotonin reuptake inhibitor (SSRI) antidepressants towards the end of pregnancy sometimes show signs of agitation, altered muscle tone, and breathing and suction problems. Similar symptoms can occur after exposure to tricyclic antidepressants. (2) These neonatal symptoms have been noted with all five SSRI antidepressants available in France, namely citalopram, fluoxetine, fluvoxamine, paroxetine and sertraline. (3) An estimated 20% to 30% of newborns exposed to an SSRI towards the end of pregnancy are affected. (4) The symptoms are variously attributed to withdrawal or to the drug itself. (5) In practice, doctors should be aware of this risk when considering antidepressant treatment for women in the third trimester of pregnancy. There is no consensus on the treatment of affected newborns, but close monitoring is mandatory.

Fluvoxamine-controlled release formulation for the treatment of generalized social anxiety disorder

BACKGROUND

Generalized social anxiety disorder is a highly prevalent anxiety disorder with deleterious effects on social and family relationships, as well as work performance. We report the results of a multicenter, randomized, placebo-controlled trial comparing the efficacy, safety, and tolerability of fluvoxamine controlled release (CR) to placebo in patients with generalized social anxiety disorder.

METHODS

A total of 279 adult patients meeting all inclusion/exclusion criteria was recruited at 23 United States sites and randomly assigned to receive either fluvoxamine CR (100-300 mg/d) or placebo for 12 weeks. The dose could be increased, based on efficacy and tolerability, in increments of 50 mg/d at weekly intervals. The dosage remained constant during weeks 6 to 12.

RESULTS

Treatment with fluvoxamine CR resulted in statistically and clinically significant improvements in symptoms associated with generalized social anxiety disorder as early as week 4 on the Liebowitz Social Anxiety Scale and the Clinical Global Impression Scale Global Improvement, and at week 6 on the Sheehan Disability Scale, Clinical Global Impression Scale Severity of Illness and the Patient Global Impression of Improvement Scale. The most frequent adverse events reported by patients on fluvoxamine CR were headache, nausea, somnolence, and insomnia. No weight gain was observed for either treatment group, and at end point, there were no differences between treatments on overall sexual function, as measured by the Arizona Sexual Experience Scale.

CONCLUSIONS

Both physician and patient-rated scales indicate that fluvoxamine CR is effective and safe for the treatment of generalized social anxiety disorder.

Efficacy and pharmacokinetics of fluvoxamine maleate in patients with mild depression undergoing hemodialysis

Seven Japanese patients on maintenance hemodialysis who were comorbid with mild depression were medicated with 50 mg/day fluvoxamine maleate for 28 days. Effectiveness was obtained in four out of seven patients (57%). The plasma fluvoxamine concentrations were examined in three patients. The plasma fuvoxamine concentration decreased by 22% by hemodialysis. There is a tendency for the dialyzed rate of fluvoxamine to become lower if the plasma albumin concentration is higher. The half-life of fluvoxamine was possibly shortened more in the patient with hypoalbuminaemia. The plasma fluvoxamine concentration reached a steady state 8 days after the start of medication and thereafter. The time required to reach steady state was lengthened when compared with the results in normal Japanese volunteers.

Add-on fluvoxamine improves primary negative symptoms: evidence for specificity from response analysis of individual symptoms

Establishing that treatment for negative symptoms improves primary features of schizophrenia rather than similar symptoms of other etiology is an important clinical issue. Primary negative symptoms may also differ among themselves in the propensity to respond to a given treatment. In this study, we examined the response of negative symptoms to add-on fluvoxamine by analyzing discrete symptoms independently and controlling for potential confounding variables. Data from two published controlled studies comparing fluvoxamine to placebo were pooled for the analysis. Eleven of sixteen Scale for the Assessment of Negative Symptoms items tested, including key negative symptoms such as affective flattening and alogia, improved. The improvement was not related to baseline levels of depressive, extrapyramidal, and positive symptoms or to changes in the symptom scores during the study. The findings support the view that fluvoxamine augmentation can improve primary negative symptoms in chronic schizophrenia patients.

