Milnacipran and pindolol: a randomized trial of reduction of antidepressant latency

BACKGROUND

New, better tolerated and faster treatments for depression are needed. Patients are understandably unhappy with having to wait 3 to 4 weeks for a response to an antidepressant, while experiencing side effects almost immediately. This frequently has an adverse effect on compliance and engagement with treatment.

AIMS

The primary objective was to assess the activity of pindolol on the onset of antidepressive response of milnacipran. The secondary objective was to assess the number of responders among the patients who received milnacipran and pindolol versus patients who received milnacipran and placebo. The tertiary objective was to evaluate the safety of milnacipran and pindolol versus milnacipran and placebo.

METHOD

Randomized, double-blind, placebo-controlled study over 42 days.

SETTING

Inner city London community mental health teams.

PARTICIPANTS

80 patients were selected and gave written consent to treatment, 78 were randomized (39 in each group) and evaluated for safety (intention-to-treat, ITT, safety data set), 77 (ITT efficacy data set), and 64 (per protocol, PP, data set) were evaluated for efficacy. The mean age was 31.9 for the pindolol group and 32.3 for the placebo.

INTERVENTION

All patients received milnacipran 50 mg twice a day plus either pindolol 2.5 mg (the 'pindolol group') or matching placebo (the 'placebo group') three times a day.

OUTCOME MEASURES

The main efficacy variable was the Montgomery-Asberg depression rating scale (MADRS) score at days 0, 4, 7, 10, 14, 21, 28, 42 on PP data set in an observation carried (OC) approach. Secondary efficacy variables were clinical global impression (global improvement) and Hamilton depression rating scale (HDRS).

RESULTS

Improvement in MADRS total score was greater in the pindolol group than in the placebo group from day 7 (p=0.03). Responder rates in the clinical global impression were 97.2% for the pindolol group and 60.6% for the placebo group. The treatment was well tolerated with the most common side effects being nausea (28.2%; 35.9%), vomiting (7.7%; 23.1%), hot flushes (15.4%; 5.1%) and sweating (12.8%; 12.8%).

CONCLUSION

The milnacipran and pindolol combination is safe, well tolerated and efficacious in major depression, and represents a rational strategy for the possible acceleration or potentiation of antidepressant action.

Diphenylcyclopropenone (diphencyprone, DPCP) in the treatment of chronic severe alopecia areata (AA)

BACKGROUND

Diphenylcyclopropenone (DPCP) has been reported to be an effective topical immunotherapy of extensive alopecia areata (AA) with highly variable reported results.

OBJECTIVE

The purposes of this study were to assess the efficacy, side effects, and adverse prognostic factors in the treatment of alopecia areata with DPCP.

METHODS

21 patients were included in the study with chronic and extensive AA. Patients were sensitized in the beginning with 2% DPCP, and the concentrations were increased gradually beginning with 0.000001% every one to two weeks for a period of 6 months.

RESULTS

15 patients (71.4%) had a complete or partial recovery at the end of the treatment period. Most frequent side effects were erythema at the site of application, pigmentation, and lymph node enlargement. The most important adverse prognostic factors were duration of AA, history of atopy, and presence of nail changes.

CONCLUSION

Treatment of AA with topical DPCP is effective. Though the treatment may have some side effects, in most cases they are tolerable and respond well to treatment.

Dual action antidepressants and some important considerations

OBJECTIVE

To review controlled studies of long-term treatment and their side-effects with newer dual action antidepressants following an acute episode of major depression.

METHOD

A literature review (MedLine) was undertaken and references were selected for their relevance and methodology in describing their contribution to the examination of our objective.

RESULT AND CONCLUSION

Three dual action antidepressants are identified: venlafaxine, mirtazapine and milnacipran. These are more effective and better tolerated than the older tricyclic antidepressants in the treatment of an acute episode of depression and in the prevention of relapse. They also offer advantages in that they lack autonomic side-effects of the tricyclics. However, sedation, nausea and sexual side-effects may occur with venlafaxine, and weight gain with mirtazapine.

