The effects of topical doxepin on responses to histamine, substance P and prostaglandin E2 in human skin

The tricyclic antidepressant, doxepin, is known to have H1 and H2 antihistaminic effects. Recently, 5% doxepin cream has been marketed in the U.S.A. for treatment of eczematous dermatoses. We investigated the effects of topical doxepin treatment on histamine-, substance P- and prostaglandin E2- (PGE2) induced responses in the skin of normal and atopic subjects. We compared the effects of topical doxepin with those of the oral antihistamine terfenadine. The weal volume and flare area responses to histamine were significantly reduced by treatment with topical doxepin or oral terfenadine in both normal and atopic subjects (P < 0.05). The mean +/- SEM percentage reduction in flare area for 10 micrograms/site of histamine in non-atopics and atopics was 48 +/- 8% and 60 +/- 17% with terfenadine, and 54 +/- 12% and 81 +/- 4% with topical doxepin, respectively. The mean percentage reduction in weal volume for the same dose of histamine in non-atopics and atopics was 70 +/- 9% and 63 +/- 16% with terfenadine, and 96 +/- 2% and 89 +/- 6% with topical doxepin, respectively. The flare but not the weal response to substance P was inhibited by both treatments in all subjects (P < 0.05). The mean +/- SEM percentage reduction in flare area for 200 pmol/site of substance P in non-atopics and atopics was 53 +/- 10% and 73 +/- 4% with terfenadine, and 74 +/- 7% and 75 +/- 4% with topical doxepin, respectively. The cutaneous responses to PGE2 were not affected by either drug. The inhibitory effects of doxepin were as great as those of terfenadine, and doxepin had a significantly greater effect than terfenadine in inhibiting the weal response to histamine and flare response to substance P in normal volunteers (P < 0.05). There was no significant difference between atopics and non-atopics in the percentage reduction of cutaneous responses by oral terfenadine or topical doxepin. Marked sedation occurred in three of the first 10 subjects treated with topical doxepin, necessitating a reduction in dosage for the remaining six subjects. In summary, topical doxepin was as effective as, and sometimes more effective than, a standard dose of oral terfenadine in the inhibition of histamine-induced and axon-reflex-mediated cutaneous responses. The marked sedative effect may limit its clinical use in some patients.

Elephantiasis nostras of the lips: a case report

Elephantiasis nostras (EN) is a clinical entity that usually presents as a persistent swelling of the lower extremities. It has been related to recurrent lymphangitis of bacterial origin that causes a fibrosis and thickening of both epidermal and connective tissue. Although very rare, EN has been previously reported in the lips. This is the first case reported in the oral medicine literature that describes EN involving the lips. We describe the clinical features and a differential diagnosis of the lip lesions and a treatment protocol to which this patient has responded. A diagnosis of EN should be entertained in patients with chronically edematous, scaling lip lesions.

[Variation of female migraine after menopause and its prophylaxis and treatment]

320 cases of female migraine after menopause according to the diagnostic criteria were studied by using 1:1 matched analysis. It was found that the additional symptoms increased after menopause. Eighty cases available for follow-up were divided into two groups, on which the treatment tests were done. Each patient in group I took Nilestrioli 2 mg twice a month and Perphenazine 12 mg and Doxepin 75 mg per day, while each patient in group II took Tolfenamic acid 300 mg a day. Two months after treatment, the cure rates were 57.58% in group I and 27.78% in group II. Two monthes after the cessation of therapy, 2 cases had relapses in group I. These data indicate that the decrease of estrin disorder and the additional symptoms after monopause play important roles in the change of migraine physiology, and the corresponding treatment methods are rational.