Fluvoxamine dose-dependent interaction with haloperidol and the effects on negative symptoms in schizophrenia

Augmentation with low-dose fluvoxamine (50-100 mg/day) to antipsychotic treatment may improve the negative symptoms in schizophrenic patients, but involves a risk of drug-drug interaction. We studied the effects of fluvoxamine on plasma concentrations of haloperidol and reduced haloperidol, and their clinical symptoms, in haloperidol treated patients. Twelve schizophrenic inpatients with prevailingly negative symptoms receiving haloperidol 6 mg/day were additionally treated with incremental doses of fluvoxamine for 6 weeks (25, 75 and 150 mg/day for 2 weeks each). Plasma drug concentrations were monitored together with clinical assessments before and after each phase of the three fluvoxamine doses. Geometric mean of haloperidol concentrations during coadministration of fluvoxamine 25, 75 and 150 mg/day were 120% (95%CI; 114-127%), 139% (95%CI; 130-149%), and 160% (95%CI; 142-178%) of those before fluvoxamine coadministration, respectively. We found positive correlations between increase in plasma haloperidol concentrations and plasma fluvoxamine concentrations. Scores in negative symptoms were significantly reduced after fluvoxamine coadministration, whereas no changes were observed in the other psychiatric symptoms or any subgrouped side effects. Therefore, this study indicates that fluvoxamine increases plasma haloperidol concentrations in a dose-dependent manner. However, relatively small elevations in haloperidol concentration did not lead to the development of extrapyramidal symptoms under the conditions of this study.

Joint Regression and Association Modeling of Longitudinal Ordinal Data

We propose models for longitudinal, or otherwise clustered, ordinal data. The association between subunit responses is characterized by dependence ratios (Ekholm, Smith, and McDonald, 1995, Biometrika 82, 847-854), which are extended from the binary to the multicategory case. The joint probabilities of the subunit responses are expressed as explicit functions of the marginal means and the dependence ratios of all orders, obtaining a computational advantage for likelihood-based inference. Equal emphasis is put on finding regression models for the univariate cumulative probabilities, and on deriving the dependence ratios from meaningful association-generating mechanisms. A data set on the effects of treatment with Fluvoxamine, which has been analyzed in parts before (Molenberghs, Kenward, and Lesaffre, 1997, Biometrika 84, 33-44), is analyzed in its entirety. Selection models are used for studying the sensitivity of the results to drop-out.

Fluvoxamine CR in the long-term treatment of social anxiety disorder: the 12- to 24-week extension phase of a multicentre, randomized, placebo-controlled trial

Fluvoxamine CR has been reported effective in the short-term (12-wk) treatment of generalized social anxiety disorder (social phobia). Social anxiety disorder (SAD) is, however, a chronic disorder thought to require maintenance treatment. We report on data from the extension phase of a short-term study, in order to explore the efficacy and safety profile of fluvoxamine CR (100-300 mg/d) in the longer-term treatment of this disorder. Adult outpatients with generalized social anxiety disorder (GSAD) at 35 centres in Europe, South Africa, and USA were included in an acute phase study (12 wk). Subjects who demonstrated at least minimal improvement by endpoint (n=112), were offered participation in an extension phase, in which medication was continued for a further 12 wk under double-blind conditions. Efficacy was assessed using the Liebowitz Social Anxiety Disorder Scale (LSAS), the Clinical Global Impression Global Improvement score (CGI-I), the Clinical Global Impressions Severity of Illness score (CGI-S), and the Sheehan Disability Scale (SDS). Safety and tolerability assessments were also performed at regular intervals. Subjects treated with fluvoxamine CR had a numerically greater decrease in LSAS total scores than subjects treated with placebo at endpoint. Analysis of data from baseline (day 1) to endpoint (last observation carried forward) demonstrated that this difference tended towards significance, while severity of illness on the CGI-S and disability on the SDS were significantly lower in the fluvoxamine CR group than in the placebo group. The same trends were observed when only data from weeks 12-24 were included in the analysis; although the magnitude of changes was smaller in the extension phase than in the acute phase, fluvoxamine CR-treated subjects continued to show improvement compared to placebo-treated subjects. Most treatment-emergent signs and symptoms (TESS) were mild to moderate in severity. No unexpected abnormalities were reported on vital signs, electrocardiagrams, or laboratory investigations. These data support the long-term efficacy, safety, and tolerability of fluvoxamine CR in the treatment of GSAD. Given the prevalence, persistence, and disability associated with GSAD, and the relative paucity of long-term treatment studies of SAD, the current dataset provides empirical support for the current clinical consensus that pharmacotherapy of this disorder should be continued beyond the acute phase.

