Relief of pruritus in patients with atopic dermatitis after treatment with topical doxepin cream. The Doxepin Study Group

BACKGROUND

Atopic dermatitis is associated with severe pruritus for which effective topical treatment is lacking. As a potent H1 and H2 antagonist, the antipruritic effect of topical doxepin was first demonstrated in histamine-induced itch in nonatopic volunteers.

OBJECTIVE

The current study was undertaken to compare the efficacy and safety of topical 5% doxepin cream in relieving pruritus associated with atopic dermatitis.

METHODS

A total of 270 patients with atopic dermatitis who had daily moderate to severe pruritus for at least 1 week were enrolled in the double-blind, vehicle-controlled, multicenter study. Treatment was randomly assigned: 5% doxepin cream or vehicle cream was applied twice on the day of the baseline visit and four times daily for the remainder of the 7-day trial.

RESULTS

Relief of pruritus was achieved in 85% of doxepin-treated patients and 57% of vehicle-treated patients by day 7; a majority of these positive responses occurred during the first 24 hours. Pruritus severity scores demonstrated significantly greater improvement with topical doxepin at each study visit (p < 0.01). Visual analogue scales for pruritus severity and pruritus relief showed similar improvement in the doxepin-treated group. At each of three visits, the physician's global evaluation for relief of pruritus also showed significant improvement in the doxepin treatment group (p < 0.01). The physician's global evaluations of eczema significantly favored topical doxepin on day 7 (p < 0.01). Nineteen patients withdrew from the study because of adverse effects (doxepin, n = 16; vehicle, n = 3). The most commonly reported were localized stinging or burning (doxepin group, n = 39; vehicle group, n = 34) and drowsiness (doxepin group, n = 37; vehicle group, n = 3), all of which decreased in frequency and severity over time.

CONCLUSION

Topical doxepin is effective in reducing pruritus in patients with atopic dermatitis. It has an apparent short-term low risk of major side effects or sensitization.

Dothiepin versus doxepin in major depression: results of a multicenter, placebo-controlled trial. Prothiaden Collaborative Study Group

BACKGROUND

The tricyclic antidepressant dothiepin is well established in Europe, but clinical experience with the drug in the United States is limited.

METHOD

In a 10-week, multicenter, randomized, double-blind, placebo-controlled study in the United States, the efficacy and tolerability of dothiepin and doxepin (both administered as a 150-mg nightly dose) were compared in 579 outpatients with major depression.

RESULTS

Patients in both active treatment groups showed significant improvements in depressive symptoms, associated anxiety, and sleep parameters compared with the placebo-treated group. The adverse effect profile of dothiepin was superior to that of doxepin, particularly with respect to drowsiness, weight gain, and increased appetite.

CONCLUSION

These results confirm that dothiepin is useful when a tricyclic agent is indicated for the treatment of depression.

A double-blind comparison of amitriptylinoxide versus doxepine in the treatment of severe depression

In a double-blind parallel group study the efficacy and safety of amitriptylinoxide were evaluated vs. doxepine in the treatment of in-patients with severe depression. Two groups of 22 patients each received amitriptylinoxide and doxepine respectively at a daily dosage of 120-360 mg for a period of 4 weeks. The total score on the Hamilton Depression Scale (HAMD) was reduced with amitriptylinoxide on an average from 28 +/- 5 before treatment to 12 +/- 8 at the end of treatment, with doxepine from 29 +/- 8 to 13 +/- 11. Of the amitriptylinoxide-treated patients, 12 showed a more than 50% reduction in this score compared with 15 under doxepine. The difference was not statistically significant. Twenty patients in each group experienced adverse drug reactions, the percentage of anticholinergic side effects being equal in the two groups.