Doxepin in the management of pruritus associated with allergic cutaneous reactions

The primary treatment of urticaria involves identification and discontinuation of the offending agent. Addition of an antihistaminic agent may then be necessary to control pruritus. Because of variable response rates between patients, several alternative agents may need to be tried before the most effective regimen is found. Based on the studies reviewed here, it appears that low-dose doxepin (10 mg po tid) is a potentially effective and well-tolerated alternative in patients who do not respond to conventional antihistamines. This success may be in part due to the more potent H1- and H2-blocking properties associated with doxepin. Data regarding the topical use of doxepin are less convincing; however, the drug appears to have some clinical use for the short-term treatment of pruritus. Doxepin cream does not appear to be as effective as systemic therapy, and adverse effects (including sedation) and drug interactions are still problematic. Topical use may be best suited to conditions involving intact skin that do not require application to large areas of the body, thereby reducing systemic absorption and adverse effects.

[Symptoms of depressive state in otolaryngology]

A psychiatric study was carried out to seek correct diagnosis and effective therapy for patients with various pain symptoms in ear, nose and throat area, and the unknown cause of pain and invalid treatment. There were 12 patients who coincided with the diagnostic criteria of depression. The therapeutic effect was satisfactory with antidepression medicine. It is suggested that the practicing ENT doctors should have some knowledge of psychiatry, understand the symptoms of depressive state, avoid misdiagnosis and offer correct management.

On the problems of switching from intravenous to oral administration in drug treatment of endogenous depression--a placebo-controlled double-blind trial with doxepin

In the treatment of depressive disorders the onset of action can be accelerated if the antidepressant drug is initially administered by intravenous infusion. It is not clear whether this effect is due to pharmacological or to psychological effects of the infusion setting. The necessary switch to oral administration may be problematic. Uncontrolled observations indicate that it could be associated with a remarkable deterioration in the course of the disease. This randomized double-blind placebo-controlled study on doxepin is the first investigation of the effect of the switch from parenteral to oral administration on symptoms of endogenous depression. The hypothesis to be tested, that there is a significant worsening of treatment response during the switch, must be rejected on the basis of objective and subjective psychometric tests. There was in fact a continuous improvement. Precondition was a selection of patients with typical "endogenous" depressions and maintenance of at least constant plasma levels of the active antidepressants. In patients under the age of 65 years this can generally be achieved by switching in a ratio of 125 mg i.v. to 250 per os in the case of doxepin. Individual case studies indicated that a worsening in the patient's progress after switching was correlated with a decreasing plasma level of the active drug. Low plasma level already during the infusion period, insufficient response, and questionable compliance on oral medication were associated. Due to large interindividual differences of plasma levels by a factor of 10, measurements before and after switching are required.

Platelet serotonergic indices in major depression: up-regulation of 5-HT2A receptors unchanged by antidepressant treatment

This study examined, in the largest sample of major depressives reported so far, platelet serotonergic parameters (5-HT uptake, [3H]paroxetine binding and 5-HT2A receptors measured by [3H]LSD binding) in 60 antidepressant-free depressed patients and 40 age- and gender-matched control subjects before treatment, and in 45 major depression patients during treatment with antidepressants. We found that, at baseline, the density (Bmax) of 5-HT2A receptors was significantly higher (by 39%) in depressed patients than in controls. Suicidal patients had significantly higher Bmax values than controls or non-suicidal patients. The rate of serotonin uptake (Vmax), but not the uptake at a single concentration, was significantly higher in depressed patients, particularly in females. There was no significant difference between the Kd or Bmax of [3H]paroxetine binding in control and depressed subjects. Treatment with antidepressant drugs of different pharmacological profile had no significant effect on the density of 5-HT2A receptors, nor did the receptor number predict the response to treatment. The affinity of serotonin uptake site for 5-HT and [3H]paroxetine significantly decreased during treatment with antidepressants, particularly SSRIs. Suppression of 5-HT uptake correlated with decreases in Hamilton depression (HAMD) scores. Our data suggest that the increased density of platelet 5-HT2A receptors may be associated with untreated major depression in antidepressant-free depressed patients, in particular those with suicidal thoughts. The persistence after antidepressant treatment and clinical improvement would suggest that up-regulation of 5-HT2A receptors is a trait rather than state phenomenon. Correlation of 5-HT uptake suppression with decreases in HAMD scores suggests that serotonin uptake inhibition is a relevant factor in antidepressant drug effect and clinical improvement.

