Reboxetine combination in treatment-resistant depression to selective serotonin reuptake inhibitors

INTRODUCTION

Treatment-resistant depression is a relatively common clinical occurrence: between 60-70% of depressive patients fail to achieve total remission to the initial treatment with selective serotonin reuptake inhibitors (SSRI).

METHODS

In this prospective 12-week open-label study, we evaluated the effectiveness of the addition of reboxetine to 141 outpatients diagnosed with major depressive disorder, according to DSM-IV-TR criteria, who were partial responders or non-responders over a period of 6 weeks, to previous treatment in monotherapy with SSRI. Evaluation of antidepressant efficacy was carried out through the application of the Hamilton Depression Rating Scale (HDRS) and the Clinical Global Impressions-Global Improvement Scale (CGI-I). Data were analyzed on an intent-to-treat basis, using the last-observation-carried-forward method.

RESULTS

Mean score on the HDRS at baseline was 26.24+/-7.21, falling to 13.96+/-8.00 in week 12 (mean decrease of 46.79%; p<0.0001) The percentages of responders (HDRS total score > or =50%) and patients considered as benefiting from complete remission (HDRS score < or =10) at 12 weeks were 50.4% and 34.5%, respectively. By the end of the treatment, a mean decrease in CGI-I score of 1.88 points was obtained (41.14% of reduction; p<0.0001), and 77% of the patients were evaluated as improved (CGI-I score <4). Nervousness was the adverse effect most frequently reported (5.21%), followed by dryness of mouth (4.38%), and insomnia (3.56%).

CONCLUSION

The results of this study suggest that the combination strategy with reboxetine appears to be a potentially useful tool in cases of SSRI-resistant depression.

[Endocannabinoid system and CNR1 gene polymorphisms in schizophrenia and addictive disorders]

Substance abuse is the most prevalent comorbid psychiatric condition associated with schizophrenia. Cannabis is a drug frequently used for schizophrenic patients. In the last decades the endocannabinoid system and their endogenous ligands have been discovered. Endogenous cannabinoids act in the brain on cannabinoid CB1 receptor. On the other hand this system may be involved in several brain functions through neuromodulation dopaminergic and other neurotransmitter system involved in schizophrenic and substance abuse disorders. Advances of genetic research have addressed the focus on the search of candidate genes for both disorders. In this review we have summarized the studies published about the CNR1 gene on schizophrenia and substance abuse disorders.

[Differences in management of depression in Spain from psychiatric and primary care physician point of view]

INTRODUCTION

Given that depression is the most prevalent psychiatric disorder in our society, the current situation in pharmacotherapy of depression in Spain has been studied from the point of view of psychiatrists and general practitioners (GP).

METHOD

A total of 339 interviews were carried out with two groups of physician (238 primary care physicians and 101 psychiatrists) from different Spanish cities. Distribution, application and questionnaires collection were made throughout 2002.

RESULTS

The diagnostic instruments most commonly used by more than 90 % of both medical groups to detect a depressive disorder in a consultation are the evaluation of symptoms and the interview with the patient. However the main diagnostic problem was "masking" of depression with other symptoms/disorders. Most GP (95 %) and psychiatrists (99 %) establish a pharmacological treatment in all their depressive patients. Both groups coincide in most community use of SSRI as drugs of first choice (93% from both samples). The pharmacological agents most used by the psychiatrist are the serotonin selective reputake inhibitors (SSRI) (98.3 %), followed by venlafaxine (84.4 %), anxiolytics (68.4 %), mirtazapine (58.9 %) and reboxetine (55.8 %). In the case of GP, the most commonly used pharmacological groups are SSRI (98.3 %) and anxiolytics (73.4 %). In primary care, the SSRI are considered the most effective antidepressant group. However, the tricyclic antidepressives (TCA) would be the most effective for the psychiatrists.

CONCLUSIONS

For psychiatrists and GP, the quality of care of depression in Spain is rated positively. However, there is a group of deficiencies and some aspects that need to be clearly improved, such as the time of consultations, coordination between GP and psychiatrists, waiting lists and available resources for mental health units.

