A double-blind study of fluvoxamine and clomipramine in the treatment of obsessive-compulsive disorder

A double-blind trial was carried out to assess the efficacy and safety of fluvoxamine, a selective serotonin reuptake inhibitor, in comparison with clomipramine, a classical tricyclic antidepressant, in the treatment of obsessive-compulsive disorder. A total of 26 individuals with obsessive-compulsive disorder and with no comorbid disorders at baseline were included in the study. The obsessive-compulsive disorder symptom severity was rated using the Yale-Brown Obsessive-Compulsive Scale and the Clinical Global Impression Scale. The primary efficacy measures indicated an equal improvement in the two groups (38% in the patients taking fluvoxamine and 40% in those taking clomipramine, as compared with baseline values), but onset was faster in the clomipramine group. Side effects, in particular anticholinergic side effects, were more prominent in the clomipramine group. The present double-blind trial confirms an equal efficacy of clomipramine and fluvoxamine in obsessive-compulsive patients. Although clomipramine had a faster onset, fluvoxamine was better tolerated, so that it seems more suitable for long-term treatment of obsessive-compulsive patients.

Considering the P450 cytochrome system as determining combined effects of antidepressants and benzodiazepines on actual driving performance of depressed outpatients

Parallel groups of depressed (DSM III-R) outpatients received moclobemide (n = 22) and fluoxetine (n = 19), double blind, for 6 weeks. Respective starting doses were 150 mg twice a day and 20 mg q.a.m. These could be doubled after 3 weeks for greater efficacy. Chronic users of benzodiazepine anxiolytics continued taking them as comedication. Therapeutic and side effects were assessed using conventional rating scales. Actual driving performance was assessed during the week before therapy and at 1, 3 and 6 weeks thereafter using a standardized test that measures standard deviation of lateral position (SDLP). Similar remissions in depressive symptoms and side effects occurred in both groups. Patients drove with normal and reliable (r = 0.87) SDLPs before treatments. Most continued to do so but a few drove with progressively rising SDLPs and the overall trends were significant in both groups (p < 0.03). A post-hoc multiple regression analysis was applied for identifying factors that correlated with SDLP in separate tests after the beginning of therapy. At 3 and 6 weeks there were significant (p < 0.03) relationships involving the same factor; patients who drove with progressively higher SDLPs appeared to be those using benzodiazepines that are metabolized by a P450 isozyme subject to inhibition by their particular antidepressant.

Emergence of kleptomania during treatment for depression with serotonin selective reuptake inhibitors

Kleptomania, one of the rare impulse-control disorders, is characterized by an irresistible impulse to steal objects not needed for personal use or monetary value. There is a comorbidity between mood disorders, eating disorders, anxiety disorders, personality disorders, and kleptomania. Several recent case reports have suggested that serotonin reuptake inhibitors could be effective in the treatment of obsessive-compulsive spectrum disorders and specifically in kleptomania. We describe three depressed patients who paradoxically experienced kleptomanic behavior during treatment with serotonin selective reuptake inhibitors.

A double-blind comparison of fluvoxamine and paroxetine in the treatment of depressed outpatients

BACKGROUND

Fluvoxamine and paroxetine, both serotonin selective reuptake inhibitors (SSRIs), were compared at two centers in a 7-week double-blind study in outpatients with major depression, diagnosed by DSM-III-R criteria.

METHOD

Sixty patients were randomly assigned to receive dosage titrated upward to between 50-150 mg/day of fluvoxamine (N = 30) or 20-50 mg/day of paroxetine (N = 30). The mean +/- SD daily dose administered at the last assessment was 102 +/- 44 mg/day for fluvoxamine and 36 +/- 13 mg/day for paroxetine. Sixteen (53%) fluvoxamine-treated patients and 10 (33%) paroxetine-treated patients were titrated to the maximum permissible dosage of either drug. Sample size was calculated to provide at least 85% power at 5% level of significance to detect at least a 1.00-point difference in mean severity of adverse events, assuming a standard deviation of 1.0.

RESULTS

Fluvoxamine and paroxetine were similarly effective in ameliorating depression as demonstrated by mean total scores of 10.9 +/- 7.3 (p < .00) and 11.5 +/- 7.4 (p < .00), respectively, in the Hamilton Rating Scale for Depression (HAM-D). Adverse events were mostly mild to moderate in severity. The most common events were headache (N = 17, 57%), nausea (N = 14, 47%), sweating (N = 10, 33%), somnolence (N = 9, 30%), diarrhea (N = 9, 30%), dry mouth (N = 8, 27%), dizziness (N = 8, 27%), and, among males, impotence (N = 3, 21%) and ejaculatory abnormality (N = 3, 21%) in the paroxetine group, and headache (N = 12, 40%), somnolence (N = 12, 40%), nausea (N = 11, 37%), dry mouth (N = 11, 37%), insomnia (N = 9, 30%), asthenia (N = 7, 23%), and dyspepsia (N = 7, 23%) in the fluvoxamine group. The only statistically significant difference between treatment groups was for sweating (33% paroxetine vs. 10% fluvoxamine, p = .028).

CONCLUSION

Observed differences in some side effects, although not statistically significant, indicate that when a patient has difficulty tolerating one SSRI, the clinician may choose to change to a different agent within the same class.

Personality disorder scores improve with effective pharmacotherapy of depression

INTRODUCTION

We hypothesized that the probability of personality disorder ('PROB') predicted by the Temperament and Character Inventory ('TCI') would decline after successful pharmacotherapy of depression.

METHODS

We administered a computerized version of the TCI to 15 patients with DSM-III-R major depression, before and after treatment with serotonergic antidepressants.