Outcome of panic disorder with or without concomitant depression: A 2-year prospective follow-up study

In a prospective 2-year follow-up study, 32 patients with panic disorder alone and 20 with panic disorder and concomitant depression were investigated. After controlled treatment with either imipramine or doxepin, patients received naturalistic treatment with antidepressants, benzodiazepines, and supportive psychotherapy. They were evaluated for anxiety, depression, and social disability at least every 3 months during the follow-up period. The data showed fluctuation of symptoms in both groups and a less favorable outcome for the patients with comorbid conditions. However, the overall outcome was better than that reported in other studies and indicates that panic disorder is quite responsive to appropriate treatment.

Facilitation of adaptation and acute tolerance to stressful sensory input by doxepin and scopolamine plus amphetamine

This work characterizes a new methodologic and pharmacologic approach to control terrestrial and space motion sickness (SMS). The experimental design allowed separate evaluation of drug action on susceptibility and adaptability, and used repeated measures to approximate the chronic stressful motion of microgravity. Daily exposure to cross-coupled angular acceleration for 5 consecutive days demonstrated that the efficacy of doxepin and scopolamine plus amphetamine in the prevention of autonomic system dysfunction was not only apparent on the first test day (P < .01), but was also evident in the substantially enhanced resistance developed over the 5-day test period (P < .01) as compared with placebo. This indicates that daily use of these medications does not diminish therapeutic efficacy (tolerance). The efficacy of doxepin was anticipated because it possesses pharmacologic properties similar to those of established anti-motion sickness drugs. Comparable efficacy after doxepin loading for 4 hours, 3 days, or 21 days suggests a mechanism distinct from its antidepressant effects, possibly related to its potent antihistaminergic actions. Use of doxepin has operational significance to the National Aeronautics and Space Administration, in comparison with current preparations of scopolamine plus amphetamine, because of doxepin's minimal impact on cognitive performance, and most importantly, its favorable pharmacokinetic profile, particularly its long half-life.

Somatisation as a presentation in depression and post-traumatic stress disorder among Cambodian refugees

Three Cambodian patients with Depression and Post-traumatic Stress Disorder (PTSD) presenting with somatic complaints are described. Their case histories support previous observations that somatisation is the most common presentation of Cambodian patients with Depression and PTSD. The probable reasons why depressed, traumatised Cambodian patients somatise their psychiatric problems are discussed. These cases illustrate the difficulties involved in engaging such patients in Western style psychotherapy, but show the effectiveness of small doses of antidepressants in treating the depressive and post-traumatic stress symptoms.

A comparison of the cardiac safety and therapeutic efficacy of trimipramine versus doxepin in geriatric depressed patients

OBJECTIVE

To compare the cardiac safety and therapeutic efficacy of trimipramine and doxepin.

DESIGN

A 1-week single-blind placebo period followed by a 5-week randomized double-blind parallel group clinical trial.

SETTING

Psychiatric out-patient clinic of a general hospital.

PATIENTS

37 young-elderly patients with a diagnosis of Major Depressive Episode (DSM-III criteria).

INTERVENTIONS

Placebo for 1 week, 2 weeks of titration with either drug in the dosage range of 75 mg/day up to a maximum of 200 mg/day.

MEASUREMENTS

We measured the psychiatric effects with the Hamilton Rating Scale for Depression, the Hamilton Anxiety Rating Scale, and the Clinical Global Impression Scale. Cardiovascular effects were assessed on 12-lead standard electrocardiograms plus 1-minute rhythm and high speed recordings; orthostatic (lying/standing) blood pressures were also taken. Physical exams, lab tests, cognitive functions (Buschke Selective Reminding Test, Hierarchic Dementia Scale, Word Fluency) and adverse reactions were also noted.

RESULTS

Both drugs were equally effective in relieving symptoms of depression and anxiety. The cardiovascular effects of both drugs were minimal. Trimipramine did lower blood pressure but this was without clinical significance. Three trimipramine patients and five doxepin patients developed occasional premature ventricular or atrial contractions. Of these, two trimipramine patients and one doxepin patient were among those with abnormal ECG's at entry. The doxepin patient was withdrawn from the study after 21 days of treatment when the PVC's became increasingly frequent.

CONCLUSIONS

Trimipramine and doxepin are equally safe and effective antidepressants in the young-elderly.