Electrocardiographic effects of fluoxetine and doxepin in patients with major depressive disorder

Cardiovascular adverse effects are amongst the most serious observed with antidepressant drugs and are often due to effects on cardiac conduction and refractoriness. However, such electrophysiologic effects may not be evident when using conventional electrocardiographic measures. Forty patients with major depressive disorder (according to DSM-III-R criteria) were enrolled in a 6-week double-blind parallel group study of fluoxetine (N = 20) or doxepin (N = 20). Cardiac conduction (QRS duration) and repolarization (corrected QT interval, QTc), were measured using signal-averaged electrocardiograms and 12-lead electrocardiogram at baseline and after 2, 4, and 6 weeks of treatment. Patients taking doxepin (mean daily dosage at 6 weeks 169 +/- 42 mg) were similar to those taking fluoxetine (37 +/- 18 mg) for demographic variables and improvement in depression scores but volunteered more side effects (p = 0.011), especially dry mouth (p < 0.001) and dizziness/lightheadedness (p = 0.005). After 6 weeks, doxepin increased heart rate (69 +/- 12 to 81 +/- 13 beats per minute; p = 0.0003) and prolonged QTc (from 417 +/- 36 to 439 +/- 28 msec; p < 0.03); overall QRS duration was not prolonged but was correlated with serum doxepin concentrations (r = 0.78, p < 0.0001). Fluoxetine had no effect on QTc (428 +/- 24 msec at baseline vs. 430 +/- 24 msec at 6 weeks) or QRS duration (97 +/- 12 msec at baseline vs. 94 +/- 12 msec at 6 weeks). The standard 12-lead electrocardiogram showed no significant change in QRS or QTc for either drug. Using a sensitive measure of electrocardiographic effects, doxepin prolongs repolarization and may slow cardiac conduction. Fluoxetine has no measurable electrocardiographic effects, which suggests an increased safety margin for cardiac adverse effects. The ability of the signal-averaged electrocardiogram to resolve small changes in the electrocardiogram is useful in the assessment of drugs with subtle electrophysiologic effects.

Predictors of outcome in panic disorder: a 5-year prospective follow-up study

A prospective 5-year follow-up study in patients with panic disorder was carried out in order to determine predictors of outcome. 50 patients presenting at an outpatient clinic for anxiety disorders were enrolled initially in a controlled treatment study using either imipramine or doxepin in addition to supportive psychotherapy and were then followed under naturalistic treatment conditions. By means of multiple stepwise regression analyses comorbidity with current depression, severity of illness and agoraphobic avoidance turned out to be the strongest predictors. These data confirm the findings of shorter-term prospective follow-up studies and of retrospective studies. In contrast to several reports, illness-related social impairment at baseline was not found to affect outcome.

Nocturnal melatonin secretion and sleep after doxepin administration in chronic primary insomnia

Nocturnal melatonin secretion and polysomnographic sleep patterns were investigated in ten patients with chronic primary insomnia (age 41.3 +/- 9.5 years) and in five healthy subject, (age 27.2 +/- 0.7 years) after either a single intravenous administration of 25 mg doxepin or placebo in a randomized, double blind, and cross-over setting. In the patient group a third session was performed after a three-week open oral treatment with 25 mg doxepin daily. The single-dose administration of doxepin did not affect plasma melatonin concentrations in either the patients on the healthy subjects. After three weeks of oral doxepin intake by the patients, the area under the curve of total nocturnal plasma melatonin concentration was significantly increased by 26% and the peak values were increased by 30%. Both after the single i.v. treatment as well as after long-term oral administration, doxepin also significantly improved sleep latency, total sleep time, and sleep efficiency in the insomniacs as well as the healthy subjects, whereas the nocturnal wake time was decreased. These findings indicate that this tricyclic antidepressant not only improves sleep and but also preserves the secretion of a hormone which is believed to play a special role in the circadian sleep-wake rhythm. Long-term doxepin treatment of chronic insomniac patients not only improves sleep but also restores nocturnal melatonin secretion in these patients.

