Short-term analysis of the effects of as needed use of sertraline at 5 PM for the treatment of premature ejaculation

OBJECTIVES

Pharmacotherapy using selective serotonin reuptake inhibitors (SSRIs) for men with primary premature ejaculation is promising. In particular, the strategy of taking a pill "as needed" may offer an attractive option. To investigate the possibility of self-therapy for the treatment of premature ejaculation, we compared the efficacy of sertraline taken as needed with that of continuous medication.

METHODS

Since 1996, we have treated 24 men with sertraline on an as needed basis for primary premature ejaculation. Sertraline was chosen from among the SSRIs because a large dose need not be divided and because peak plasma levels occur 4 to 8 hours after oral administration, making 5 PM a suitable time for administration (by which time a man may know whether sexual intercourse is likely to occur later that evening). Each patient was started on 50 mg daily for 2 weeks, and the dose was then adjusted to 50 or 100 mg on the day of intercourse only (PRN).

RESULTS

After 6 weeks, 18 men were still taking medication, and 6 had dropped out. Among the 18, the mean ejaculation latency was 23 +/- 19 seconds before treatment, 5.9 +/- 4.2 minutes after 2 weeks of 50 mg daily, 5.1 +/- 3.8 minutes after 2 weeks of 50 or 100 mg PRN, and 4.5 +/- 2.7 minutes after 4 weeks of 50 or 100 mg PRN. Mean sexual satisfaction scores (5, extremely satisfied; 0, extremely unsatisfied) for men were 0.8 +/- 0.8 before treatment, 3.8 +/- 1.2 after 2 weeks of 50 mg daily, 3.4 +/- 1.0 after 2 weeks of 50 or 100 mg PRN, and 3.2 +/- 0.7 after 4 weeks of 50 or 100 mg PRN. For their partners, mean sexual satisfaction scores were 1.1 +/- 0.7 before treatment, 3.2 +/- 1.6 after 2 weeks of 50 mg daily, 3.1 +/- 1.4 after 2 weeks of 50 or 100 mg PRN, and 3.3 +/- 1.2 after 4 weeks of 50 or 100 mg PRN. Side effects were intermittent excessive delay of ejaculation in 1 patient, fatigue in 2, and numbness in 1.

CONCLUSIONS

If our results are supported by additional long-term clinical studies, self-therapy with sertraline taken PRN at 5 PM for the treatment of premature ejaculation could be as attractive as self-injection therapy for the treatment of erectile dysfunction.

Hypoglycemia associated with high doses of sertraline and sulphonylurea compound in a noninsulin-dependent diabetes mellitus patient

Unlike other selective serotonin reuptake inhibitors (SSRIs), sertraline has linear pharmacokinetics so that increases in dose lead to proportional increases in drug concentration. The half-life of sertraline is about 26 h so that it reaches a steady state in one week, according to the product monograph. Hypoglycemia associated with sertraline and coadministration of oral hypoglycemics belonging to the sulphonylurea derivatives has rarely been reported. A patient with schizoaffective disorder with non-insulin-dependent diabetes mellitus (NIDDM) treated with sertraline, risperidone and glyburide who developed hypoglycemia is presented. The article highlights that inhibition of P450 enzymes can be affected by several different factors. Interactions are possible whenever a patient concomitantly receives two drugs that bind to the same P450 system Greater inhibition was likely induced at doses higher than those recommended. This process was reversed within 10 days of discontinuing the sertraline. Good glycemic control followed discontinuation of psychotropic drugs and the oral hypoglycemic agent. Knowledge of the individual P450 enzymes is important in the metabolism of individual drugs, together with an understanding of the patient's drug metabolizing ability. These factors may lead to more appropriate prescribing and further research into specific P450 enzymes responsible for metabolism of particular drugs, which remains unclear.

Multicenter open-label sertraline study in adolescent outpatients with major depression

OBJECTIVE

The aim of this multicenter outpatient study was to assess the therapeutic benefits, response patterns, and safety of sertraline in adolescent major depressive disorder (MDD).

METHOD

Fifty-three adolescent outpatients with MDD were treated in an open-label, 10-week, acute-phase trial with sertraline and, if responders, for an additional 12-week continuation phase. Diagnostic and response assessments included the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), 17-item K-SADS-derived depression severity score, Hamilton Depression Rating Scale, Beck Depression Inventory, and Clinical Global Impression Scale.