Monoamine oxidase A gene polymorphism, 5-HT 2A receptor gene polymorphism and incidence of nausea induced by fluvoxamine

Selective serotonin reuptake inhibitors cause a side effect of nausea with high frequency, but there have been no accurate methods to predict its incidence. The authors first investigated whether a functional polymorphism in the monoamine oxidase A (MAOA-VNTR) and a -1438G/A polymorphism in the promoter region of the 5-HT(2A) gene were associated with the incidence of nausea induced by fluvoxamine. Fluvoxamine was administered for 6 weeks with a specific dosage plan (50-200 mg/day) in 66 Japanese major depressive patients. The frequency of MAOA-VNTR allele 1 was significantly higher in the patients without nausea than in ones with nausea in the statistical analysis including the patients whose plasma levels were below the average and who were considered to be pharmacodynamically more sensitive to nausea. This study showed that the genetic polymorphism of MAOA-VNTR might affect the incidence of nausea induced by SSRIs. If this finding is replicated in other studies with more subjects, MAOA-VNTR polymorphism would be of great clinical use to predict the incidence of nausea induced by SSRIs.

Successful electroconvulsive therapy in major depression with fluvoxamine-induced bruxism

A 61-year-old patient with major depression and selective serotonin reuptake inhibitor-induced bruxism was successfully treated with a course of bilateral electroconvulsive therapy. Both the depressive symptoms and bruxism completely remitted after six treatments. Possible mechanisms of this effect are discussed.

Schneiderian first-rank symptoms associated with fluvoxamine treatment: a case report

This communication describes a patient who developed Schneiderian first-rank symptoms in the course of treatment with fluvoxamine. The patient, a 28-year-old man suffering from panic disorder, developed several first-rank symptoms during fluvoxamine administration. These symptoms abated 1 week after fluvoxamine treatment was discontinued and haloperidol was started. Although haloperidol was discontinued, no further hallucinations or delusions occurred. This finding suggests that fluvoxamine can precipitate Schneiderian first-rank symptoms in some susceptible patients.

A double-blind, placebo-controlled study of the efficacy and safety of controlled-release fluvoxamine in patients with obsessive-compulsive disorder

OBJECTIVE

The aim of this 12-week, double-blind, flexible-dose, placebo-controlled, parallel-arm, multicenter trial was to determine the safety and efficacy of fluvoxamine in a controlled-release (CR) formulation in adult outpatients with obsessive-compulsive disorder (OCD).

METHOD

253 adult outpatients with DSM-IV OCD were randomly assigned to receive 100 to 300 mg of fluvoxamine CR (N = 127) or placebo (N = 126) once daily for 12 weeks. Intent-to-treat analyses of efficacy assessments with the Yale-Brown Obsessive Compulsive Scale (YBOCS), Clinical Global Impressions-Severity of Illness scale (CGI-S), and Clinical Global Impressions-Improvement scale (CGI-I) were conducted.