RESULTS

PROB declined from 58.9% +/- 18.0% to 42.4% +/- 22.8% (P < 0.003), due to a significant increase in the Self-Directedness scale. This change in PROB correlated with improvement in self-rated severity of depression (P < 0.02).

CONCLUSION

TCI prediction of personality disorder is susceptible to state effects of depression.

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.

Long-term pharmacotherapy of obsessive-compulsive disorder: a double-blind controlled study

The aim of this study was to investigate whether obsessive-compulsive patients previously treated successfully with clomipramine or fluvoxamine could tolerate reduction of the daily dosage without worsening of the clinical condition. Thirty informed obsessive-compulsive patients, given a diagnosis according to DSM-III-R criteria, were recruited consecutively into the study. Patients were blindly assigned to one of the groups of treatment with different rates of reduction of the previously effective daily drug dosage: group 1 (control group, no reduction), group 2 (reduction of 33-40%), and group 3 (reduction of 60-66%). The entire study lasted 102 days. From baseline to the end of the study, the clinical condition was evaluated by the administration of standardized tests (Yale-Brown Obsessive-Compulsive Scale, Hamilton Rating Scale for Depression, Clinical Global Impression [CGI] scale), and blood samples were collected for plasma drug level determinations. The criterion for discontinuation of the study was the worsening of obsessive-compulsive symptoms, arbitrarily defined by an increase of > 5% from the baseline total Yale-Brown Obsessive-Compulsive Scale score, as measured in two successive assessments, and a worsening of global clinical condition as measured by the CGI scale. The main result of the study was borne out from the survival analysis. There were no significant differences in the cumulative proportion of patients from each group of treatment who did not worsen during the 102 days of observation. This preliminary result, which needs to be confirmed in larger samples, suggests that long-term maintenance therapy for obsessive-compulsive disorder might be provided with lower dosages of the antiobsessional drug, with clear advantages for tolerability and compliance.

The serotonin syndrome and psychosis-like side-effects of fluvoxamine clinical use--an estimation of incidence

OBJECTIVE

The incidence of the serotonin syndrome or serotonin-syndrome-like side effects during treatment with the selective serotonin reuptake inhibitor (SSRI) fluvoxamine should be evaluated.

METHOD

200 inpatients treated for the first time with fluvoxamine were prospectively evaluated for the occurrence of a serotonin syndrome over a period of 8200 treatment days. Retrospective follow-up data of outpatient treatment covered 8891 days.

RESULTS

No full-blown serotonin syndrome occurred, but 3 patients developed a reversible change of mental status with insomnia, agitation, confusion and incoherent thoughts without other symptoms of the serotonin syndrome.

CONCLUSIONS

It is concluded that the occurrence of a potentially lethal serotonin syndrome is rare in fluvoxamine treatment psychosis-like syndromes as a side effect of serotonergic stimulation might occur. In the investigated sample the rate was 0.006-0.04 per 100 treatment days.

[Maprotiline versus fluvoxamine: comparison of their effects on the hypothalamo-hypophyseal-thyroid axis]

The TRH test has been used in psychiatry these last 20 years. One of the most promising results is that concerning the possibility to use it to identify the best moment to stop a treatment after clinical recovery of the depressive episode. For that it is necessary to demonstrate an absence of intrinsic action of antidepressants on the HPT axis physiology. This overt, randomized study has compared the actions on T3, T4, basal TSH and its response to the TRH test after 75 mg/day of maprotiline and 100 mg/day of fluvoxamine, both administrated in depressed patients during 28 days. Forty patients (20 men and 20 women) were studied, 20 patients per treatment. The inclusion criteria were those of DSM III-R for major depression and dysthymia as well a minimum score of 25 at MADRS scale. Blood samples for T3, T4 and basal TSH dosages were made before TRH intranasal administration (2 mg) at days 1 and 28 of the treatment. We haven't observed any difference before treatment between the 2 groups for clinical and biological studied parameters. After treatment both antidepressants produced equivalent improvement of depression evaluated by MADRS (fluvoxamine:dMADRS = 16.95 +/- 7.11; maprotiline: dMADRS = 17.10 +/- 6.84. t = 0.07, NS). T3 and T4 variations between the beginning and the end of the study weren't also significantly different between the 2 groups. Basal TSH was increased in the maprotiline group but decreased in the fluvoxamine group resulting in a significant difference (fluvoxamine: dTSH = 0.31 +/- 0.76 mUI/l. Maprotiline : dTSH = -0.23 +/- 0.66 mUI/l. t = 2.40, p < 0.02). The TSH response to TRH was decreased in the fluvoxamine group (ddTSH = 0.24 +/- 6.65 mUI/l. dAUC = 103.98 +/- 596.84 mUI/l) while it was increased in the maprotiline group (ddTSH = -3.59 +/- 5.88 mUI/l. dAUC = -355.80 +/- 505.67 mUI.min/l). The difference between the 2 treatments was not significant when evaluated by ddTSH (t = 1.53, NS) but it became significant if evaluated by dAUC (t = 2.63, p < 0.01). As we could demonstrate an absence of influence of the clinical evolution between both groups in the hormonal variations observed, we concluded to a intrinsic difference action on HPT axis between fluvoxamine and maprotiline. This difference could be linked to the different aminergic action of these 2 antidepressants.

Relationship between fluvoxamine pharmacokinetics and CYP2D6/CYP2C19 phenotype polymorphisms

OBJECTIVE

The purpose of this study was to investigate whether the disposition of fluvoxamine is associated with the CYP2D6 and CYP2C19 phenotype polymorphisms.