RESULTS

By 2 weeks, when analyzed as continuous variables, all severity scores showed significant differences from baseline. This pattern persisted through 10 weeks, with a significantly greater response occurring when treatment was extended from 6 to 10 weeks. Both clinician- and patient-rated improvement was maintained during continuation treatment. Response rates varied considerably when depression rating scales were analyzed categorically. Sertraline was generally well tolerated and did not induce manic symptoms.

CONCLUSIONS

In open treatment of adolescent MDD with sertraline, significant improvement occurred early on and was maintained for 22 weeks. Absolute response rates varied depending on the rating scales used, definition of response, and length of treatment. Maximal response rates were obtained by clinician-defined ratings after 10 weeks of treatment.

The potentiating effect of sertraline and fluoxetine on amphetamine-induced locomotor activity is not mediated by serotonin

Sertraline dose-dependently increased the locomotor stimulating effect of amphetamine. At the highest dose, 20 mg/kg sertraline had a biphasic effect on amphetamine-induced hyperactivity, producing an initial reduction in amphetamine-induced hyperactivity that was later followed by an augmentation of amphetamine-induced hyperactivity in the last hour of the 3-h test. Sertraline, at doses of 5 and 10 mg/kg, produced an augmentation of amphetamine-induced hyperactivity over the last 2 h of the 3-h test session. Further, there was an increase in the concentration of amphetamine in the brain in rats pretreated with 5 mg/kg sertraline. Both sertraline (5 mg/kg) and fluoxetine (5 mg/kg) produced an augmentation of amphetamine-induced hyperactivity that was unaltered by a serotonergic lesion of the median and dorsal raphe nuclei that resulted in a greater than 90% depletion of serotonin in hippocampus, striatum, and nucleus accumbens. Further, both sertraline and fluoxetine inhibited spontaneous locomotor activity and this effect was also unaltered by the depletion of serotonin. Thus, serotonergic neurotransmission is not essential for the effects of sertraline and fluoxetine on spontaneous and amphetamine-induced locomotion. It is probable that sertraline and fluoxetine augment the locomotor stimulatory effect of amphetamine by decreasing the metabolism of amphetamine, perhaps via actions on cytochrome P450 isozymes.

CYP2D6 status of extensive metabolizers after multiple-dose fluoxetine, fluvoxamine, paroxetine, or sertraline

The aim of this study was to evaluate the CYP2D6 inhibitory effects of four selective rerotonin re-uptake inhibitors (SSRIs). Thirty-one healthy subjects were phenotyped as extensive metabolizers using the dextromethorphan/dextrorphan (DM/DX) urinary ratio as a marker for CYP2D6 activity before and after 8 days of administration of fluoxetine 60 mg (loading dose strategy), fluvoxamine 100 mg, paroxetine 20 mg, or sertraline 100 mg in a parallel-group design. Statistical analysis was performed on log-transformed DM/DX ratios because of variability within and between treatment groups. DM/DX ratios before (DM/DX(BL)) and after (DM/DX(SSRI)) were compared within and between the four SSRI groups. DM/DX(BL) ratios were not significantly different between the four SSRI treatment groups. Comparing within groups, significant differences between DM/DX(BL) and DM/DX(SSRI) were found for the fluoxetine (p < 0.001; ratio values, 0.020 vs. 0.364) and paroxetine (p = 0.0005, ratio values 0.029 vs. 1.085) but not for the fluvoxamine or sertraline groups. Comparing between groups, significant differences in DM/DX(SSRI) ratios were found for fluoxetine versus sertraline (p = 0.0019, DM/DX = 0.364 vs. 0.057), fluoxetine versus fluvoxamine (p < 0.0001, DM/DX = 0.364 vs. 0.019), paroxetine versus sertraline (p = 0.0026, DM/DX = 1.085 vs. 0.057), and paroxetine versus fluvoxamine (p < 0.0001, DM/DX = 1.085 vs. 0.019). No significant differences were noted between the two potent CYP2D6 inhibitors, fluoxetine and paroxetine, or the two weakest inhibitors, fluvoxamine and sertraline. Five subjects in the fluoxetine and four subjects in the paroxetine groups changed to poor metabolizer phenotype (DM/DX > or = 0.3) after treatment. Although CYP2D6 inhibitory effects of fluvoxamine and sertraline did not yield significant differences from baseline, some subjects exhibited DM/DX ratio increases of 150 to 200%. One paroxetine-treated subject did not exhibit any CYP2D6 inhibition. SSRI dose and plasma concentration may be correlated with the extent of CYP2D6 inhibition and should be further investigated.