RESULTS

Fluvoxamine CR was significantly (p <.05) superior to placebo in decreasing YBOCS total score beginning at week 2. This early response was sustained at all subsequent visits. At endpoint, there was a mean decrease of 8.5 +/- 0.7 (31.7%) in the YBOCS total score compared with baseline in the fluvoxamine CR treatment group versus a mean decrease of 5.6 +/- 0.7 (21.2%) in the placebo group (p =.001). Fluvoxamine CR was also significantly superior to placebo in lowering the severity of illness (CGI-S, p =.002) and in producing clinical improvement (CGI-I, p <.01). At endpoint, significantly greater percentages of the fluvoxamine CR treatment group were responders (p =.002) and remitters (p =.019) compared with the placebo group.

CONCLUSION

Over 12 weeks, fluvoxamine CR treatment was associated with a statistically significant and clinically relevant reduction in OCD severity and was found to be safe and well tolerated. The early onset of therapeutic effect, starting from week 2, was of particular interest.

[Studies on the adverse effects of fluvoxamine treatment in children with autistic disorder: correlation with genetic polymorphism in serotonin related genes]

Selective serotonin re-uptake inhibitors (SSRIs) have recently been applied to the children with autistic disorder. To create better treatment, we studied here clinical adverse effects of fluvoxamine and correlated them with genetic polymorphism of two genes, the promoter region of serotonin transporter gene (5-HTTLPR) and serotonin 2A receptor gene (5-HT2AR). Twenty-eight subjects, consisting of 23 boys and 5 girls, aged from 3 to 18 years old diagnosed as having autistic disorder were analyzed during fluvoxamine administration. The dosages and duration of fluvoxamine treatment are 1.5 to 3 mg/kg/day and 2 weeks to 17 months (mean 7.9 months), respectively. There were several clinical adverse effects such as sleep disturbance in 9 cases, climb up to high places in 8, gastrointestinal symptoms in 6, hyperactivities in 5, excitement in 4, general fatigability in 2 and urticaria in 1. Medication was discontinued in 2 patients with fatigability and 1 with sleep disturbance, diarrhea and poor appetite. There was no significant correlation between genetic polymorphism in 5-HTTLPR and the occurrence of clinical adverse effects of fluvoxamine. However hyperactivity was significantly more frequent in the subjects with 102T/102T polymorphism of 5-HT2AR, and patients with sleep disturbance were significantly less frequent in the subjects with 102C/102C polymorphism. We conclude that the clinical adverse effects such as climb up to high places and hyperactivity during fluvoxamine treatment may be relatively specific in children, and that genetic polymorphism of 5-HT2AR may be related to the appearance of clinical adverse effects.

Suitable dose and duration of fluvoxamine administration to treat depression

The purpose of the present paper was to determine the suitable dose and appropriate trial duration of fluvoxamine to treat for depression. A retrospective cohort analysis was performed among depression patients who were treated in the Department of Psychiatry, Kawasaki Medical School Hospital, Kurashiki, Japan, in 2000. A total of 72 patients received fluvoxamine to treat depression. The dose-response was compared and the initial significant clinical action was examined. The percentage showing improvement after receiving a high daily dose (100-150 mg) of fluvoxamine was 73.7%, but that showing improvement on a low daily dose (50-75 mg) was 47.1%. A significant difference between the two groups was seen on Kaplan-Meier analysis and log-rank test (chi2 = 4.814; d.f. = 1; P = 0.0282). The cumulative percentage of responder patients was more than 80% at the end of a 6-week period. Fluvoxamine is recommended at a daily dose of 100 mg or 150 mg as the initial dose. If a patient does not show improvement by the end of 6 weeks the treatment regimen of fluvoxamine should be altered.

Fluvoxamine as effective as clomipramine against symptoms of severe depression: results from a multicentre, double-blind study

BACKGROUND

Although selective serotonin reuptake inhibitors (SSRIs) are better tolerated than tricyclic antidepressants, their efficacy in severe depression remains to be further elucidated.

METHOD

A double-blind, multicentre study was conducted in 86 severely depressed inpatients (>or= 25 on the 17-item Hamilton depression rating scale [HAMD] total score) to compare the efficacy and safety of fluvoxamine with that of clomipramine. Following placebo run-in, 86 patients were randomised to receive fluvoxamine or clomipramine (100-250 mg/day) for 8 weeks.