METHODS

The serum concentration of fluvoxamine was followed for 48 h after oral administration of a single dose of 50 mg fluvoxamine to five poor metabolizers of the CYP2D6 test drug dextromethorphan, five poor metabolizers of the CYP2C19 test drug mephenytoin, and five extensive metabolizers of both test drugs.

RESULTS

Poor metabolizers of dextromethorphan had significantly higher areas under the serum concentration-time curve than extensive metabolizers of dextromethorphan (mean 1.31 vs 1.00 mumol.h.l-1). There were no differences between poor and extensive metabolizers of mephenytoin (mean, 1.00 vs 1.15 mumol.h.l-1).

CONCLUSION

The results are consistent with a possible minor to moderate role of CYP2D6, but not CYP2C19, in fluvoxamine metabolism.

SSRI-induced sexual dysfunction: fluoxetine, paroxetine, sertraline, and fluvoxamine in a prospective, multicenter, and descriptive clinical study of 344 patients

The authors analyzed the incidence of sexual dysfunction (SD) with different selective serotonin reuptake inhibitors (SSRIs; fluoxetine, fluvoxamine, paroxetine, and sertraline) and hence the qualitative and quantitative changes in SD throughout time in a prospective and multicenter study. Outpatients (192 women and 152 men; age = 39.6 +/- 11.4 years) under treatment with SSRIs were interviewed with an SD questionnaire designed for this purpose by the authors and that included questions about the following: decreased libido, delayed orgasm or anorgasmia, delayed ejaculation, inability to ejaculate, impotence, and general sexual satisfaction. Patients with the following criteria were included: normal sexual function before SSRI intake, exclusive treatment with SSRIs or treatment associated with benzodiazepines, previous heterosexual or self-erotic current sexual practices. Excluded were patients with previous sexual dysfunction, association of SSRIs with neuroleptics, recent hormone intake, and significant medical illnesses. There was a significant increase in the incidence of SD when physicians asked the patients direct questions (58%) versus when SD was spontaneously reported (14%). There were some significant differences among different SSRIs: paroxetine provoked more delay of orgasm or ejaculation and more impotence than fluvoxamine, fluoxetine and sertraline (chi 2, p < .05). Only 24.5% of the patients had a good tolerance of their sexual dysfunction. Twelve male patients who suffered from premature ejaculation before the treatment preferred to maintain delayed ejaculation, and their sexual satisfaction, and that of their partners, clearly improved. Sexual dysfunction was positively correlated with dose. Patients experienced substantial improvement in sexual function when the dose was diminished or the drug was withdrawn. Men showed more incidence of sexual dysfunction than women, but women's sexual dysfunction was more intense than men's. In only 5.8% of patients, the dysfunction disappeared completely within 6 months, but 81.4% showed no improvement at all by the end of this period. Twelve of 15 patients experienced total improvement when the treatment was changed to moclobemide (450-600 mg/day), and 3 of 5 patients improved when treatment was changed to amineptine (200 mg/day).

Fluvoxamine: a review of the controlled trials in depression

Fluvoxamine, a serotonin selective reuptake inhibitor, has been available as an antiobsessional agent in the United States since 1995. However, it has been utilized as an effective antidepressant for many years in various European countries. The controlled trials of fluvoxamine in the pharmacotherapy of depression are reviewed. The drug compares well with a variety of other antidepressants. It appears safe and well tolerated in daily doses of 50 to 300 mg. The most common adverse events are gastrointestinal complaints, particularly nausea. Initiating pharmacotherapy at lower doses and increasing over the period of 1 to 2 weeks minimizes this discomfort.

[A comparative clinical evaluation of the antidepressive activity of fluoxetine and fluvoxamine]

Comparative study of the peculiarities of clinical action of fluoxetine and fluvoxamine in 65 patients with endogenous depressions revealed their high efficiency (in 74.3% and 64.3% respectively). Fluoxetine was characterised by predominance of a stimulating effect from the first days of treatment as well as by relatively late manifestation of very thymoleptic and tranquilizing impact (during 3-4 weeks). Fluvoxamin displayed relatively uniform occurrence of separate clinical effects together with predominance and early appearance of antidepressive influence. On the basis of the comparison of the peculiarities of either clinical action of fluoxetine and fluvoxamin or their side effects with those of traditional antidepressive drugs (amitryptilin and ludiomil) the preferable indications for their prescription were determined. Thus fluoxetine was very good in treatment of apathetic-adynamic depressions while fluvoxamin was recommended for therapy of anxious and melancholic depressions. Antidepressants studied were ranked in the following way in terms of decrease of sedative effect and increase of stimulating action: amitryptilin, fluvoxamin, ludiomil, fluoxetine. The proper thymoleptic effect of fluoxetine and fluvoxamin exceeded the same effect of amitryptilin and ludiomil.

A comparison of the post-marketing safety of four selective serotonin re-uptake inhibitors including the investigation of symptoms occurring on withdrawal

1. We have addressed the question of whether there is a 'serotonin withdrawal syndrome' by analysis of spontaneous reports of suspected adverse drug reactions (ADRs) associated with four SSRIs. A comparison of the post-marketing safety profiles of the four SSRIs has also been made. 2. The UK database of ADRs was examined for reactions associated with fluoxetine, fluvoxamine, paroxetine and sertraline. The safety profiles of the four SSRIs were similar. However, withdrawal reactions with paroxetine constitute a greater proportion of reports (5.1%) than with the other SSRIs (0.06-0.9%). They have been reported more often with paroxetine (0.3 reports per thousand prescriptions) than with sertraline and fluvoxamine (0.03), and least often with fluoxetine (0.002). 3. Descriptions of withdrawal reactions received and further details of 217 reports of withdrawal reaction with paroxetine obtained by mailing a questionnaire to the reporting doctor were examined. Withdrawal symptoms were diverse but most commonly comprised dizziness, paraesthesia, tremor, anxiety, nausea and palpitation. They usually occurred after 2 days and lasted for an average of 10 days. There was no evidence of a physical drug dependency syndrome. 4. Symptoms different from the previous depressive illness occur after discontinuing an SSRI, and are reported most often with paroxetine. Paroxetine is the most pharmacologically specific of the SSRIs, but it is not clear whether the reactions constitute a 'serotonin withdrawal syndrome'.

