Escitalopram: a review of its use in the management of major depressive disorder

Escitalopram for the management of major depressive disorder: a review of its efficacy, safety, and patient acceptability

Escitalopram (escitalopram oxalate; Cipralex(®), Lexapro(®)) is a selective serotonin reuptake inhibitor (SSRI) used for the treatment of major depressive disorder (MDD) and anxiety disorder. This drug exerts a highly selective, potent, and dose-dependent inhibitory effect on the human serotonin transport. By inhibiting the reuptake of serotonin into presynaptic nerve endings, this drug enhances the activity of serotonin in the central nervous system. Escitalopram also has allosteric activity. Moreover, the possibility of interacting with other drugs is considered low. This review covers randomized, controlled studies that enrolled adult patients with MDD to evaluate the efficacy of escitalopram based on the Montgomery-Asberg Depression Rating Scale and the Hamilton Depression Rating Scale. The results showed that escitalopram was superior to placebo, and nearly equal or superior to other SSRIs (eg, citalopram, paroxetine, fluoxetine, sertraline) and serotonin-noradrenaline reuptake inhibitors (eg, duloxetine, sustained-release venlafaxine). In addition, with long-term administration, escitalopram has shown a preventive effect on MDD relapse and recurrence. Escitalopram also showed favorable tolerability, and associated adverse events were generally mild and temporary. Discontinuation symptoms were milder with escitalopram than with paroxetine. In view of the patient acceptability of escitalopram, based on both a meta-analysis and a pooled analysis, this drug was more favorable than other new antidepressants. The findings indicate that escitalopram achieved high continuity in antidepressant drug therapy.

Effects of escitalopram in prevention of depression in patients with acute coronary syndrome (DECARD)

OBJECTIVE

Depression is a major problem in patients after acute coronary syndrome (ACS) with negative impact on survival and quality of life. No studies have examined prevention of post-ACS depression. We examined whether treatment with escitalopram can prevent post-ACS depression.

METHODS

We have conducted a randomised controlled trial. Between November 2004 and December 2007, 240 patients in 2 university hospitals in Copenhagen, Denmark, with ACS were randomised. Patients were randomised to a double-blind treatment with escitalopram or matching placebo for 1 year. Main outcome measure was the incidence of ICD-10 depressive episode.

RESULTS

Of 120 patients treated with escitalopram 2 developed depression versus 10 in placebo treated group (log rank, p=0.022). In multivariate analysis treatment with placebo and high Hamilton Depression Scale score at baseline were associated with development of depression. Patients were well matched at baseline.

CONCLUSION

Twelve months treatment with escitalopram prevented depression in post-ACS patients.

Depression in vascular pathologies: the neurologist's point of view

The coexistence of depression and cardiovascular disease (CVD) is regularly discussed, and much debated. There is strong evidence that there are pathophysiological mechanisms, particularly endothelial dysfunction, altered platelet aggregation, and hyperactivation of the thrombosis cascade, which coexist with hypothalamic-pituitary-adrenocortical axis dysfunction, and link depression to CVD. Therefore, depression should not be automatically considered to be a consequence of life impairment due to myocardial infarction or major stroke. Probably, it should be considered as one of the many other stressful events, or “genetic reactions to life”, which are risk factors for CVD development. This review will examine the significance of depression in clinical daily practice, its pathophysiology as a determinant in vascular events, and its real importance in, before, and after many CVD events.