[Anorexia nervosa beginning after the menopause]

Anorexia nervosa (AN) in older patients is not often described. We present a 70-year-old woman with AN which started at the age of 50 after her menopause. We suggest that AN starting after the menopause is a unique disturbance with characteristics different from those in younger age groups. The causes of anorexia in the older patient and its special dynamics should be recognized. It may be necessary to create a different diagnostic system and devise special treatment for AN in post-menopausal women.

A guide to the understanding and use of tricyclic antidepressants in the overall management of fibromyalgia and other chronic pain syndromes

The purpose of this review is to present relatively detailed information on the characteristics of tricyclic antidepressants, mainly amitriptyline hydrochloride and doxepin hydrochloride, for use as an integral part of the safe and effective management of fibromyalgia and, to a lesser extent, other chronic pain syndromes. Data sources include MEDLINE searches in English, relevant reference books and textbooks, my personal database and library, as well as personal clinical experience. I discuss these data with regard to the pharmacologic characteristics, mechanisms of action, adverse effects, and precautions involved with the use of tricyclic antidepressants. Additional information is given on drug selection and dosage titration. Much emphasis is placed on the fact that while tricyclic antidepressants play a major role in the management of fibromyalgia and other chronic pain syndromes, lifestyle alterations (eg. physical reconditioning and exercise), as well as behavior modification, are also vital to a successful outcome in management.

Low serum levels of tricyclic antidepressants in amitriptyline- and doxepin-treated inpatients with depressive syndromes are associated with nonresponse

Nonresponse to tricyclic antidepressant (TCA) treatment is observed in about one-third of depressed patients. The cause(s) for nonresponse - apart from disease-specific effects - might be the failure to build up sufficiently high serum TCA levels due to noncompliance, substance abuse, rapid metabolism, or low dose. We carried out a retrospective analysis relating antidepressant serum levels to patient data obtained in the naturalistic setting of the Psychiatric Hospital of the Bonn University during the introductory phase of drug-monitoring. Case reports of 110 depressed inpatients who were treated with amitriptyline or doxepin were analyzed with respect to the following: medication and comedication, daily dose, type and duration of treatment, serum TCA concentrations (analyzed by the fluorescence polarization immunoassay), age, sex, body weight, abuse of nicotine or alcohol intake, serum transaminases (ALT, alanine aminotransferase, and AST, aspartate amino transferase), gamma-glutamyltranspeptidase (gamma-GT) and creatinine, compliance, and response. The salient findings were: 1. Serum TCA concentrations increased linearly with the daily amitriptyline dose but not with that of doxepin. 2. Interindividually, there was an eight to ten-fold difference in serum TCA concentrations at steady-state with 150 mg/day of either drug; longitudinally, we observed intraindividually a coefficient of variation of 8% and 12% for amitriptyline and doxepin respectively. 3. With amitriptyline (150 mg/day), the correlation between age and serum TCA concentrations was low (r = 0.33, p < 0.055) and no correlation was found after the administration of doxepin (150 mg/day), nor was there any correlation between age and dose-adjusted serum TCA concentrations after the administration of either drug. 4. Nonresponders had significantly lower serum levels than responders. These results suggest that patients should not qualify as nonresponders unless it can be demonstrated (and it is clinically applicable) that the steady-state serum TCA levels are stable within the upper limit of the recommended therapeutic range and serum level.

A double-blind study comparing the efficacy and tolerability of mirtazapine and doxepin in patients with major depression

One hundred and sixty-three patients with major depression were randomly assigned to treatment with mirtazapine or doxepin for 6 weeks in a double-blind clinical trial. Initially, patients received mirtazapine 20 mg/day or doxepin 75 mg/day; dosages were then titrated up to a maximum of 60 mg/day and 300 mg/day, respectively. Both drugs produced considerable improvement in depressive symptoms with no statistically significant differences between the two patient groups. In the mirtazapine group only two patients prematurely terminated the study due to adverse drug experiences, as compared to six in the doxepin-treated group. Moreover, doxepin-treated patients complained more frequently of dry mouth and movement disorders. In conclusion, mirtazapine is an effective treatment for major depression and appears to offer advantages in tolerability over doxepin.