C957T DRD2 polymorphism is associated with schizophrenia in Spanish patients

OBJECTIVE

The objective was to confirm whether a homozygous genotype for the C957 allele of the C957T DRD2 gene single nucleotide polymorphism (SNP) is associated with schizophrenia in an independent study population.

METHOD

We examined the genotypic distribution of this SNP in a set of clinically ascertained schizophrenic patients (n = 131) and age-matched control subjects (n = 364). Individuals were genotyped using automated analysis of fluorescently labeled PCR products.

RESULTS

The distribution of grouped genotypes for the C957T DRD2 SNP (CC vs. CT, TT) showed that C homozygote genotype was over-represented in our patient sample when compared with control subjects. This difference reaches the statistical significance (chi(2) = 7.0; df = 1; P = 0.008; OR = 2.05; % CI 1.2-3.4).

CONCLUSION

The findings of this study provide additional evidence that genetic variation at the DRD2 gene plays an important role in the vulnerability to schizophrenia.

Impulsivity and Sustained Attention in Pathological Gamblers: Influence of Childhood ADHD History

Pathological gambling (PG) has been associated to both impulsiveness and attention deficit/hyperactivity disorder (ADHD) in different studies. Our objective was to compare different impulsivity and sustained attention variables, using both behavioural tasks and self-administered questionnaires, in a group of pathological gamblers with a history of childhood ADHD (PG-ADHD; n = 16), a group of pathological gamblers without this history (PG-non-ADHD; n = 39), and a control group (n = 40). As instruments of measure, we used the stop signal task (to evaluate inhibitory control/impulsivity), the differential reinforcement of Low Rate Responding Task (delay of gratification/impulsivity) and the Continuous Performance Test (sustained attention). The Barratt Impulsivity Scale (BIS-11) was used as a self-administered questionnaire to measure impulsiveness. Our results show that patients in the PG-ADHD group exhibit a significantly lower capacity to delay gratification than those in the PG-non-ADHD and control groups, and less inhibitory control than patients in the PG-non-ADHD group. On self-administered questionnaires such as the BIS-11 the PG-ADHD group obtained higher scores than the PG-non-ADHD and control groups. However, no differences were found with respect to sustained attention using the CPT. Our results suggest a possible selective implication of the prefrontal cortex in PG, which would be especially evident in those with a childhood history of ADHD.

Every-other week capecitabine (C7) combinations: An active and well tolerated treatment in heavily pretreated patients (p) with advanced solid tumours

10649

Background: Standard C schedule is 14 days every 3 w (C14). However, data have shown that C7 schedule is as effective as and significantly less toxic than C14. The objective is to evaluate retrospectively the response rate and toxicity of C7 as single agent or in combination in heavily pretreated p with advanced solid tumours. Methods: p with advanced solid tumour, age ≤ 75 years, ECOG PS <2 and adequate bone marrow, renal and hepatic functions were analyzed. p received C7: 1250 mg/m2/12 h x 7 days every-other week. The combination drugs doses were adjusted to be used days 1 and 15. Cycles every 28 days. Response was evaluated every 3 cycles according to RECIST criteria Results: 20 p received C7. Cancer type: 11 breast (BC), 7 colo-rectal (CRC), 1 H&N and 1 gastric (GC). Median age 56 y (33–75). M/F: 8p/12p. ECOG 0/1: 39%/61%. 19 p stage IV and 1 (H&N) stage III. The most frequent metastatic site was liver 42.2%. 90% p had been heavily pretreated with chemotherapy (CT): 55% p had received ≥ 2 CT lines. 15% p had been treated with taxanes, 45% p taxanes + anthracyclines, 10% p 5-FU, 15% p oxaliplatin (Oxa) and/or raltritexed. 2 BC p had also received herceptin (Her) and 2 p (1BC/1CRC) had been previously treated with C14. Median nº cycles: 6 (1–19). C7 combinations were: 5/7 CRC p Oxa or CPT-11 and 11/11 BC p docetaxel (1p) or gemcitabine (1 p) or carboplatin (9 p) ± Her. 4 p received C7 alone. Toxicity (20 p). Grade I/II: HFS 55%, diarrhoea 25%, nausea/vomiting 15%, mucositis 5%, skin 5% and parestesias 5%. Grade III/IV: diarrhoea in 2 p (1CRC and 1 BC). Response (20 p): 2 CR (10%) both CRC p; 6 PR (30%) 5 BC p and 1 CRC p; 4 SD (20%) and 8 PD (40%). 40% ORR rate and 60% TGC. Median response duration: 37 w (22–44 w). 2 p who achieved CR received C7 combined with CPT-11. C7 combination in p with PR were Oxa (1 CRC p) and carboplatin ± Her (5 BC p). Conclusions: C7 schedule is an active regimen in patients with advanced CRC and BC heavily pretreated with CT and it shows a very favourable toxicity profile. These results warrant a phase II trial of carboplatin-C7 in MBC as front line therapy that will by lauched by Feb-2006.