Coadministration of short-term zolpidem with sertraline in healthy women

This study was undertaken to determine whether there are pharmacokinetic (PK) interactions between zolpidem, a hypnotic, and sertraline, an antidepressant. Twenty-eight healthy female volunteers received a single dose of zolpidem alone and five consecutive dose(s) of zolpidem 10 mg in the presence of chronic doses (19 days) of sertraline 50 mg. Using HPLC, plasma levels of zolpidem, sertraline, and N-desmethylsertraline were determined at different times throughout the study and PK parameters derived. Compared to zolpidem alone, the T 1/2 of the first dose of zolpidem in the presence of sertraline was reduced, the Cmax of the fifth zolpidem dose in the presence of sertraline was significantly increased, and its Tmax was significantly reduced. After five doses of zolpidem, the AUC of sertraline (-6%) and the Cmax of N-desmethylsertraline (+13%) were changed. There were no next-day effects of zolpidem on the Digit Symbol Substitution Test, and both drugs were well tolerated. Overall, coadministration of sertraline 50 mg and zolpidem 10 mg appears to be safe in healthy females but could result in a shortened onset of action and increased effect of zolpidem.

Trends in the use of selective serotonin reuptake inhibitors in nine Department of Veterans Affairs outpatient facilities

The average daily dose and need for dose escalations for the drugs known as selective serotonin reuptake inhibitors (SSRIs) has frequently been a point of controversy. This study reports on the information gathered from nine Veterans Affairs hospitals over a two six-month periods. Average daily doses of fluoxetine, paroxetine, and sertraline started at 30.9 mg, 24.2 mg, and 87.8 mg and ended at 28.4 mg, 24.2 mg, and 89.8 mg, respectively. Cost, number of prescriptions, and dosage strength data is also presented.

Comparative bioavailability of two sertraline tablet formulations in healthy human volunteers after a single dose administration

OBJECTIVE

To compare the bioavailability of 2 sertraline tablets formulations (Tolrest from Laboratórios Biosintética, and Zoloft from Laboratórios Pfizer, Brazil) in 24 healthy volunteers of both sexes (12 male and 12 female) who received a single 50 mg dose of each sertraline formulation.

MATERIAL AND METHODS

The study was conducted open with randomized two-period crossover design and a 14-day washout period. Plasma samples were obtained over a 96-hour interval and sertraline concentrations were analyzed by combined reversed phase liquid chromatography and tandem mass spectrometry (LC-MS-MS) with positive ion electrospray ionization using selected ion monitoring method. From the plasma sertraline concentration vs. time curves the following pharmacokinetic parameters were obtained: AUC(0-96h), AUC(0-infinity), Cmax, Cmax/AUC(0-96h), Tmax, ke, and t(1/2).

RESULTS

Pharmacokinetic parameters presented normal distribution according to Probit' s plot and Kolmogorov Smirnov's test, and the variance of AUC(0-96h), AUC(0-infinity) or Cmax were homoscedastic. Geometric mean Tolrest/Zoloft individual percent ratio was 95.22% for AUC(0-96h), 99.87% for Cmax, 100.4% for AUC(0-infinity), 103.6% for Ke, 96.0% for t(1/2) and 93.7% for Tmax.

CONCLUSION

Since the 90% CI for both Cmax and AUC(0-96h) mean ratio were within the 80-125% interval proposed by the Food and Drug Administration, it was concluded that Tolrest was bioequivalent to Zolof for both extent and rate of absorption in a single dose administration.

Co-administration of sertraline and haloperidol

Along with recent increased interest in the selective serotonin reuptake inhibitors, a number of studies has been undertaken to observe interactions with different drugs. When selective serotonin reuptake inhibitor was administered together with antipsychotics to schizophrenics showing depressive or obsessive symptoms and negative symptoms, meaningful results were observed. The objective of our research was to identify the changes in the concentration of plasma haloperidol when sertraline was administered to patients who already were being treated with haloperidol. Sixteen patients who did not respond to the traditional antipsychotics after 2 weeks of treatment with a certain dosage of haloperidol were administered with 50 mg of sertraline for a period of 2 weeks. The concentration changes between plasma haloperidol and the reduced haloperidol were observed using high-powered liquid chromatography equipped with a UV detector. There was a significant increase (P < 0.01) in the concentration of haloperidol, the change being from 8.52 +/- 4.22 to 10.91 +/- 5.38 ng/mL. However, the change in the concentration of reduced haloperidol was from 7.41 +/- 7.93 to 5.22 +/- 6.10 ng/mL, showing a significant decrease. The concentrations of total plasma haloperidol showed no significant changes at all. In comparing the ratio of the reduced haloperidol and the haloperidol, the reduction ratio was down to 0.39 +/- 0.27 from 0.94 +/- 0.65 showing a significant decrease. There seems to be few studies done on interactions using serotonergic drugs together with antipsychotics in spite of their clinically applicable possibility. According to similar studies done in the past, co-administering of such drugs not only increases the plasma concentration of antipsychotics, but it also results in clinical improvement of negative symptoms and aggravation of extrapyramidal symptoms. Changes in clinical symptoms and adverse effects were not observed in our study. However, we think these observations need to be included in upcoming larger scale studies.