Non-response to citalopram in depressive patients: pharmacokinetic and clinical consequences of a fluvoxamine augmentation

The effect of comedication with fluvoxamine on the plasma concentrations of the enantiomers of citalopram and its metabolites in dextromethorphan/mephenytoin phenotyped patients pretreated with citalopram (CIT) was studied: seven female patients (45.1 +/- 13.9 years) suffering from a major depressive episode [ICD-10: F32.2 (n = 3 patients), F33.2 (n = 2), F32.10 (n = 1) or F32.11 (n = 1)], who were non-responders to a 3-week treatment with 40 mg/day CIT (From day-21 to day 0) (day 0: MADRS score > or = 12), were co-medicated for another 3 weeks with fluvoxamine (50 mg/day from day 1-7, 100 mg/day from day 14-21). All patients were extensive metabolizers of mephenytoin (CYP2C19) and dextromethorphan (CYP2D6), except one patient, who had a genetic deficiency of CYP2D6. There was a significant increase of the plasma concentrations of S- and R-citalopram from day 0 (27 +/- 14 micrograms/l and 55 +/- 23 micrograms/l, respectively) to day 21 (83 +/- 38 micrograms/l and 98 +/- 44 micrograms/l, respectively), after addition of fluvoxamine (P < 0.02, for each comparison), and the mean ratio S/R-citalopram increased from 0.48 to 0.84. S-Citalopram inhibits more potently 5-HT uptake than R-citalopram: therefore, fluvoxamine increases the pharmacologically more active S-citalopram with some stereoselectivity. According to a previous in vitro study, this pharmacokinetic interaction occurs on the level of CYP2C19, but also of CYP2D6 and CYP3A4 which, in contrast to CYP1A2, contribute to the N-demethylation of citalopram and which are stereoselectively inhibited by fluvoxamine. All but one patient showed clinical improvement by a decrease of the MADRS score by at least 50% and a final score < or = 13 (mean +/- SD: day 0:30.6 +/- 9.2; day 21:11.0 +/- 6.5). Some patients showed minor symptoms, such as nausea and tremor, but the combined treatment was generally well tolerated.

[Serious drug interaction between clozapine-Leponex and fluvoxamine-Fevarin]

A 67 year-old woman in steady-state treatment with clozapine 150 mg/24 h was co-medicated with 100 mg/24 h of fluvoxamine. During the next months the patient suffered from nausea and occasionally vomited, but these symptoms were ascribed to fluvoxamine, and as she mentally improved, both treatments were continued. Two months after the start of fluvoxamine her serum clozapine concentration was 7570 nmol/l or 7.5 fold higher than before fluvoxamine was added. The woman was admitted to hospital, suffering from abdominal pain, dehydration and fever (38.5 degrees C). Serum creatinine concentration was increased, but normalized during hydration. After 18 days care the woman felt well and was discharged from hospital. The case report shows that certain combinations of selective serotonin reuptake inhibitors and neuroleptic drugs should either be avoided or the serum concentrations of the drugs closely followed.

[Sexual dysfunction secondary to SSRIs. A comparative analysis in 308 patients]

The authors analyze the incidence of sexual dysfunction (SD) with different SSRIs (Fluoxetine, Fluvoxamine, Paroxetine and Sertraline) and hence the qualitative and quantitative changes in SD throughout time 308 outpatients (169 women, 139 men; mean +/- SD age = 41 +/- 7) under treatment with SSRIs were interviewed with an SD questionnaire designed for this purpose by the authors including questions about the following items decreased libido, delayed orgasm or anorgasmia, delayed ejaculation inability to ejaculation, impotence and general sexual satisfaction. Patients with the following criteria were included: normal sexual function before SSRIs intake, exclusive treatment with SSRIs or associated with benzodiazepines, previous heterosexual or self-orone current sexual practices. We excluded patients with previous sexual dysfunction, association of SSRIs with neuroleptics, recently hormone intake and significant medical illnesses.

RESULTS

There is a significant increase in the incidence of SD when the physicians ask the patients direct questions (55.29%) versus spontaneous SD reported (14.2%). There are some significant differences among different SSRIs paroxetine provoked more delay of orgasm/ejaculation and more impotence than fluvoxamine, fluoxetine and sertraline (Chi square p < 0.05). Only 22.6% of the patients had a good tolerance about their sexual dysfunction. SD has positive correlation with the dose. The patients experienced substantial improvement in sexual function when the dose was diminished or the drug was withdrawn. Men showed more incidence of sexual dysfunction than women but women's sexual dysfunction was more intense than men. Seven of nine patients (77.7%) experienced total improvement when the treatment was changed to Moclobemide (450 mg/day) and two of four patients (50%) improved when treatment was changed to Amineptine.

Movement disorders associated with the serotonin selective reuptake inhibitors

BACKGROUND

To review the case reports and case series of movement disorders ascribed to the use of serotonin selective reuptake inhibitors (SSRIs).

METHOD

Reports of SSRI-induced extrapyramidal symptoms (EPS) in the literature were located using a MEDLINE search and review of bibliographies.