Milnacipran in the treatment of bulimia nervosa: a report of 16 cases

Controlled trials in patients with bulimia nervosa have demonstrated efficacy of antidepressant medications with serotonergic function (e.g. fluoxetine) as well as noradrenergic function (e.g. desipramine). Sixteen out-patients with bulimia nervosa according to DSM-IV criteria were treated in a drug surveillance with 100 mg of milnacipran, a specific serotonin and noradrenaline reuptake inhibitor (SNRI). Ten patients completed the 8-week observation period. The reasons for premature attrition were improvement in one patient (no. 12), a generalized exanthema in one patient (no. 7), severe nausea in one patient (no. 8) and non-compliance due to non-drug-related reasons in three patients (no. 1, 2, and 16). An intent-to-treat analysis exhibited a significant reduction in weekly binge eating and vomiting frequency from baseline to the end of treatment. Three patients stopped binge eating and purging completely during the last week of treatment. Furthermore, there was a concomitant decrease of depression ratings (HAMD, BDI). Our preliminary data give rise to the notion that milnacipran may be promising in the treatment of bulimia nervosa.

[Experience with ixel (milnacipran hydrochloride) use in the treatment of patients with post-stroke depression]

AIM

To evaluate antidepressive efficacy of ixel in patients with poststroke depression (PSD).

MATERIAL AND METHODS

The study included 59 PSD patients aged 43-79 years divided into two groups: the test group (31 patients) treated with antidepressive drugs and the control group (28 patients) was not treated with such drugs. The test group took a two-month treatment with oral ixel in a dose 100 mg/day. The neurological status was assessed by Lindmark scale (LS), severity of depression-by Hamilton scale (HS).

RESULTS

On ixel treatment day 10-14 the patients felt better, by the treatment day 60 depression disappeared in 60.9%, only borderline conditions were seen in 39.1%. Mean score by HS fell from 15.8 to 5.7. The controls showed moderate reduction of some symptoms of depression, mean score by HS decreased insignificantly (from 14.5 to 13.4). By LS, significant differences between the groups were not registered. Side effects arose in 10 patients, 6 of them withdrew.

CONCLUSION

Ixel is an effective drug against depression in stroke survivors.

Clinical utility of milnacipran in comparison with other antidepressants

The utility of milnacipran in the treatment of major depression has been the subject of an extensive clinical development programme. Comparative studies with tricyclic antidepressant drugs have demonstrated equivalent efficacy, with improved tolerability, in particular with respect to autonomic effects. In comparison with selective serotonin reuptake inhibitors (SSRIs), milnacipran shows similar good tolerability. It appears superior to such drugs in the treatment of severe depression, but equivalent to them for mild to moderate depression. In contrast to treatment with SSRIs, treatment response to milnacipran appears to be associated with the degree of psychomotor retardation. The good tolerability of milnacipran makes it safe in overdose. This drug also has a beneficial effect on suicidal ideation. Maintenance therapy with milnacipran has been demonstrated to reduce the recurrence of depressive episodes.

Therapeutic effects of milnacipran, a serotonin and noradrenaline reuptake inhibitor, on post-stroke depression

Depression is common after stroke. While several reports have been published on the use of antidepressants such as selective serotonin reuptake inhibitors and tricyclics for the treatment of post-stroke depression (PSD), no previous study has examined the use of a selective serotonin and noradrenaline reuptake inhibitor (SNRI) for this condition. The present study investigated the efficacy and safety of milnacipran, a SNRI, for the treatment of PSD. A 6-week open study was conducted in 12 patients (two males and 10 females) aged 53-88 years. All patients were diagnosed with major or minor depressive disorder according to DSM-IV, where onset was subsequent to a cerebral infarction or haemorrhage (stroke). Severity of depression was assessed using the 21-item Hamilton rating scale for depression (HAM-D). The maximum total daily dose of milnacipran was in the range of 30-75 mg b.i.d. Three patients experienced side-effects, but none of the side-effects were serious. Two patients dropped out of the study. At the end of the study, 58.3% (7/12) of the total patient population and 70% (7/10) of the patients completing the study were in remission (a final HAM-D score of less than 7 and no longer meeting criteria for major or minor depression). These results suggest that milnacipran may be an effective treatment for PSD.