The antipruritic effect of 5% doxepin cream in patients with eczematous dermatitis. Doxepin Study Group

BACKGROUND AND DESIGN

Eczematous dermatitis is commonly characterized by intense pruritus. Current treatment modalities for this condition, regardless of its cause, are primarily directed at blunting the cutaneous inflammatory response and thereby providing relief of pruritus. To expand on our previous findings in atopic dermatitis, the present multicenter double-blind trial was conducted to evaluate the safety and antipruritic efficacy of 5% doxepin hydrochloride cream in patients with lichen simplex chronicus (n = 136), nummular eczema (n = 87), or contact dermatitis (n = 86). A total of 309 patients with moderate to severe pruritus were randomly assigned to apply either doxepin cream (n = 154) or vehicle cream (n = 155) to eczematous areas four times per day for a period of 7 days. Efficacy was assessed using a pruritus severity rating scale, a Physician's Global Evaluation for pruritus relief, and a Visual Analogue Scale for pruritus relief.

RESULTS

Twenty-four hours after initiation of treatment, and continuing throughout the remainder of the study, patients treated with doxepin cream experienced significantly greater pruritus relief than did vehicle-treated patients as determined by all efficacy parameters (P < .002). Sixty percent of doxepin-treated patients experienced pruritus relief within 24 hours. The response rate increased to 84% by conclusion of the study. As judged by significant changes (P < or = .05) occurring in at least one assessment of efficacy, doxepin cream provided pruritus relief in all forms of eczematous dermatitis that were examined. The study medication was well tolerated. The two most common adverse effects, stinging at the site of application and drowsiness, were usually transient and mild to moderate in severity.

CONCLUSION

Topical application of doxepin provides significant antipruritic activity with a favorable safety profile, suggesting a role for doxepin cream in the symptomatic treatment of pruritus associated with eczematous dermatitis.

A double-blind comparison of moclobemide and doxepin in depressed general practice patients

A total of 56 patients attending a general practitioner for treatment of depression, most of whom met the criteria for major depression, were included in this double-blind, parallel group, 6-week study, in which the selective MAO-A inhibitor moclobemide (MOC; maximum dose 600 mg) was compared with the tricyclic antidepressant doxepin (DOX; maximum dose 250 mg). Thirty patients on MOC and 23 on DOX were assessed after treatment for at least 1 week and are included in the response evaluation. Improvement was assessed primarily with the Montgomery-Asberg Depression Rating Scale (MADRS). There were only 4 drop-outs in the MOC group and three in the DOX group after 1 week. Overall improvement measures showed a nonsignificant difference in favor of DOX. Two factors were found to have prognostic significance: (1) previous or present panic attacks (10 patients in the MOC group and--by chance--only one in the DOX group) were associated with significantly lower improvement within the MOC group. Since we had no a priori hypothesis about this effect, it could be a chance finding. (2) Improvement was negatively correlated with age; this was statistically significant in the total group as well as in the MOC group, with a nonsignificant trend in the same direction in the DOX group. Side effects differed little between the two groups; only dryness of mouth appeared with markedly higher frequency in the DOX group.

A Markov process analysis comparing the cost effectiveness of maintenance therapy with citalopram versus standard therapy in major depression

The objective of this study was to demonstrate the cost effectiveness of long term maintenance treatment with citalopram versus standard therapy (defined as short term antidepressant treatment) in patients with major depression in Germany. We chose doxepin, amitriptyline and trimipramine as standard therapy because these drugs are the leading antidepressants in that country. A Markov process analysis was used to model health status and economic outcomes as they accrued over a 1-year follow-up period. The main outcome measures were time without depression, direct costs and indirect costs (work days lost). All costs were in 1993 Deutsche marks. The clinical data were obtained from the published literature and US clinical practice guidelines; the associated unit costs of the medical resources used were derived from official German tariff lists. The results show that, compared with standard therapy, long-term maintenance treatment with citalopram is associated with a mean increase in time without depression of 7.9% (8.2 vs 7.6 months). The total costs of maintenance treatment with citalopram were substantially lower than with standard therapy (DM7985 vs DM11,948 per patient per year. In addition, both the direct and indirect costs of maintenance treatment with citalopram (DM3764 vs DM4221 per patient, respectively) were lower than with standard therapy (DM4577 vs DM7371 per patient, respectively). In conclusion, the study demonstrates that one year's maintenance treatment with citalopram is both more effective and less costly than standard therapy in the treatment of patients with major depression.