Escitalopram affects cytoskeleton and synaptic plasticity pathways in a rat gene-environment interaction model of depression as revealed by proteomics. Part II: environmental challenge

Large-scale investigations aimed at elucidating the molecular mechanism of action of antidepressant treatment are achievable through the application of proteomic technologies. We performed a proteomic study on the Flinders Sensitive Line (FSL), a genetically selected rat model of depression, and the control Flinders Resistant Line (FRL). To evaluate gene-environment interactions, FSL and FRL animals were separated from their mothers for 3 h from postnatal days 2 to 14 (maternal separation; MS), since early-life trauma is considered an important antecedent of depression. All groups received either escitalopram (Esc) admixed to food pellets (25 mg/kg.d) or vehicle for 1 month. Protein extracts from prefrontal/frontal cortex and hippocampus were separated by 2D electrophoresis. Proteins differentially modulated were identified by mass spectrometry. Bioinformatics analyses were performed to discover gene ontology terms associated with the modulated proteins. This paper was focused on the modifications induced by the environmental challenge of MS, both on the predisposed genetic background and on the resistant phenotype. The combination between Esc treatment and MS was investigated by comparing the MS, Esc-treated rats with rats subjected to each single procedure. In MS rats, antidepressant treatment influenced mainly proteins involved in carbohydrate metabolism in FSL rats and in vesicle-mediated transport in FRL rats. When studying the interaction between Esc and MS vs. non-separated rats, proteins playing a role in cytoskeleton organization, neuronal development, vesicle-mediated transport and synaptic plasticity were identified. The results provide further support to the available reports that antidepressant treatment affects intracellular pathways and also suggest new potential targets for future therapeutic intervention.

Escitalopram modulates neuron-remodelling proteins in a rat gene-environment interaction model of depression as revealed by proteomics. Part I: genetic background

The wide-scale analysis of protein expression provides a powerful strategy for the molecular exploration of complex pathophysiological mechanisms, such as the response to antidepressants. Using a 2D proteomic approach we investigated the Flinders Sensitive Line (FSL), a genetically selected rat model of depression, and the control Flinders Resistant Line (FRL). To evaluate gene-environment interactions, FSL and FRL pups were separated from their mothers for 3 h (maternal separation, MS), as early-life trauma is considered an important antecedent of depression. All groups were treated with either escitalopram (Esc) admixed to food (25 mg/kg.d) or vehicle for 1 month. At the week 3, forced swim tests were performed. Protein extracts from prefrontal/frontal cortex and hippocampus were separated by 2D electrophoresis. Proteins displaying statistically significant differences in expression levels were identified by mass spectrometry. Immobility time values in the forced swim test were higher in FSL rats and reduced by antidepressant treatment. Moreover, the Esc-induced reduction in immobility time was not detected in MS rats. The impact of genetic background in response to Esc was specifically investigated here. Bioinformatics analyses highlighted gene ontology terms showing tighter associations with the modulated proteins. Esc modulated protein belonging to cytoskeleton organization in FSL; carbohydrate metabolism and intracellular transport in FRL. Proteins differently modulated in the two strains after MS and Esc play a role in cytoskeleton organization, vesicle-mediated transport, apoptosis regulation and macromolecule catabolism. These findings suggest pathways involved in neuronal remodelling as molecular correlates of response to antidepressants in a model of vulnerability.

Remission of major depressive disorder without adverse events: a comparison of escitalopram versus serotonin norepinephrine reuptake inhibitors

OBJECTIVE

An antidepressant's tolerability, generally captured as the frequency and severity of adverse events (AEs), is often as important as its efficacy in determining treatment success. This study used a composite outcome - remission of major depressive disorder (MDD) without AEs - to compare the benefit-risk profiles of escitalopram versus the norepinephrine reuptake inhibitors (SNRIs) duloxetine and venlafaxine extended release (XR).

METHODS

Pooled data from three randomized, double-blind, multicenter trials were analyzed, in which patients with MDD were treated for 8 weeks with either escitalopram (n = 462) or an SNRI (n = 467).

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov identifiers: NCT00108979; NCT00384436.

MAIN OUTCOME MEASURES

The composite outcome was defined as remission (Montgomery-Åsberg Depression Rating Scale [MADRS] score ≤10) and concurrent absence of an AE. The proportions of remitted patients free of (1) any AEs, (2) moderate-to-severe AEs, and (3) study drug-related AEs were compared between treatment groups at each study visit and longitudinally across study visits common to all trials during the first 8 weeks of treatment.