Maintenance phase efficacy of sertraline for chronic depression: a randomized controlled trial

CONTEXT

The chronic form of major depression is associated with a high rate of prevalence and disability, but no controlled research has examined the impact of long-term treatment on the course and burden of illness.

OBJECTIVE

To determine if maintenance therapy with sertraline hydrochloride can effectively prevent recurrence of depression in the high-risk group of patients experiencing chronic major depression or major depression with antecedent dysthymic disorder ("double depression").

DESIGN

A 76-week randomized, double-blind, parallel-group study, conducted from September 1993 to November 1996.

SETTING

Outpatient psychiatric clinics at 10 academic medical centers and 2 clinical research centers.

INTERVENTION

Maintenance treatment with either sertraline hydrochloride (n = 77) in flexible doses up to 200 mg or placebo (n = 84).

PATIENTS

A total of 161 outpatients with chronic major or double depression who responded to sertraline in a 12-week, double-blind, acute-phase treatment trial and continued to have a satisfactory therapeutic response during a subsequent 4-month continuation phase.

MAIN OUTCOME MEASURE

Time to recurrence of major depression.

RESULTS

Sertraline afforded significantly greater prophylaxis against recurrence than did placebo (5 [6%] of 77 in the sertraline group vs 19 [23%] of 84 in the placebo group; P = .002 for the log-rank test of time-to-recurrence distributions). Clinically significant depressive symptoms reemerged in 20 (26%) of 77 patients treated with sertraline vs 42 (50%) of 84 patients who received placebo (P = .001). With use of a Cox proportional hazards model, patients receiving placebo were 4.07 times more likely (95% CI, 1.51-10.95; P = .005) to experience a depression recurrence, after adjustment for study site, type of depression, and randomization strata.

CONCLUSIONS

Maintenance therapy with sertraline is well tolerated and has significant efficacy in preventing recurrence or reemergence of depression in chronically depressed patients.

Sertraline in the treatment of panic disorder: a flexible-dose multicenter trial

BACKGROUND

The serotonin selective reuptake inhibitors are increasingly being used for the treatment of panic disorder. We examined the efficacy and safety of the serotonin selective reuptake inhibitor sertraline hydrochloride in patients with panic disorder.

METHODS

One hundred seventy-six nondepressed outpatients with panic disorder, with or without agoraphobia, from 10 sites followed identical protocols that used a flexible-dose design. After 2 weeks of single-blind placebo, patients were randomly assigned to 10 weeks of double-blind, flexible-dose treatment with either sertraline hydrochloride (50-200 mg/d) or placebo.

RESULTS

Sertraline-treated patients exhibited significantly greater improvement (P=.01) at end point than did patients treated with placebo for the primary outcome variable, panic attack frequency. Significant differences between groups were also evident for clinician and patient assessments of improvement as measured by the Clinical Global Impression Improvement (P=.01) and Severity (P=.009) Scales, Panic Disorder Severity Scale ratings (P=.03), high end-state function assessment (P=.03), Patient Global Evaluation rating (P=.01), and quality of life scores (P=.003). Adverse events, generally characterized as either mild or moderate, were not significantly different in overall incidence between the sertraline and placebo groups.

CONCLUSION

Results support the safety and efficacy of sertraline for the short-term treatment of patients with panic disorder.

The treatment of chronic depression, part 2: a double-blind, randomized trial of sertraline and imipramine

BACKGROUND

Chronic depression appears to be a common, frequently disabling illness that is often inadequately treated. Unlike episodic depressions with shorter illness duration, neither acute nor long-term treatment approaches for chronic depression have been well studied.