No significant financial relationships to disclose.

The femoral nerve in the repair of inguinal hernia: well worth remembering

Injury to the nerves after inguinal hernia surgery is uncommon. The femoral nerve may be damaged by suture or staples, tissue scar entrapment, local anesthesia blockade or direct compression. We present a case of a transient lesion of the femoral nerve after mesh hernioplasty for a re-recurrent inguinal hernia, confirmed by radiological studies, electrophysiology and clinical recovery. The diagnosis, mechanism of injury and surgical approach are reviewed. Surgery to a recurrent hernia may be underestimated. The role of electromyography nerve conducting studies is emphasized insisting on the importance of clinical evolution for the successful management of these infrequent injuries.

[Oxcarbazepine in the prevention of epileptic syndromes in alcohol detoxification]

INTRODUCTION

Alcohol withdrawal syndrome may be accompanied by severe complications, such as epileptic syndromes or delirium tremens. A number of pharmacological strategies, especially benzodiazepines (BZD), have been used in their treatment and prevention, although problems can arise from the use of these drugs due to their addictive properties. The classical anticonvulsive drugs are rarely employed as an alternative because of their side effects, but the latest generation of substances could be especially useful. AIMS. The aim of this study was to examine the safety of oxcarbazepine (OXC) in the prevention of epileptic seizures and complications deriving from the withdrawal syndrome in alcohol detoxification treatment.

PATIENTS AND METHODS

The study involved a comparison of two groups of patients with a syndrome of physical dependence on alcohol, 42 of whom were treated with OXC and the remaining 42 received BZD as part of a programmed detoxification therapy.

RESULTS

Both OXC and BZD were equally efficient in preventing the appearance of epileptic complications and in reducing withdrawal symptoms. Overall, OXC produced fewer adverse events (p < 0.001) and offered fewer problems when it came to ending administration (p < 0.001).

CONCLUSIONS

OXC can be a valuable alternative to BZD and other pharmacological treatments in the prevention of complications in detoxification therapy, especially because of the absence of addictive properties and its having a better safety profile than classical anticonvulsant drugs.

CLINICAL PREDICTORS OF RESPONSE TO NALTREXONE IN ALCOHOLIC PATIENTS: WHO BENEFITS MOST FROM TREATMENT WITH NALTREXONE?

AIMS

To determine the clinically ascertained variables that are related to satisfactory response to naltrexone (NTX) treatment of alcohol dependence after detoxification.

METHODS

The use of intake and outcome variables were measured in a randomized 3-month open-controlled trial comparing the effects of naltrexone plus psychotherapy treatment versus psychotherapy treatment alone on the maintenance of abstinence in the final 28 days (n = 336, all male).

RESULTS

Predictors of a positive response to NTX treatment were family history of alcoholism (P = 0.010), early age at onset of drinking problems (P = 0.014) and comorbid use of other drugs of abuse (P < 0.001). Among the subjects not treated with NTX, the greater the number of predictor variables, the lower the final 28 days abstinence rates (P = 0.00003), but this was not the case in patients treated with NTX (P = 0.844).