RESULTS

Fluvoxamine and clomipramine both resulted in marked improvements; there were no statistically significant differences between them on the 17-item HAMD total score, the clinical global impression severity of illness or global improvement items or the Montgomery-Asberg depression rating scale, at any visit. At the end of the study, 71% in the fluvoxamine group and 69% in the clomipramine group were responders (>or= 50% decrease in 17-item HAMD total score). However, fluvoxamine was better tolerated than clomipramine. Clomipramine was associated with a higher incidence of overall and treatment-related adverse events. In addition, the percentage of patients discontinued prematurely due to adverse events was more than twice as high with clomipramine than with fluvoxamine (24% vs 11%).

CONCLUSION

Fluvoxamine and clomipramine are equally effective in severe depression, but fluvoxamine has a better safety and tolerability profile.

Emerging skin-picking behaviour after serotonin reuptake inhibitor-treatment in patients with obsessive-compulsive disorder: possible mechanisms and implications for clinical care

Pathological skin-picking is a self-injurious, impulsive behaviour with repetitive, and ritualistic characteristics. A number of studies show that selective serotonin reuptake inhibitors (SSRIs) may be efficacious in reducing skin-picking behaviour. Two case reports are presented demonstrating that SSRI-treatment may induce or aggravate pathological skin-picking behaviour. Possible mechanisms of SSRI-induced pathological skin-picking and implications for clinical care are discussed.

The onset and time course of response of negative symptoms to add-on fluvoxamine treatment

Not enough is known about the propensity of individual negative symptoms to respond to treatment and the dynamics of this change. We have previously shown that adding the selective serotonin reuptake inhibitor fluvoxamine to antipsychotics can improve negative symptoms, and now provide data on the response of individual negative symptoms to such treatment. We examined items on the Schedule for the Assessment of Negative Symptoms for patients participating in two published controlled studies comparing the effect of add-on fluvoxamine and placebo on negative symptoms. Using a mixed regression model, we analysed item scores at each week of the study to identify the first signs of a treatment effect. Potential confounding effects of depressive extrapyramidal and positive symptoms were statistically controlled. Eleven of 16 items tested showed improvement, five within 2 weeks and a further four within 3 weeks of starting treatment. The most rapidly responding items included core negative symptoms such as alogia. The propensity for and rate of improvement with fluvoxamine treatment differs for the various negative symptoms. Many symptoms, including those generally agreed to be core features of the illness such as alogia, improved within 2-3 weeks of treatment initiation.

Antidepressant response and fluvoxamine plasma concentrations: a pilot study

The objective of this pilot study was to examine the relation between fluvoxamine (FVX) plasma concentrations, therapeutic response and side effects during a four-week treatment period. Twenty-two patients who met the DSM-IV criteria for major depression received 100 mg FVX during the first 2 days of treatment and then 150 or 200 mg/day. No clear relationship between plasma concentrations and side effects was detectable. A relationship between plasma concentrations and clinical efficacy was detectable after 21 days but not after 28 days of treatment. These preliminary results indicate that therapeutic drug monitoring might be useful for patients treated with FVX.

Possible involvement of peripheral serotonin 5-HT3 receptors in fluvoxamine-induced emesis in Suncus murinus

Selective serotonin reuptake inhibitors fluvoxamine and fluoxetine, as well as serotonin (5-HT), induced vomiting in Suncus murinus (a house musk shrew). Fluvoxamine- and fluoxetine-induced vomiting gradually decreased with their repeated administration. Vomiting induced by serotonin also decreased with repeated treatment with serotonin. In these shrews, fluvoxamine-induced vomiting was partially inhibited. Fluvoxamine might induce vomiting, at least partially, by indirectly activating peripheral 5-HT(3) receptors, since serotonin has been reported to induce vomiting by activating peripheral 5-HT(3) receptors and granisetron, a 5-HT(3) antagonist, partially suppressed fluvoxamine-induced vomiting in our previous finding. In addition, fluvoxamine-induced vomiting was impaired more effectively using a step-wise dose-up schedule of fluvoxamine than a fixed high-dose schedule. Therefore, a careful dosing strategy starting with a low dose might be effective for avoiding emesis associated with the clinical use of fluvoxamine.