RESULTS

At endpoint (week 8), escitalopram-treated patients were more likely than SNRI-treated patients to experience remission free of any AEs (28.4 vs. 21.6%; p = 0.0179) and remission free of study drug-related AEs (45.2 vs. 36.8%; p = 0.0092). Compared to SNRI-treated patients, escitalopram-treated patients had 38% greater odds of remission free of any AEs, 28% greater odds of remission free of moderate-to-severe AEs, and 34% greater odds of remission free of study drug-related AEs (all p < 0.05).

CONCLUSION

Treatment of adult MDD patients with escitalopram was significantly more likely to result in remission without concurrent AEs compared to treatment with current SNRIs. Study limitations include focus on only the initial 8 weeks of treatment and exclusion of trials for which individual patient data were not obtained.

'Bench to behavior': translating comparative effectiveness research into improved clinical practice

The new national emphasis on comparative effectiveness research is likely to generate an unprecedented volume of new findings. It is essential to anticipate the obstacles that front-line health care professionals will face in translating these results into better clinical decision making. We review the current barriers to the dissemination of evidence-based clinical recommendations, including problems with continuing medical education, provider incentives, and quality assurance. We then propose solutions, including more effective educational outreach programs, requirements for practitioners to master important findings, and alignment of incentives to encourage evidence-based practice. Such strategies can lead to policies that could encourage the uptake of new comparative effectiveness data and encourage their translation into better clinical practice.

Escitalopram: a review of its use in the management of major depressive disorder in adults

Escitalopram (escitalopram oxalate; Cipralex, Lexapro), a selective serotonin reuptake inhibitor (SSRI) indicated for the treatment of major depressive disorder (MDD), demonstrates a highly selective and potent, dose-dependent inhibition of the human serotonin transporter, inhibiting serotonin reuptake into presynaptic nerve terminals and thus increasing serotonergic activity in the CNS. With regard to primary endpoints (such as improved scores on the Montgomery-Asberg Depression Rating Scale [MADRS] and the Hamilton Depression Rating Scale [HAM-D]), escitalopram was generally more effective than placebo, at least as effective as citalopram, and generally at least as effective as other comparator drugs, including the SSRIs fluoxetine, paroxetine and sertraline, the serotonin-noradrenaline (norepinephrine) reuptake inhibitors (SNRIs) venlafaxine extended release and duloxetine, and the aminoketone bupropion in adult patients with MDD in short-term, well designed trials. Moreover, it demonstrated a rapid onset of antidepressant action. Escitalopram was also found to be cost effective in several studies, dominating other SSRIs and venlafaxine extended release. Maintenance therapy is commonly required to prevent recurrence of depression. Long-term trials corroborated short-term results, with escitalopram demonstrating greater efficacy than placebo in relapse prevention. Additionally, escitalopram was at least as effective as citalopram, paroxetine and duloxetine in long-term comparative trials. Escitalopram has a predictable tolerability profile with generally mild to moderate and transient adverse events, and a low propensity for drug interactions. Sexual dysfunction with escitalopram treatment appeared to occur to a similar or lower extent to that with paroxetine (another SSRI), to a similar or greater extent to that with the SNRI duloxetine, and to a greater extent than that with the aminoketone bupropion. Thus, escitalopram is an effective and generally well tolerated treatment for moderate to severe MDD. Escitalopram, like other SSRIs, is an effective first-line option in the management of patients with MDD.

Copper-catalyzed cyanation of heterocycle carbon-hydrogen bonds

A method for regioselective cyanation of heterocycles has been developed. A number of aromatic heterocycles as well as azulene can be cyanated in reasonable to good yields by using a copper cyanide catalyst and an iodine oxidant.