RESULTS

Among the 71 cases of SSRI-induced EPS reported in the literature, the most common side effect was akathisia (45.1%), followed by dystonia (28.2%), parkinsonism (14.1%), and tardive dyskinesia-like states (11.3%). Among patients with Parkinson's disease treated with SSRIs, there were 16 cases of worsening parkinsonism. Patients who developed dystonia, parkinsonism, or tardive dyskinesia were older on average than patients with akathisia; 67.6% of affected patients were females. Fluoxetine, the most commonly prescribed SSRI to date, was implicated in 53 (74.6%) of cases of SSRI-induced EPS. Several reports (57.7%) were confounded by the concomitant use of other medications that can contribute to the development of EPS.

CONCLUSION

SSRI-induced EPS are probably related to agonism of serotonergic input to dopaminergic pathways within the CNS. Several patient-dependent and pharmacokinetic variables may determine the likelihood that EPS will emerge. Although these side effects are infrequent, clinicians should be alert to the possibility of their occurrence.

Serotonin reuptake inhibitor withdrawal

We studied reported withdrawal symptoms in a retrospective chart review of 352 patients treated in an outpatient clinic with the nonselective serotonin reuptake inhibitor clomipramine or with one of the selective serotonin reuptake inhibitors (SSRIs), fluoxetine, fluvoxamine, paroxetine, or sertraline. In 171 patients who were supervised during medication tapering and discontinuation, the most common symptoms were dizziness, lethargy, paresthesia, nausea, vivid dreams, irritability, and lowered mood. When patients with at least one qualitatively new symptom were defined as cases, these symptoms occurred significantly more frequently in patients who had been treated either with one of the shorter half-life SSRIs, fluvoxamine or paroxetine (17.2%), or with clomipramine (30.8%), than in patients taking one of the SSRIs with longer half-life metabolites, sertraline or fluoxetine (1.5%). The rate was not significantly different between the different shorter half-life treatments. Cases treated with fluvoxamine or paroxetine had received a significantly longer period of treatment (median 28 weeks) than noncases (16 weeks), but there were no significant associations with age or with diagnostic grouping. There was a trend toward an association with male sex. The majority of cases occurred despite slowly tapered withdrawal. Symptoms persisted for up to 21 days (mean = 11.8 days) after onset. These symptoms were relieved within 24 hours by restarting the medication, but were not relieved by benzodiazepines or by moclobemide. A role has been suggested for serotonin in coordinating sensory and autonomic function with motor activity. We suggest that this may lead to useful hypotheses about the pathophysiology of withdrawal symptoms from serotonin reuptake inhibitors.

A comparison of fluvoxamine and fluoxetine in the treatment of major depression

This randomized, double-blind, parallel-group design study of 100 outpatients with major depressive disorder is the first study in the United States to compare the efficacy and tolerability of fluvoxamine (100-150 mg/day) and fluoxetine (20-80 mg/day). After a variable, single-blind, washout period, patients were randomized to receive either fluvoxamine (51 patients) of fluoxetine (49 patients) for 7 weeks. Efficacy was assessed with the 21-item Hamilton Rating Scale for Depression (HAM-D), and Clinical Global Impressions scale for severity and improvement. Eighty-four percent of each treatment group completed the study with each group having a mean score at end point of less than 10. Both groups demonstrated a 60% improvement in HAM-D scores over the 7-week trial. There were no statistically significant differences observed between the two groups on any efficacy parameter. The medications were well tolerated, with only two patients in each group who were terminated because of side effects. There were differences in the side-effect profiles, with fluvoxamine being associated with less nausea than fluoxetine. In summary, fluvoxamine and fluoxetine were equally effective in reducing depressive symptoms, but the two drugs displayed slightly different side-effect profiles.

[Reports of suspected side effects of selective serotonin reuptake inhibitors in Belgium and The Netherlands]

OBJECTIVE

To study the adverse drug reaction (ADR) profile of selective serotonin re-uptake inhibitors (SSRI) in Belgium and the Netherlands.

DESIGN

Descriptive study.

SETTING

The Belgian Pharmacovigilance Centre and the Dutch Drug Safety Unit.

METHOD

All adverse reactions of fluoxetine, fluvoxamine, paroxetine and sertraline, reported between the moment of registration of these drugs and January 1st 1995, were assessed for causality. Possible, probable and certain adverse reactions were counted per drug and per country.

RESULTS

At the national monitoring centres of Belgium and of the Netherlands adverse reactions were reported 78 and 537 times, respectively. Approximately 30% of the adverse reactions were well-established. Approximately 60% of the reactions were poorly documented or not serious. Less than 1% of the adverse reactions reported in Belgium and approximately 13% of the reactions reported in the Netherlands, were less established and/or serious. These reactions were: movement disorders and extrapyramidal reactions, convulsions, galactorrhoea, hyponatraemia and syndrome of inappropriate antidiuretic hormone secretion, and purpura.

CONCLUSION

The ADR profile was compatible with the ADR profile in the medical literature, but not all ADR were similarly represented in the product information of the different SSRI. More adverse reactions were reported in the Netherlands than in Belgium.

Digital infarction in a patient with Raynaud's phenomenon associated with treatment with a specific serotonin reuptake inhibitor. A case report

The authors report the worsening of preexisting Raynaud's phenomenon during treatment of depression with a selective serotonin reuptake inhibitor, fluvoxamine.

Selective serotonin reuptake inhibitors (SSRIs) in the treatment of elderly depressed patients: a qualitative analysis of the literature on their efficacy and side-effects

A qualitative analysis of studies on the efficacy and side-effects of selective serotonin reuptake inhibitors (SSRIs) for the treatment of elderly people with depression is presented. Only placebo-controlled or comparison studies of SSRI versus other antidepressants were included. The description and methodological quality of the analysed studies were important criteria in the outcome of the analysis. Quality was assessed by means of a blinded review approach. After excluding duplicate publications, 16 studies were analysed, of which six turned out to be of good quality. The results indicated that at the end of the treatment periods (4-8 weeks) all antidepressants were equally effective. Side-effects occurred less frequently with SSRIs than with tricyclics (TCAs), and different side-effect profiles were found. Significantly fewer SSRI-treated patients than TCA-treated patients dropped out both overall and due to side-effects.