CONCLUSIONS

Patients with these features, suggesting biological vulnerability overall have poorer outcomes, but this can be reduced with NTX treatment. The type of alcoholism should be considered before deciding on the pharmacological strategy.

[Efficacy of naltrexone in the treatment of alcohol dependence disorder in women]

Alcoholism is a major public health problem. Although its prevalence is higher in men, the clinical and social repercussions of alcoholism in women are also of great concern, as they have differential characteristics in different vulnerability, and thus therapeutic implications. In recent years, we have seen an increase of the percentages of women with problems related to alcohol consumption in Spain. Several pharmacological treatments as the antagonist of the opioid receptors naltrexone have demonstrated efficacy in the treatment of dehabituation of alcoholism in males, however, there are no studies in the female population. This report is the first randomized study about the efficacy of naltrexone in the treatment of dehabituation in women with alcohol dependence disorder.

METHODS

In a 12 week, single-blind, randomized trial, we studied 100 women with alcohol dependence disorder (DSM-IV), evaluating the efficacy of adding naltrexone as adjunctive treatment to the dehabituation treatment.

RESULTS

The naltrexone group showed a lower rate of alcohol relapse during the follow-up period (76 % vs. 46%; chi2=8.239; p=0.004), and significantly lower dropout rates (16% vs. 38 %; chi2=5.074; p=0.024). We also found a lower number of days of intoxication (2.88 vs. 14.64; t=2.732; p=0.011).

CONCLUSIONS

Naltrexone shows efficacy as adjunctive treatment to maintain abstinence in women with alcohol dependence disorder. Further studies are needed to confirm the efficacy of this treatment and to find specific predictors of good outcome in women.

Effects of topiramate in the treatment of alcohol dependence

BACKGROUND

Anticonvulsant drugs have been used in the treatment of alcohol addiction with relatively good results. The purpose of the present study was to evaluate tolerance and safety of topiramate in patients presenting alcohol dependence.

METHODS

We studied 24 patients that fulfilled alcohol-dependence criteria (DSM-IV) and presented other psychiatric disorders for which the use of topiramate was indicated. During the 12 weeks of the study, the patients received topiramate (262 mg/day) plus the psychoactive drugs they were taking for the other disorders. Carbohydrate-deficient transferrin (CDT) values and measures of craving and alcohol use were taken every 2 weeks.

RESULTS

Baseline rating of amount and frequency of craving and alcohol use decreased significantly by week 2, and CDT values decreased from week 6. Topiramate was well tolerated, and there were only three dropouts due to adverse events.

CONCLUSION

Topiramate is safe and well tolerated, and may be beneficial in the treatment of alcohol dependence. A placebo-controlled study would be of interest.

IDRD2 TaqIA polymorphism is associated with urinary homovanillic acid levels in a sample of Spanish male alcoholic patients

The TaqIA1 allele of the dopamine receptor gene D2 (DRD2) has been associated with alcoholism, as well as with other addictive behaviours. The exact nature of how the presence of this allele can be a vulnerability factor in the development of alcoholism remains unclear. In this study we found that the presence in the DRD2 genotype of the TaqIA1 allele in Spanish alcoholics is associated with higher levels of urine homovanillic acid (HVA) when compared to patients homozygous for the TaqIA2 allele. A sample of 142 Spanish male alcoholic patients was split into 2 groups on the basis of the presence or absence of the A1 allele in their genotype. The urine sample was analyzed by high performance liquid cromatography (HPLC), and the concentration of homovanillic acid (HVA), 5-hydroxyindoleacetic acid (5-HIAA) and vanilylmandelic acid (VMA) was determined. We found a statistical difference in the concentration of HVA between the groups, that suggests this polymorphism could be related to the variance of urine HVA levels.

The A1 allele of the DRD2 gene (TaqI A polymorphisms) is associated with antisocial personality in a sample of alcohol-dependent patients

BACKGROUND

Presence of A1 allele of the DRD2 gene has been associated with a predisposition for alcoholism although there are limited data about its phenotypic expression in alcoholism.