SSRI treatment of borderline personality disorder: a randomized, placebo-controlled clinical trial for female patients with borderline personality disorder

OBJECTIVE

Selective serotonin reuptake inhibitors (SSRIs) are recommended for treatment of affect lability, impulsivity, and aggression in patients with borderline personality disorder. This recommendation is based on positive findings in at least 10 open studies and one small double-blind study of SSRIs for patients with borderline personality disorder and one study of impulsive aggressive patients with different personality disorders. A randomized, placebo-controlled SSRI study with borderline personality disorder patients, however, provided inconclusive results because of a large response to placebo. It was, therefore, decided to conduct a new randomized trial with a larger study group.

METHOD

A double-blind, placebo-controlled, randomized trial using the SSRI fluvoxamine for 6 weeks followed by a blind half-crossover for 6 weeks and an open follow-up for another 12 weeks was conducted with 38 nonschizophrenic, nonbipolar female patients with borderline personality disorder. The outcome measures were the rapid mood shift, impulsivity, and aggression subscales from the Borderline Personality Disorder Severity Index.

RESULTS

Fluvoxamine but not placebo produced a robust and long-lasting reduction in the scores on the subscale for rapid mood shifts. In contrast, no difference between the fluvoxamine and placebo groups was observed in the effect on the impulsivity and aggression scores.

CONCLUSIONS

In this study, fluvoxamine significantly improved rapid mood shifts in female borderline patients, but not impulsivity and aggression. This latter finding may be due to gender-specific differences in impulsivity and aggression.

No association between the serotonergic polymorphisms and incidence of nausea induced by fluvoxamine treatment

We investigated the association between serotonergic polymorphisms and incidence of nausea, which is the most frequent side-effect of selective serotonin reuptake inhibiters (SSRIs), in 66 patients treated with fluvoxamine in a protocolized-dosing method. We focused on three polymorphisms of serotonin (5-HT) neuronal systems such as 5-HT transporter (5-HTT) gene-linked polymorphic region (5-HTTLPR), a variable number of tandem repeat (VNTR) polymorphism in the second intron of the 5-HTT gene (STin2) and tryptophan hydroxylase (TPH) gene polymorphism in intron 7 (TPH-A218C), which have been reported to possess positive association with treatment response to SSRIs. In addition to this, the relationship between development of nausea and treatment response was also analyzed. Results suggested that these three polymorphisms did not affect the development of fluvoxamine-induced nausea, and that incidence of nausea was not a phenomenon that predicts the treatment response to fluvoxamine.

Delayed recurrent SIADH associated with SSRIs

BACKGROUND

Depression is a common problem in elderly patients and is frequently treated with selective serotonin-reuptake inhibitors (SSRIs).

OBJECTIVE

To report a case of delayed recurrent hyponatremia after switching from one SSRI to another.

CASE SUMMARY

An 87-year-old depressed woman began treatment with fluvoxamine. One week later, she was diagnosed with hyponatremia, most likely syndrome of inadequate antidiuretic hormone. Following discontinuation of fluvoxamine, the serum sodium concentration normalized. Later, she began treatment with paroxetine. Sixteen months after initiating paroxetine, she developed symptomatic recurrent hyponatremia. After paroxetine was discontinued, the sodium concentration normalized.

DISCUSSION

In this case, unlike those previously reported, hyponatremia recurred 16 months after a different SSRI was initiated. The Naranjo probability scale indicates a probable relationship between recurrent hyponatremia and paroxetine. The mechanism of SSRI-induced hyponatremia is multifactorial.