Suicidal risk during controlled clinical investigations of fluvoxamine

BACKGROUND

Suicide is a serious risk factor in major depressive disorder. Paradoxical emergence of suicidal ideation or behavior during antidepressant treatment has been reported in isolated cases. An evaluation was undertaken to assess the risk of suicidality during treatment with fluvoxamine, a serotonin selective reuptake inhibitor.

METHOD

Meta-analyses were conducted on pooled data from double-blind, randomized, placebo-controlled, parallel-group clinical trials. The primary outcome measure was the suicide item of the Hamilton Rating Scale for Depression. Tests for emergence of substantial suicidal ideation and improvement or worsening in suicidal ideation were performed using the Mantel-Haenszel adjusted incidence difference. The Breslow-Day test was used to test for lack of homogeneity across trials. Secondary analysis, which consisted of Pearson's chi-square test, was used to confirm the Mantel-Haenszel result.

RESULTS

In comparison to placebo, fluvoxamine was associated with significantly greater improvement in suicidal ideation (p = .01) and significantly less worsening of suicidal ideation (p < .01). No differences were found in the emergence of substantial suicidal ideation.

CONCLUSION

These findings demonstrate that fluvoxamine is not associated with an increased risk of emergence of substantial suicidal thoughts among depressed patients. On the contrary, the results are suggestive of a protective effect of fluvoxamine upon the risk of suicidal ideation.

Efficacy and tolerability of citalopram in comparison with fluvoxamine in depressed outpatients: a double-blind, multicentre study. The LUCIFER Group

In 16 depression clinics in hospitals and outpatient facilities in the Netherlands, a study was performed to evaluate and compare the efficacy and tolerability of citalopram and fluvoxamine and to determine the difference in the incidence of gastrointestinal side-effects. A total of 217 patients with a depressive disorder (DSM-III-R criteria) and a score of at least 16 on the Hamilton rating scale for depression were randomized to treatment. The results of this study indicate that the two drugs are equally effective. The adverse events occurring during treatment show a similar pattern between the two drugs, but citalopram is better tolerated than fluvoxamine. Citalopram induces fewer gastrointestinal adverse events compared with fluvoxamine. However, this did not affect the drop-out rates.

Hyponatremia and the syndrome of inappropriate secretion of antidiuretic hormone associated with the use of selective serotonin reuptake inhibitors: a review of spontaneous reports

OBJECTIVE

To review reported cases of hyponatremia and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) associated with the use of selective serotonin reuptake inhibitors (SSRIs).

DATA SOURCES

A search of MEDLINE for reports of hyponatremia and SIADH associated with the use of fluoxetine, fluvoxamine, paroxetine or sertraline published between January 1980 and May 1995. Unpublished reports of cases were requested from the pharmaceutical industry, the Ontario Medical Association, the Health Protection Branch of Health Canada, the US Food and Drug Administration and the World Health Organization.

DATA SELECTION AND EXTRACTION

Spontaneous reports from postmarketing surveillance.

DATA SYNTHESIS

A total of 736 cases of hyponatremia [corrected] and SIADH associated with SSRI use were reported. Fluoxetine was involved in 554 (75.3%) of the cases, paroxetine in 91 (12.4%), sertraline in 86 (11.7%) and fluvoxamine in 11 (1.5%). Reports of 30 cases were published. The remaining 706 cases were reported to monitoring bodies and the pharmaceutical industry. According to information in the published reports, the median time to onset of hyponatremia was 13 days (range 3 to 120 days). Most (83%) of the published cases involved patients 65 years of age or more, as compared with 74% of the unpublished cases.

CONCLUSION

Elderly people may be at increased risk for hyponatremia associated with SSRI use. Physicians caring for elderly patients should be aware of this potentially serious but reversible adverse effect. Further research is required to determine the incidence of this adverse effect, the relative risk of hyponatremia and SIADH in different age groups and the risk associated with different SSRI drugs.

Antidepressant-induced hypomania in obsessive-compulsive disorder

Out of ten consecutive patients with DSM-III-R obsessive-compulsive disorder without any previous history of bipolarity, three patients showed antidepressant-induced hypomania (clomipramine, one patient; fluvoxamine, two patients) within the first 5 to 8 weeks of the drug treatment. These data support the previous results on a strong association between obsessive-compulsive disorder and bipolar affective illness.

A risk-benefit assessment of drugs used in the management of obsessive-compulsive disorder

Established efficacy and tolerability in large multicentre controlled studies have made serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SRIs) the mainstay of monotherapy for adult obsessive-compulsive disorder (OCD). When compared with the selective serotonin reuptake inhibitors (SSRIs), the tricyclic compound clomipramine has a higher incidence of adverse effects but is well tolerated by most OCD patients and may confer the best overall antiobsessional effects. Consideration of specific adverse effect profiles, special patient population characteristics, drug interactions and relative cost of the various agents may direct clinicians in choosing the most appropriate first-line drug. Alternative agents as monotherapies have been explored, but none has consistently proven effective to date. Investigations of SRI augmentation with serotonin-enhancing agents have also failed to demonstrate substantial benefits for treatment-refractory OCD. Combination treatment with SRIs and dopamine receptor antagonist drugs appears to provide an improved response for the subpopulation of OCD patients who have comorbid 'tic-spectrum' disorders, though large-scale studies of the efficacy and tolerability of these regimens are not yet available.