Differential effects of milnacipran and fluvoxamine, especially in patients with severe depression and agitated depression: a case-control study

We attempted to compare the antidepressant efficacy of milnacipran and fluvoxamine in 202 outpatients with major depression, using the 17-item Hamilton Depression Rating Scale (HDRS). Special attention was paid to the difference of responsiveness as a function of the severity of depression and individual HDRS factors. As a result, while no significant difference between the treatment groups was found overall, a positive response (50% or more decrease in total score from the baseline) was recorded significantly more often with milnacipran than fluvoxamine recipients whose baseline HDRS total score was greater than 19 points. Furthermore, there was a significant difference of response for the 'agitation' and 'insomnia' factors in favour of milnacipran. In both treatment groups, the incidence of adverse events, characteristic of tricyclic antidepressants such as dry mouth, constipation, somnolence and postural hypotension, was low. While complaints concerning the upper intestinal tract, such as epigastric distress, were predominant in the fluvoxamine group, urological complications and palpitations were reported only in the milnacipran group. In conclusion, we suggest that milnacipran is preferred to selective serotonin reuptake inhibitors for the treatment of depressed patients with agitation as well as severely depressed patients.

Blood concentration of milnacipran in a case of a fatal automobile accident

A fatal automobile accident involving milnacipran and ethyl alcohol is reported. The drug was identified and quantitated in blood by high-performance liquid chromatography-diode-array detection. The concentration of milnacipran in peripheral blood was 3.15 microg/mL exceeded 10.5 times the therapeutic concentration. The blood ethyl alcohol level was 1.3 g/L.

Anticonvulsant profile and teratogenicity of N-methyl-tetramethylcyclopropyl carboxamide: a new antiepileptic drug

PURPOSE

The studies presented here represent our efforts to investigate the anticonvulsant activity of N-methyl-tetramethylcyclopropyl carboxamide (M-TMCD) and its metabolite tetramethylcyclopropyl carboxamide (TMCD) in various animal (rodent) models of human epilepsy, and to evaluate their ability to induce neural tube defects (NTDs) and neurotoxicity.

METHODS

The anticonvulsant activity of M-TMCD and TMCD was determined after intraperitoneal (i.p.) administration to CF#1 mice, and either oral or i.p. administration to Sprague-Dawley rats. The ability of M-TMCD and TMCD to block electrical-, chemical-, or sensory-induced seizures was examined in eight animal models of epilepsy. The plasma and brain concentrations of M-TMCD and TMCD were determined in the CF#1 mice after i.p. administration. The induction of NTDs by M-TMCD and TMCD was evaluated after a single i.p. administration at day 8.5 of gestation in a highly inbred mouse strain (SWV) that is susceptible to valproic acid-induced neural tube defects.

RESULTS

In mice, M-TMCD afforded protection against maximal electroshock (MES)-induced, pentylenetetrazol (Metrazol)-induced, and bicuculline-induced seizures, as well as against 6-Hz "psychomotor" seizures and sound-induced seizures with ED50 values of 99, 39, 81, 51, and 10 mg/kg, respectively. In rats, M-TMCD effectively prevented MES- and Metrazol-induced seizures and secondarily generalized seizures in hippocampal kindled rats (ED50 values of 82, 45, and 39 mg/kg, respectively). Unlike M-TMCD, TMCD was active only against Metrazol-induced seizures in mice and rats (ED50 values of 57 and 52 mg/kg, respectively). Neither M-TMCD nor TMCD was found to induce NTDs in SWV mice.

CONCLUSIONS

The results obtained in this study show that M-TMCD is a broad-spectrum anticonvulsant drug that does not induce NTDs and support additional studies to evaluate its full therapeutic potential.

[Serotonin-noradrenaline reuptake inhibitors(SNRIs)]

Pharmacology, clinical efficacy and tolerability of serotonin noradrenaline reuptake inhibitors(SNRIs) are overviewed. They include milnacipran, venlafaxine, duloxetine, MCI-225 and nefazodone, however, only milnacipran is currently used in Japan. Pharmacology of SNRIs is characterized by inhibition of both serotonin and noradrenaline at the presynaptic membrane and by weak affinity with receptors at the postsynaptic membrane, which expects the same efficacy on major depressive disorder(MDD) as tricyclic antidepressant drugs(TCAs) with less adverse effects in clinical use. Currently available evidences show that SNRIs possess antidepressant effects on MDD at least similar potencies to TCAs with more potencies than selective serotonin reuptake inhibitors. SNRIs are well tolerated in general and safer than TCAs. SNRIs can be considered to be first-line antidepressant drugs.