Quantitative determination of E- and Z-doxepin and E- and Z-desmethyldoxepin by high-performance liquid chromatography

A high-performance liquid chromatographic (HPLC) method was developed for the quantitative, simultaneous determination of the following four compounds in serum: E-doxepin, Z-doxepin, E-desmethyldoxepin, and Z-desmethyldoxepin. A 3-microns analytical silica column (6 x 100 mm) was employed with the mobile phase 0.025 M phosphate:acetonitrile:n-nonylamine (80:20:1). This HPLC method allows for the accurate measurement of all four isomeric compounds.

Panic disorder with or without concomitant depression 5 years after treatment: a prospective follow-up

50 patients with panic disorder (30 without and 20 with concomitant depression) were enrolled in a controlled treatment study using either imipramine or doxepin in addition to supportive psychotherapy and were then studied under naturalistic treatment conditions over a 5-year period. While patients with concomitant depression scored higher in overall measures of illness severity (as measured by HAMA, HAMD and GAS), no differences were detected between the groups with regard to panic disorder symptoms and degree of impairment. Our data suggest that comorbidity of panic disorder and depression is no prerequisite for poorer long-term outcome compared with panic disorder without depression.

Does bright-light therapy influence autonomic heart-rate parameters?

30 inpatients suffering from major depression (DSM-III-R), who did not fulfill the criteria of seasonal affective disorder (SAD), were treated with either doxepin or amitripytyline as monotherapy and supportively with bright light for 14 days. From days 15 to 19, bright light was replaced by dim light. 18 drug-free control subjects underwent an analogous sequence of bright- and dim-light applications. Phototherapy was applied between 06:00 and 07:30. Heart-rate (HR) analysis was performed in the patients and control subjects before and after the 5th session of bright and dim lights, respectively. 12 patients (40%) experienced improvement of mood during bright-light therapy (group I) while 18 (60%) did not (group II). Patients of group I, who reached significantly higher scores in the seasonal pattern assessment questionnaire than patients of group II, showed an increase of the coefficient of HR variation (HRV) during deep breathing as well as an increment of the high-frequency (HF) peak of spectral analysis exclusively after the bright-light sessions. Patients of group II did not show a significant alteration of these parameters, neither under the conditions of bright-light treatment nor under dim light. The control subjects experienced an increment of the HF power exclusively after bright light. The results suggest that a distinct subgroup of patients with non-SAD major depression shows a more pronounced light-associated increment of parasympathetically controlled cardiac functions than the other depressed patients and the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Fluctuation of symptoms and social functioning in panic disorder with or without concomitant depression. A 5-year prospective follow-up

After controlled treatment with either imipramine or doxepin with additional psychotherapy, 30 patients with pure panic disorder and 20 with concomitant depression were followed under ordinary treatment conditions over a 5-year period. While the overall level of illness severity was mild in both groups (slightly worse in the group with comorbidity), social impairment as well as fluctuation of symptoms were similar in both groups. Therefore, comorbidity of panic disorder and depression does not necessarily imply a poorer outcome in a self-referred patient sample initially treated with psychotropic drugs combined with supportive psychotherapy.

[Anxiety-depressive neurosis in ambulatory treatment conditions]

A group of 48 patient was treated for fear and depressive neurosis at Psychical Health Consulting Unit. They were observed and evaluated in period from April 5th, 1990 till December 31st, 1990. The group included 32 women and 16 men. The conclusion is the women was 66.6% and the men 33.4%. 23 persons (47.9%) was treated with Doxepin and 25 persons (52.1%) was treated with Alprazolam (Xanax, Valeans). The administration of one medicine was the rule, in case of the failure a medicine was change for another one. One used also individual psychotherapy.