METHOD

635 outpatients at 12 sites who met DSM-III-R criteria for chronic major depression or double depression were randomly assigned to 12 weeks of double-blind treatment with either sertraline (in daily doses of 50-200 mg) or imipramine (in daily doses of 50-300 mg). Efficacy and safety were assessed either weekly or every 2 weeks during the 12 weeks of acute treatment.

RESULTS

Despite high rates of chronicity (mean duration of major depression = 8.9+/-9.1 years; mean duration of dysthymia = 23+/-13 years) and high rates of comorbidity, 52% of patients achieved a satisfactory therapeutic response to sertraline or imipramine (by a conservative, intent-to-treat analysis). Approximately 21% of the patients who had achieved a therapeutic response at week 12 had not done so at week 8, confirming the longer time to response in depressions with high chronicity. Patients treated with sertraline reported significantly fewer adverse events and were significantly less likely to discontinue treatment due to side effects than imipramine-treated patients (6.3% vs. 12.0%).

CONCLUSION

These results indicate that patients suffering from depression with high chronicity can achieve a good therapeutic response to acute treatment with either sertraline or imipramine, although sertraline is better tolerated.

A double-blind study of adjunctive sertraline in haloperidol-stabilized patients with chronic schizophrenia

We conducted a placebo-controlled, randomized, double-blind, 8-week trial of sertraline added to haloperidol treatment in patients with schizophrenia to evaluate changes in clinical measures and pharmacokinetic interactions with haloperidol. In addition to their haloperidol regimen, 36 inpatients with chronic schizophrenia were randomly assigned to receive capsulized sertraline (50 mg/day; N = 18) or identically capsulized placebo (N = 18) for 8 weeks. The results from the Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression (CGI) Scale, Simpson-Angus Extrapyramidal Effects (S-A) Scale, and plasma concentration levels of haloperidol and reduced haloperidol were examined at baseline and 2, 4, 6, and 8 weeks of treatment. No significant differences between the three PANSS factors (positive, negative, general psychopathology) scores, CGI Scale scores, or S-A Scale scores were recorded at any point during sertraline and placebo treatment. Neither plasma haloperidol or reduced haloperidol concentrations was changed significantly at any point during the sertraline and placebo treatments. In this study, the addition of sertraline 50 mg to the treatment regimen of inpatients did not differ significantly from the placebo effect on positive and negative symptoms and extrapyramidal side effects. The results further indicate that the pharmacokinetics of haloperidol are seemingly unaffected by sertraline.

Dose-dependent influence of buspirone on the activities of selective serotonin reuptake inhibitors in the mouse forced swimming test

Recent clinical data suggest that buspirone may enhance the efficacy and/or reduce the latency to therapeutic effect of selective serotonin reuptake inhibitors (SSRIs) in unipolar major depressive disorder. The present study, using the mouse forced swimming test, was performed to investigate further the mechanisms involved in the potential antidepressant-enhancing effects of buspirone. Prior administration of buspirone (0.06 mg kg(-1), i.p.) significantly enhanced the anti-immobility effects of subactive doses of fluvoxamine (4 mg kg(-1), i.p.; P < 0.01), paroxetine (4 mg kg(-1), i.p.; P < 0.01), citalopram (4 mg kg(-1), i.p.; P < 0.01) and sertraline (2 mg kg(-1), i.p.; P < 0.01) in the forced swimming test. However, pretreatment with buspirone did not induce antidepressant-like effects when tested in combination with fluoxetine (4 mg kg(-1), i.p.). Each antidepressant tested reduced immobility time in the forced swimming test [citalopram (16 mg kg(-1), i.p.; P < 0.01), fluoxetine (32 mg kg(-1), i.p.; P < 0.01), fluvoxamine (32 mg kg(-1), i.p.; P < 0.01), paroxetine (16 mg kg(-1), i.p.; P < 0.01) and sertraline (16 mg kg(-1), i.p.; P < 0.01)]. Pretreatment with buspirone (0.5 mg kg(-1), i.p.), or its major metabolite 1-PP (0.5 mg kg(-1), i.p.), attenuated all SSRI-induced anti-immobility effects (P < 0.01). Concomitant studies of locomotor activity ruled out any stimulant or sedative effects of the interactions. The results of the present study suggested that low dose buspirone enhanced the activity of subactive doses of SSRIs in the mouse forced swimming test, probably via an action at 5-HT1A receptors. On the other hand, a high dose of buspirone attenuated the antidepressant-like effects of active doses of these drugs, possibly via the generation of an active metabolite (1-PP) acting at alpha2-adrenoreceptors.