A comparison study of moclobemide and doxepin in major depression with special reference to effects on sexual dysfunction

A double-blind parallel-group comparison study of moclobemide versus doxepin in 237 patients with major depression confirmed that moclobemide was equal in efficacy and better tolerated than doxepin. It was less sedating and caused fewer anticholinergic adverse events as measured by the UKU side-effect rating scale. Unexpectedly, moclobemide therapy more often than doxepin resulted in increased sexual desire. An exploratory analysis of UKU-measured symptoms of impaired sexual function prior to commencement of the study revealed that moclobemide more often than doxepin led to an improvement of reduced libido and impaired erection, ejaculation and orgasm. This finding is compatible with the assumption that there is a greater likelihood that the anticholinergic reuptake inhibitor doxepin has a higher risk of impairing sexual function than the non-anticholinergic RIMA moclobemide. A single case report of moclobemide-induced sexual hyperarousal supports the alternative assumption that moclobemide has a specific sexually stimulative effect in depression.

The noisy elderly patient: prevalence, assessment, and response to the antidepressant doxepin

To measure the prevalence of noisy behavior as a nursing problem, a survey of head nurses was done in a chronic care hospital to identify patients whose vocalizing was frequently disturbing to other patients, staff, or visitors. We found 17 patients among the total of 154. Subsequently, the medical records of 13 surviving subjects were reviewed more exhaustively, and 11 were described as disruptive, usually when they were left alone. Of these "lonely" patients, eight had a previously documented diagnosis of depression. All were demented. Antipsychotic medication had previously been given to all 11 "lonely" patients, but had failed to control their disruptive behavior. Empirically, six patients were treated with doxepin, and in five, all with a history of previous depression, agitation and noisiness diminished. These observations suggest that the prevalence rate of disturbingly noisy behavior among long-term institutionalized elderly patients is about 11% and that the disturbingly noisy patient is often demonstrating depression in conjunction with dementia.

Urticaria and angioedema

Urticaria and angioedema are commonly seen in the outpatient setting. Their pathogenesis involves complex cellular and humoral factors. Diagnosis depends on historical information such as duration of symptoms, exacerbating factors, and atopy. While many etiologic factors have been implicated, in most chronic cases no specific etiology is found. This article reviews physical and hereditary syndromes and discusses therapeutic regimens based on the duration and severity of symptoms.

Cold urticaria as a model of mediator release: platelet factor 4, eosinophil cationic protein and histamine

Platelet factor 4 (PF4) has previously been linked to precipitation of cold urticaria (CU). The aim of the study was to assess the liberation of PF4, eosinophil cationic protein (ECP) and histamine after cold challenge in patients with CU. Ten controls and 8 patients with CU verified by clinical data and cold challenge test were investigated. Assessment of histamine, ECP and PF4 were done using radioimmunoassays. In patients histamine increased after 10 min on the challenged arm (NS), PF4 increase was statistically significant (p less than 0.05) both in patients and controls. ECP release showed no significant changes. Treatment with doxepin results in clinical improvement, but no changes in mediator release were seen. Thus, in contrast to previous reports an increase of PF4 was seen both in controls as well as in patients. An involvement of ECP was not ascertained. Our data suggest that neither basophils, nor eosinophils or platelets are directly involved in cold urticaria and that mast cell-dependent mediators may be of greater relevance.

Predictors of response to antidepressant medications

In a 10-year interval, 175 residents of a state institution who had severe or profound mental retardation were treated with heterocyclic antidepressants when other medications and forms of treatment had proved ineffective. Responders to the medication were identified and compared with nonresponders to determine which presenting symptoms and other parameters might serve as predictors of medication efficacy.