Disposition of fluvoxamine in humans is determined by the polymorphic CYP2D6 and also by the CYP1A2 activity

BACKGROUND

Fluvoxamine is a selective serotonin reuptake inhibitor used widely in the treatment of depression and other psychiatric diseases, but little is known about the specific isozymes involved in its metabolism. This study investigated the relationship between fluvoxamine disposition and the polymorphic CYP2D6 and the polycyclic aromatic hydrocarbon (as contained in cigarette smoke) inducible CYP1A2.

METHODS

Fluvoxamine (50 mg orally) was given to 10 extensive metabolizers and four poor metabolizers of debrisoquin, and concentrations were assessed in plasma by high performance liquid chromatography. Five of the extensive metabolizers and one of the poor metabolizers were smokers of more than 10 cigarettes per day. The CYP1A2 activity was determined by means of a urinary caffeine test.

RESULTS

Compared with nonsmoking extensive metabolizers, nonsmoking poor metabolizers had a statistically significant (p = 0.02, Mann-Whitney U test) about twofold higher maximum plasma concentration, longer half-life, and fivefold lower oral clearance of fluvoxamine. The oral clearance of fluvoxamine correlated to the CYP1A2 index in the 14 subjects (rs = 0.58; p < 0.05; Spearman rank correlation).

CONCLUSION

The disposition of fluvoxamine in humans is associated with the polymorphic CYP2D6 activity, but CYP1A2 also seems to be involved.

A double-blind comparative study of brofaromine and fluvoxamine in outpatients with panic disorder

Previous studies have shown that both selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs) are effective in the treatment of panic disorders (PD). In this study, the SSRI fluvoxamine (Fluv) was compared with the MAO-A-I brofaromine (Brof). Thirty patients with the diagnosis of PD with or without agoraphobia were treated with either Fluv or Brof (150 mg daily) in a double-blind design. After 12 weeks of treatment, 93% of the Brof group and 87% of the Fluv group considered themselves much or very much improved. Taking a reduction in the Hamilton Rating Scale for Anxiety score of 50% or more, 33% of the Fluv patients and 47% of the Brof patients were responders to treatment. After an increase in anxiety in the 1st week, which was more severe in Fluv-treated patients than for Brof, a clinically relevant decrease in anxiety symptoms and reduction in panic attacks and avoidance behavior was observed. There was no significant difference between the treatment groups. The most prominent side effects were middle-sleep disturbance (Brof), tiredness (Fluv), and nausea after taking the medication (Brof and Fluv). During a double-blind follow-up period of another 12 weeks, a further improvement was found in both treatment groups without significant differences between the two groups. The selective and reversible MAO-A-I brofaromine and the SSRI fluvoxamine are equally effective in the treatment of PD. Both compounds lead to a reduction in the number of panic attacks and a subsequent reduction in agoraphobic avoidance.

[Evaluating quality of life of depressed patients in ambulatory care treatment]

This study concerns 1257 depressed outpatients, whose quality of life was evaluated before the beginning of a fluvoxamin treatment and six weeks later. We used the "Subjective Quality of Life Profile", questionnaire which has been previously validated in somatic diseases. The validation performed with these depressed patients appears to be quite satisfactory. The results provide a good description of the patients before the treatment: they seem to be indifferent to most domains by their health which they describe as very unsatisfactory. Contrasting with these results, patients' expectations appear to be very important in most domains, and the greater these initial expectations the poorer the evolution of their quality of life. After six weeks the patients' improvement in their quality of life is quite obvious especially in the somatic area. Another interesting finding concerns the high initial level of patients' expectations as compared with patients having somatic diseases. The higher these expectations, the poorer the outcome. It thus appears that a very sensitive self-questionnaire dealing with patients' quality of life in depression is available.

Responders and non-responders to drug treatment in social phobia: differences at baseline and prediction of response

Differences between responders and non-responders to drug therapy were investigated in social phobia. Two previously published studies were pooled to obtain data of 30 patients who were treated for 12 weeks with brofaromine or fluvoxamine. Four criterion variables were used to divide patients in responders and non-responders. Depending on the criterion variable up to 72% of the patients were regarded as responders. Non-responders differed from responders in that they had a higher heart rate and a higher blood pressure. They were also characterized by higher scores on several psychometric scales, indicative of illness severity.

Effect of dropouts in a longitudinal study: an application of a repeated ordinal model

An analysis is presented of a longitudinal study of fluvoxamine, an antidepressant drug, with ordinal responses, regressed on a combination of discrete and continuous covariates and with a substantial proportion of dropouts. Classical methods, such as weighted least squares (SAS procedure CATMOD) and logistic regression, are not suitable for the analysis of such data. Instead, we illustrate how a recently introduced model can be used to solve most of the problems posed. The method is likelihood-based and is an extension of the bivariate Dale model to an arbitrary number of outcomes. The method is suitable for several types of designs commonly employed in clinical trials.