CONCLUSIONS

This case illustrates that replacement of one SSRI with another can cause delayed, recurrent hyponatremia in elderly patients. Plasma sodium concentrations must be monitored, not only in the first weeks of treatment, but throughout the full course.

Fluvoxamine: safety profile in extensive post-marketing surveillance

The safety profile of the selective serotonin reuptake inhibitor, fluvoxamine, has been assessed in clinical and post-marketing studies. Post-marketing surveillance provides the opportunity to assess a drug's safety in every day clinical conditions in a much greater patient population than in clinical trials and therefore serves as a useful tool to detect signals for adverse effects with an incidence of less than 1 : 10,000. The safety profile of fluvoxamine was evaluated based on data from 17 years of global post-marketing surveillance in an estimated 28 million patients exposed to fluvoxamine. A total of 6,658 adverse drug reaction reports received from world-wide sources were reviewed and analysed. Post-marketing surveillance data confirmed the favourable safety profile already observed in clinical and post-marketing studies. A remarkably low level of suicidality, switch to mania, and sexual dysfunction was found. Serotonin syndrome appeared to be a very rare complication of fluvoxamine treatment. No signals for drug interactions unknown so far were identified. Withdrawal symptoms were observed in everyday clinical conditions, which were generally mild and resolved spontaneously. However, no cases suggestive for drug dependence have been reported. In conclusion, the data presented underlined that fluvoxamine offers a safe and well-tolerated option in the treatment of depression and obsessive-compulsive disorder.

Neurotoxic syndrome associated with risperidone and fluvoxamine

OBJECTIVE

To report a case of a neurotoxic syndrome in a patient undergoing concomitant treatment with risperidone and fluvoxamine.

CASE REPORT

A 24-year-old African American woman hospitalized for psychosis was unresponsive to risperidone. Because of obsessive symptoms, low doses of fluvoxamine were added to her treatment regimen. Within 2 days, she developed confusion, diaphoresis, diarrhea, hyperreflexia, and myoclonus, which then progressed to rigidity, fever, and unresponsiveness, requiring endotracheal intubation. Symptoms resolved over 10 days with discontinuation of medication, hydration, and bromocriptine 5 mg 3 times daily. Ultimately, she was treated with olanzapine and fluvoxamine without adverse effects.

DISCUSSION

This represents the first reported case of a neurotoxic syndrome secondary to treatment with risperidone and fluvoxamine. Differential diagnosis between neuroleptic malignant syndrome (NMS) and serotonin syndrome (SS) could not be accurately determined because of the overlap of signs and symptoms of both syndromes. NMS and SS may represent different aspects of a more generalized neurotoxic syndrome. This could be an important consideration in formulating treatment for neurotoxic syndromes.

CONCLUSIONS

Clinicians should be aware of potentially serious adverse reactions that may occur during concomitant treatment with antipsychotics and selective serotonin-reuptake inhibitors.

Differential effects of milnacipran and fluvoxamine, especially in patients with severe depression and agitated depression: a case-control study

We attempted to compare the antidepressant efficacy of milnacipran and fluvoxamine in 202 outpatients with major depression, using the 17-item Hamilton Depression Rating Scale (HDRS). Special attention was paid to the difference of responsiveness as a function of the severity of depression and individual HDRS factors. As a result, while no significant difference between the treatment groups was found overall, a positive response (50% or more decrease in total score from the baseline) was recorded significantly more often with milnacipran than fluvoxamine recipients whose baseline HDRS total score was greater than 19 points. Furthermore, there was a significant difference of response for the 'agitation' and 'insomnia' factors in favour of milnacipran. In both treatment groups, the incidence of adverse events, characteristic of tricyclic antidepressants such as dry mouth, constipation, somnolence and postural hypotension, was low. While complaints concerning the upper intestinal tract, such as epigastric distress, were predominant in the fluvoxamine group, urological complications and palpitations were reported only in the milnacipran group. In conclusion, we suggest that milnacipran is preferred to selective serotonin reuptake inhibitors for the treatment of depressed patients with agitation as well as severely depressed patients.