Antidepressant efficacy and tolerability of milnacipran, a dual serotonin and noradrenaline reuptake inhibitor: a comparison with fluvoxamine

The antidepressant efficacy and tolerability of milnacipran, a dual action serotonin-noradrenaline reuptake inhibitor, were compared with those of the selective serotonin reuptake inhibitor, fluvoxamine, in 113 patients with moderate to severe major depression. Treatment with milnacipran, 50 mg b.d. for 6 weeks, produced a significantly greater reduction in Montgomery-Asberg Depression Rating Scale (MADRS) scores than fluvoxamine, 100 mg b.d. (P = 0.007; 65.4% versus 49.9%, respectively); significantly greater decreases were also seen on days 7 (P = 0.04) and 28 (P = 0.03). The response rate (the proportion of patients showing a decrease in MADRS scores of at least 50%) was 78.9% in patients receiving milnacipran, compared with 60.7% in fluvoxamine-treated patients (P = 0.04). Milnacipran also produced greater improvements in 24-item Hamilton Depression Rating Scale scores (P = 0.05). On the Clinical Global Impression Improvement scale, 77.2% of milnacipran-treated patients were rated as considerably or markedly improved, compared with 60.7% of patients receiving fluvoxamine (P = 0.06 chi-squared). Both treatments were well tolerated; the only significant difference between the two groups was a higher incidence of tremor and drowsiness in patients treated with fluvoxamine. It is concluded that milnacipran may offer some advantages over selective serotonin reuptake inhibitors, such as fluvoxamine, in the treatment of moderate to severe major depression.

Tedisamil (Solvay)

Tedisamil, a potassium channel blocker (class III anti-arrhythmic agent)from Solvay, is in phase II trials for the potential treatment of atrial fibrillation [342434]. The drug had completed phase III trials for angina pectoris [342434], [177648], and although an NDA dossier for angina pectoris in refractory patients was ready for filing with the US FDA, Solvay has decided to pursue the broader indication of atrial fibrillation instead [342434]. Tedisamil is bradycardic without producing a negative inotropic effect. In a canine model of exercise-induced angina, myocardial function was maintained. In rat, rabbit, canine and simian hearts, there was a marked prolongation of action potential, due to tedisamil's modulating effects on potassium channels. Diastolic arterial pressure was not influenced [276934]. Tedisamil also rapidly terminated sustained atrial fibrillation and prevented its reinitiation in a canine model of the condition [315378]. The class III antiarrhythmic effect of tedisamil is related predominantly to the strong blocking effect of the drug on the rapid component of the delayed rectifier potassium current [334806].

The use of topical diphenylcyclopropenone for the treatment of extensive alopecia areata

BACKGROUND

Highly variable results of topical diphenylcyclopropenone (DPCP) in the treatment of alopecia areata have been reported so far.

OBJECTIVE

The purposes of our study were to evaluate the efficacy and tolerability of DPCP in the treatment of chronic, extensive alopecia areata and to assess the long-term overall benefit of treatment.

METHODS

Fifty-six patients with chronic, extensive alopecia areata were enrolled in an open-label clinical trial. After sensitization with 2% DPCP, progressively higher concentrations beginning at 0.001% were applied weekly for 6 to 12 months to one side of the scalp.

RESULTS

Fifty-two of 56 patients completed therapy. Total regrowth of terminal hair was achieved in 25 of 52 patients (48%) at 6 months. The most frequent side effect was an eczematous reaction at the site of application. Notably, persistent response was observed in 60% of these patients after 6 to 18 months of follow-up (mean, 12 months).

CONCLUSION

Topical DPCP treatment for alopecia areata is effective and well tolerated and provides prolonged therapeutic benefits.

Topical immunotherapy of severe alopecia areata with diphenylcyclopropenone: evaluation of 68 cases

BACKGROUND

Currently, topical immunotherapy with diphenylcyclopropenone (DCP) represents the most accepted therapeutic modality in the treatment of severe alopecia areata (AA).

OBJECTIVE

Efficacy, side effects and prognostic factors of DCP treatment in severe AA.

METHODS

Retrospective study of 68 patients with severe AA (> 40% scalp hair loss), treated for at least 5 months at the Department of Dermatology, University Hospital of Zürich, between May 1989 and December 1996.

RESULTS

The overall response rate was 70.6%, complete remission was obtained in 30.9% and partial remission in 39.7%. Among the investigated prognostic factors for the outcome of DCP therapy, only the extent of AA at the time of initiation of treatment was found to be of significance.

CONCLUSION

DCP treatment of severe AA is an effective, albeit symptomatic therapy with frequent side effects and a relatively high relapse rate. The response rate depends on the type of AA.