[Multiple angiolipomas--analgesics therapy with doxepin]

Angiolipomas are rare benign tumours of the subcutaneous fat; they are sometimes solitary but their occurrence is more frequently multiple. Angiolipomas can be differentiated from lipomas clinically by their pronounced tenderness and histologically by their variable vascularization. The disease occurs mostly in young adults, the sites of predilection being the trunk and proximal extremities. Multiple angiolipomas have to be differentiated from other lipomatoses, especially from adiposis dolorosa (Dercum's disease). The case reported in this paper was characterized by typical clinical and histological findings. The systemic administration of acetylsalicylic acid, diclofenac, ketotifen, ranitidine, tramadol, tilidine combined with naloxone did not provide adequate pain relief. In contrast, the therapeutic efficiency of the antidepressant doxepin, which also displays antihistaminic effects, suggests a possible role of mediators in the development of pain in angiolipomas.

Two combined, multicenter double-blind studies of paroxetine and doxepin in geriatric patients with major depression

Depressive illness among the elderly is an important public health concern. However, treatment of the elderly may be complicated by age-related changes in physiology, general medical status, and susceptibility to side effects. There is therefore a need for improved treatment modalities for depressed elderly patients. Paroxetine is an antidepressant that acts through selective inhibition of serotonin reuptake. It lacks the anticholinergic and cardiovascular side effects of most first- and second-generation antidepressants. The authors present the combined data from two similarly designed comparisons of paroxetine and doxepin in outpatients over 60 years of age with major depression. The results show that paroxetine was an effective as doxepin in alleviating depression as measured on the Hamilton Rating Scale for Depression (HAM-D) total score, the Montgomery and Asberg Depression Rating Scale (MADRS), and the Hopkins Symptom Checklist (SCL) depression factor score. Paroxetine was significantly superior to doxepin on the Clinical Global Impressions (CGI) scale for severity of illness, the HAM-D retardation factor, and the HAM-D depressed mood item. Doxepin produced significantly more anticholinergic effects, sedation, and confusion. Paroxetine was associated with more reports of nausea and headache. These results suggest that paroxetine may be a valuable tool for the treatment of major depression in the elderly.

Pharmacologic approaches to smoking cessation

Only 25 years ago, tobacco dependence was believed to be a simple overuse problem. Research in the last 5 years has demonstrated a much more complex and profound neurochemical and behavioral disorder. Nicotine receptors in the locus coeruleus and the midbrain mesolimbic dopaminergic system activate both arousal state and enhance cognitive functioning (locus coeruleus) and activate the brain's "pleasure center" (mesolimbic system). Pharmacologic treatments, which must be completely integrated into the behavioral treatment plan, alter these profound central nervous system nicotine effects. Currently the only agent with clear scientific evidence for treatment efficacy is nicotine itself. Available only in a transmucosally delivered ion-exchange resin as nicotine polacrilex (Nicorette), nicotine should soon be available in other delivery forms that will have different absorption kinetics: transdermal patch, nasal spray, and vapor inhaler. Other agents in various phases of preclinical and clinical evaluation include 5-HT1A partial agonists such as buspirone; alpha 2-noradrenergic agonists such as clonidine; tricyclics such as doxepin; serotonin re-uptake antagonists such as fluoxetine; ACTH; 5-HT2 antagonists such as ritanserin; central excitatory amino acid inhibitors such as kynurenate; and calcium channel blockers.

[Central anticholinergic intoxication syndrome. A contribution to the differential diagnosis of exogenous psychoses]

A withdrawal syndrome in a 50-year-old alcoholic subsided within 5 days in response to treatment with doxepin (150 mg/d). But 2 days later he developed auditory hallucinations which were interpreted as alcohol hallucinations, for which he was additionally given haloperidol, 15 mg/d. He then developed early dyskinesia which was treated with 5 mg biperiden i.v. followed by twice 2 mg/d by mouth, while doxepin and haloperidol were continued. 5 days after detoxification there occurred, under this combination of drugs which included two with marked anticholinergic action, an anticholinergic intoxication syndrome characterized by restlessness, optical hallucinations, dysarthritic speech, mydriasis, urinary retention, fever, tachycardia and red, dry skin. After all previous drugs had been discontinued and clomethiazole started, the intoxication syndrome began to regress within 3 days. The case demonstrates the need to consider a central anticholinergic syndrome, which could end fatally, as a possible cause of otherwise unexplained delirium.