OBJECTIVES

To determine the importance of the A1 allele in clinical variables of alcohol dependence.

METHODOLOGY

A sample of 103 alcohol-dependent males was studied. All patients were recruited consecutively from the general hospital and community settings. The diagnostics were made with the structured clinical interview for DSM-III-R (SCID); and the International Personality Disorder Examination (IPDE). Diagnosis of family alcoholism was made by direct interview or with the Research Diagnostic Criteria-Family History (RDC-FH). The Addiction Severity Index (ASI) and the Severity of Alcohol Dependence Scale (SADS) were used to assess alcohol dependence severity. Genotyping was done by polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) methods.

RESULTS

Approximately 39% of the sample carried the A1 allele (A1+ group). This group had higher prevalences of antisocial personality disorder (60% vs. 15.9%); and alcoholism family history (72.5% vs. 52.4%). Also A1+ had early onset alcohol abuse and more drinking problems. The presence of A1+ was the main factor to explain the diagnosis of antisocial personality disorder, but the weight of this factor was not sufficient to explain the complications assessed by the ASI.

CONCLUSIONS

Our results support the existence of an association between the A1 allele and factors resulting from dopaminergic deficiency, otherwise denominated reward deficiency syndrome.

[Combination therapy with reboxetine for major depression patients who are partial or nonresponders to serotonin selective reuptake inhibitors]

INTRODUCTION

Recent studies have confirmed the usefulness of the therapeutical combination of two antidepressants from different pharmacological families in patients with single drug therapy resistant depression.

METHODS

In this prospective 6 weeks open-labeled study, efficacy of combination strategy was evaluated. This included the addition of reboxetine to 34 outpatients with DSM-IV major depressive disorder, who had not responded previously, or who partially responded to conventional treatment in single drug therapy with serotonin selective reuptake inhibitors (SSRI). Data were analyzed on a intent-to-treat basis.

RESULTS

Mean decrease in the 21 item Hamilton depression rating scale (HDRS) score was 49.4% (from 26.9 to 13.6; p<0.0001) and in the clinical global impressions scale (CGI) was 40.4% (from 4.6 to 2.7; p < 0.0001). At the end of the treatment, 47.1% of the patients we re considered in remission (HDRS < or = 10), 55.9% evaluated as responders (HDRS < or = 50%) and 58.8% considered as having improvement (CGI<4). No serious side effects were observed during combination therapy, the most frequent being nervousness and the urinary hesitancy (5.9%).

CONCLUSIONS

The results of this study suggest that addition of reboxetine to SSRI may be an effective and well-tolerated strategy in treatment-resistant patients who have failed to adequately respond to single drug therapy with SSRI.

Kaposi's sarcoma in renal transplant patients: experience at the Cruces Hospital in Bilbao

BACKGROUND

Kaposi's sarcoma (KS) in renal transplant recipients (RTRs) probably arises from a complex interplay of multiple factors.

OBJECTIVE

In order to analyze the prevalence of KS in patients transplanted at the Cruces Hospital in Bilbao, together with their clinical features, treatment, and etiologic factors, we performed a study using the registry of RTRs in our center.

METHODS

The records of 1,230 kidney transplant patients at the Cruces Hospital between 1979 and 1998 were reviewed. Immunosuppressive therapy was reduced once a diagnosis of KS was made. A nested polymerase chain reaction was used to detect human herpesvirus 8 (HHV-8) DNA in the biopsy tissue. The DNA was extracted from fresh tissue (n = 2) or from formalin-fixed, paraffin-embedded specimens (n = 5).

RESULTS

Six cases of KS were diagnosed. All patients with cutaneous KS improved with a reduction in immunosuppressive drugs. HHV-8 was detected in 100% (2/2) of the frozen biopsies and 20% (1/5) of the formalin-fixed samples investigated.

CONCLUSIONS

Our experience indicates that a continuous state of immunodeficiency is important for the development of KS in RTRs. The association, previously described between HHV-8 and transplant-associated KS, also exists in the studied population.