Fluvoxamine versus imipramine and placebo: a double-blind comparison in depressed patients

Approximately 20 million patients suffer from major depressive disorder each year, indicating a need for antidepressant agents that are synonymous with effectiveness, tolerability and patient compliance. The authors examined the effects of fluvoxamine, a selective serotonin reuptake inhibitor, in the treatment of outpatients meeting DSM-III-R criteria for major depressive disorder. A randomized, double-blind, parallel group, placebo- and imipramine-controlled single center study was conducted in 150 outpatients. Patients were randomized to receive up to 150 mg/day of fluvoxamine as a single bedtime dose, 240 mg/day of imipramine on a twice-daily (BID) schedule, or placebo for six weeks. Efficacy measurements included HAM-D, MADRS, CGI, Raskin-Covi and SCL-56 scales. The HAM-D total score indicated that both active treatment groups showed significantly (p < or = 0.05) greater therapeutic benefit than did placebo. Severely depressed patients (HAM-D > or = 30) responded better to fluvoxamine in five of six measures. Side-effects from fluvoxamine were similar to those reported for other selective serotonin reuptake inhibitors (nausea, somnolence) and were well tolerated. Imipramine was associated with anticholinergic effects such as dry mouth and dizziness. The pharmacokinetic properties of fluvoxamine which allow the drug to be administered as a single daily dose should aid in the maintenance of patient compliance, while offering significant clinical benefit in the improvement of depressive symptoms.

Fluvoxamine and lithium in long-term treatment of unipolar subjects with high recurrence rate

We prolonged from 24 to 36 months a follow-up study of unipolar subjects with a high probability of recurrence treated with fluvoxamine (n = 32) or lithium (n = 32). During the extra observation period, two patients developed mania and were excluded from the study. There were no further recurrences in either the lithium or the fluvoxamine group. In our sample, previous prescriptions of tricyclics seem to predict a worse prognosis.

Fluvoxamine maleate in the treatment of depression: a single-center, double-blind, placebo-controlled comparison with imipramine in outpatients

The efficacy and safety of fluvoxamine maleate, a selective serotonin reuptake inhibitor, was compared with placebo and imipramine in patients with major depressive disorder. Previous literature has cited a dose range of 100 to 300 mg/day of fluvoxamine maleate for the treatment of major depression; however, this study demonstrates that a dose range of 50 to 150 mg/day is as effective as imipramine (80-240 mg/day). After a 1- to 2-week, single-blind, placebo washout phase, 150 depressed outpatients were randomized to double-blind treatment with fluvoxamine maleate (50-150 mg/day), imipramine (80-240 mg/day), or placebo for 6 weeks. Fluvoxamine produced a significant therapeutic benefit over placebo (p < or = 0.05) as assessed by the total score on the Hamilton Rating Scale for Depression; imipramine (80-240 mg/day) produced similar results. The secondary outcome variables (i.e., Clinical Global Impression severity of illness item and 56-Item Hopkins Symptom Checklist depression factor) also showed significant differences between fluvoxamine maleate and placebo during three of the four final weeks of the study. Both fluvoxamine maleate and imipramine appeared to be safe and well tolerated by the majority of patients. As expected from the pharmacology of these agents, the imipramine groups reported more anticholinergic effects (dry mouth, dizziness, and urinary retention) and electrocardiographic effects, whereas the fluvoxamine group reported more nausea, somnolence, and abnormal ejaculation. The majority of these adverse events were mild to moderate and, with the exception of dry mouth (imipramine) and abnormal ejaculation (fluvoxamine), were transient. The data clearly demonstrate the antidepressant activity and tolerability of fluvoxamine maleate (50-150 mg/day) as compared with placebo; it is also as effective as the tricyclic antidepressant imipramine (80-240 mg/day) in patients with major depressive disorder.

Serotonin syndrome and fluvoxamine: a case study

OBJECTIVE

To report a serotonin syndrome reaction in a patient taking fluvoxamine to replace an earlier SSRI agent.

CASE REPORT

A female patient with Obsessive Compulsive Disorder on paroxetine after resurgence in her obsessive ruminations was started on fluvoxamine 50 mg daily. One week later she became suicidal and was hospitalized. The fluvoxamine was increased to 50 mg morning and 100 mg bedtime and the paroxetine was discontinued. Over the next few days she began to have trouble with her concentration. A low grade fever set in after she experienced auditory hallucinations. Fluvoxamine was discontinued and she had an uneventful recovery after twenty-four hours.

DISCUSSION

Fluvoxamine is a recently approved serotonin selective reuptake inhibitor (SSRI) with few side effect profiles. It is effective in the treatment of Depressive Disorder and Obsessive Compulsive Disorder and is used to potentiate or replace other anti-OCD drugs including already available serotonin specific reuptake inhibitors (SSRI). We wish to draw attention to the potential for serotonin syndrome in patients on fluvoxamine who may have previously been on other SSRIs.

Fluvoxamine versus clomipramine for obsessive-compulsive disorder: a double-blind comparison

The efficacy and tolerability of fluvoxamine (100-300 mg/day) and clomipramine (100-250 mg/day) were compared in a randomized, double-blind, parallel-group study of 79 patients with obsessive-compulsive disorder (OCD) without coexisting major depression. After a 2-week placebo lead-in period, patients were randomized to fluvoxamine (37 patients) or clomipramine (42 patients) for 10 weeks. Efficacy was evaluated with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the National Institute of Mental Health Obsessive-Compulsive scale, and Patient and Clinical Global Improvement scales. Hamilton Rating Scale for Depression scores and somatic symptoms were also assessed. Seventy-eight percent of fluvoxamine patients and 64% of clomipramine patients completed the study. At the end of treatment, 56% of fluvoxamine patients were classified as responders (> or = 25% decrease in Y-BOCS score), compared with 54% of clomipramine patients. Both groups showed steady improvement throughout the study; no statistically significant differences were observed between the groups for any efficacy variable at any time. A similar percentage of patients in both groups withdrew because of adverse events. No serious adverse events related to drug occurred with either drug. Insomnia, nervousness, and dyspepsia were more statistically frequent with fluvoxamine; dry mouth and postural hypotension were more frequent with clomipramine. In this study, fluvoxamine and clomipramine were equally effective in reducing OCD symptoms over a 10-week treatment period but displayed different side effect profiles.