Effects of carbamazepine on serum antidepressant concentrations in psychiatric patients

The combination of carbamazepine and an antidepressant (doxepin, amitriptyline, mianserin) was given to 22 psychiatric inpatients with 29 measurements of their serum antidepressant concentrations. For comparison, sex-, age-, and dose-matched inpatients, treated with the antidepressant but not with carbamazepine, were selected as controls (N = 29). All the patients were treated with their routine daily dose for at least 7 days before the gas-chromatographic measurement of serum predose concentrations of the antidepressants. In patients with carbamazepine, serum doxepin and doxepin + nordoxepin concentrations (N = 17) were decreased significantly (p less than 0.05), on average to 46% and 45%, respectively, as compared to that in subjects without carbamazepine. Also in carbamazepine + amitriptyline patients, serum nortriptyline and amitriptyline + nortriptyline concentrations (N = 8) were significantly lower than in those not receiving carbamazepine (p less than 0.05). The mean serum antidepressant levels were decreased to 42% and 40%, respectively. The serum mianserin concentration of carbamazepine patients (N = 4) was reduced to 30% of that in patients not treated with carbamazepine (p less than 0.01). The percentage fractions of demethylated metabolites (nordoxepin, nortriptyline) from the total antidepressant levels were not influenced by carbamazepine. In patients treated with carbamazepine, serum total antidepressant concentrations remained more often below the suggested therapeutic ranges than in those patients without carbamazepine. The results suggest that serum antidepressant concentrations are reduced by concurrent carbamazepine therapy, and that the concentrations should be carefully monitored when carbamazepine is added to the antidepressant regimen.

Is doxepin a safer tricyclic for the heart?

BACKGROUND

Many clinicians believe that doxepin is the safest tricyclic with respect to cardiovascular effects. This belief has persisted for two decades despite the absence of rigorous prospective evaluation.

METHOD

To address this issue, the authors studied the cardiovascular effects of doxepin in 32 depressed patients with preexisting left ventricular impairment, ventricular arrhythmias, and/or conduction disease.

RESULTS

Doxepin (1) did not have a robust effect on heart rate, (2) did not adversely affect left ventricular function, (3) did have a significant antiarrhythmic effect, (4) slowed cardiac conduction, and (5) caused a significant increase in orthostatic hypotension. Five (16%) of the 32 patients dropped out due to cardiovascular side effects. The overall dropout rate was 41%.

CONCLUSIONS

The cardiovascular effects of doxepin in depressed patients with heart disease are comparable to those documented for imipramine and nortriptyline. Doxepin afforded no greater margin of cardiovascular safety; in fact, the drug was poorly tolerated by this patient population.

Role of depressive illness in the outcome of treatment of temporomandibular joint pain-dysfunction syndrome

The aim of this study was to assess the role of a depressive illness in the outcome of the treatment of patients with temporomandibular joint pain-dysfunction syndrome. One group was considered psychiatrically normal and the other had a concurrent depressive illness. The latter group was subdivided equally to produce three treatment groups: one undergoing occlusal splint therapy, one receiving antidepressant medication, and the third having a combination of occlusal splint and antidepressant therapy. The results showed clearly that there was a significant difference in response in the nonpsychiatric and combined-therapy depressed groups in comparison with the two depressed groups treated either with occlusal splint or with antidepressant therapy. The combined therapy led to resolution of the painful problem and the depression, whereas the single therapies were only partly successful in relieving the pain-dysfunction syndrome. The preexisting duration of this painful problem did not influence the response to therapy.

[Changes in hemodynamic indicators during doxepin therapy as a prognostic factor in the treatment of endogenous depression]

Hemodynamic studies with a radiocardiographic method were conducted in 28 male patients with unipolar affective disorder during treatment of a current depressed phase with doxepin. Total Peripheral Resistance Index (TPRI) indicated the best potential for prediction of hemodynamic tolerance to doxepin and of final treatment outcome.