Escitalopram: in the treatment of major depressive disorder in adolescent patients

Escitalopram is a selective serotonin reuptake inhibitor (SSRI), and is the second antidepressant to be approved for use in treating major depressive disorder (MDD) in adolescent patients (aged 12-17 years) in the US. In a randomized, double-blind, flexible-dose, multicenter trial, once-daily escitalopram 10-20 mg (n = 154) for 8 weeks was significantly better than placebo (n = 157) in improving the severity of depressive symptoms (as assessed by the change in the Children's Depression Rating Scale-Revised [CDRS-R] total score) in adolescent patients with MDD. Preliminary data from a combined analysis of the double-blind data from this trial and double-blind data from a 16-week, fixed-dose, extension study suggest a significant difference between escitalopram and placebo recipients in the change in CDRS-R total scores after 24 weeks of treatment. In a similarly designed flexible-dose trial in pediatric patients (aged 6-17 years), a significant difference between once-daily escitalopram 10-20 mg (n = 77) and placebo (n = 80) for 8 weeks, as assessed by the change in CDRS-R total score, was not shown in the primary analysis (i.e. patients of all ages). In a pre-specified subgroup of adolescent patients, no significant difference was shown between the escitalopram and the placebo groups when analyzed using the last observation carried forward method, but was shown using the observed case method. Escitalopram 10-20 mg/day showed better efficacy than placebo for some secondary endpoints (e.g. the change in the Clinical Global Impression [CGI]-Severity score, the CGI-Improvement response rate) but not others (e.g. CDRS-R response rate, rate of remission) [corrected].Once-daily escitalopram 10-20 mg for 8 weeks was generally well tolerated in clinical trials in adolescent or pediatric patients with MDD. The incidence of suicidality-related adverse events was generally similar between escitalopram and placebo recipients.

Influence of escitalopram treatment on 5-HT 1A receptor binding in limbic regions in patients with anxiety disorders

There is an increasing interest in the underlying mechanisms of the antidepressant and anxiolytic treatment effect associated with changes in serotonergic neurotransmission after treatment with selective serotonin (5-HT) reuptake inhibitors (SSRIs) in humans. The 5-HT(1A) receptor is known to play a crucial role in the pathophysiology of affective disorders, and altered 5-HT(1A) receptor binding has been found in anxiety patients. SSRI treatment raises the 5-HT level in the synaptic cleft and might change postsynaptic receptor densities. Therefore, our study in patients suffering from anxiety disorders investigated the effects of long-term treatment with escitalopram on the 5-HT(1A) receptor. A longitudinal positrone emission tomography (PET) study in 12 patients suffering from anxiety disorders was conducted. Two dynamic PET scans were performed applying the selective 5-HT(1A) receptor antagonist [carbonyl-(11)C]WAY-100635. Eight regions of interest were defined a priori (orbitofrontal cortex, amygdala, hippocampus, subgenual cortex, anterior and posterior cingulate cortex, dorsal raphe nucleus and cerebellum as reference). After the baseline PET scan, patients were administered escitalopram (average dose of 11.2+/-6.0 mg day(-1)) for a minimum of 12 weeks. A second PET scan was conducted after 109+/-27 days. 5-HT(1A) receptor binding potentials in 12 patients were assessed by PET applying the Simplified Reference Tissue Model.There was a significant reduction in the 5-HT(1A) receptor binding potential after a minimum of 12 weeks of escitalopram treatment in the hippocampus (P=0.006), subgenual cortex (P=0.017) and posterior cingulate cortex (P=0.034). The significance of the hippocampus region survived the Bonferroni-adjusted threshold for multiple comparisons. These PET data in humans in vivo demonstrate a reduction of the 5-HT(1A) binding potential after SSRI treatment.

Treatment persistence, healthcare utilisation and costs in adult patients with major depressive disorder: a comparison between escitalopram and other SSRI/SNRIs

OBJECTIVE

Compare treatment persistence, healthcare utilisation and costs for patients treated with escitalopram versus other SSRI/SNRIs in a real-world setting.

METHODS

Patients with a diagnosis for major depressive disorder (MDD) and at least one prescription for an SSRI or SNRI were identified from the Ingenix Impact Database (2002-2005). The baseline and study observation periods were defined as the 6 months before and after the index date (first date for an SSRI /SNRI pharmacy claim). Comparisons were made between patients initiated on escitalopram versus other SSRI/SNRIs using descriptive statistics and multivariate regressions.

RESULTS

Escitalopram patients (n=10,465) had better treatment persistence compared to patients initiated on other SSRI/SNRIs (n=28,310): the hazard ratio of all discontinuation was 0.96 (95% confidence interval [CI]=0.94-0.99) for the escitalopram therapy (p=0.003), and the hazard ratio of switching to another second-generation antidepressant was 0.91 (95% CI=0.87-0.94) for the escitalopram therapy (p<0.001). Escitalopram patients also had fewer inpatient service and emergency room visits. Adjusted average total all-cause healthcare costs and inpatient services costs were $839 and $405 lower in the escitalopram group (both p<0.05).

CONCLUSIONS

Escitalopram may be associated with lower healthcare utilisation and costs among adult MDD patients compared to other SSRI/SNRIs.

Rationale, design and methodology of a double-blind, randomized, placebo-controlled study of escitalopram in prevention of Depression in Acute Coronary Syndrome (DECARD)

BACKGROUND

The prevalence of depression in patients with acute coronary syndrome, i.e. myocardial infarction and unstable angina, is higher than in the general population. The prevalence of anxiety is higher as well. Both depression and anxiety are associated with poor cardiac outcomes and higher mortality. Comorbid depression in patients with acute coronary syndrome often goes undiagnosed, and it is therefore a challenging task to prevent this risk factor. The study of DEpression in Coronary ARtery Disease (DECARD) is designed to examine if it is possible to prevent depression in patients with acute coronary syndrome.

METHODS

Two hundred forty non-depressed patients with acute coronary syndrome are randomized to treatment with either escitalopram or placebo for 1 year. Psychiatric and cardiac assessment of patients is performed to evaluate the possibility of preventing depression. Diagnosis of depression and Hamilton Depression Scale are the primary outcome measures.

DISCUSSION

This is the first study of prevention of depression in patients after acute coronary syndrome with a selective serotonin reuptake inhibitor.

TRIAL REGISTRATION

http://www.ClinicalTrials.gov. Identifier: NCT00140257.

Predictive factors for generalized seizures after deliberate citalopram overdose

AIMS

Seizures are a recognized complication of citalopram overdose. The present study sought to establish risk factors for seizures in this high-risk patient group, including stated dose ingested, co-ingested drugs or ethanol, and electrolyte disturbances.

METHODS

A retrospective casenote review was carried out of patients who attended the Emergency Department due to citalopram overdose between January 2000 and July 2007 inclusive. Stepwise logistic regression analysis considered age, gender, stated citalopram dose, acute ethanol consumption, co-ingested drugs, administration of activated charcoal, and hyponatraemia.

RESULTS

There were 241 patients (177 women), and the median (interquartile range) stated citalopram dose was 300 mg (200 to 600 mg). Generalized seizures occurred in 18 patients (7.5%). Logistic regression analysis found co-ingested tricyclic antidepressants or venlafaxine predicted seizures with odds ratio = 15 (95% confidence interval 3, 75). In the absence of co-ingested drugs, the minimum citalopram dose associated with seizures was 400 mg. Odds ratio for seizures = 1.1 (95% confidence interval 1.0, 1.2) for every 100 mg increment in citalopram dose. Seizures were associated with a greater need for invasive ventilatory support, higher creatine kinase activity, and prolonged hospital stay.

CONCLUSIONS

Generalized seizures are an important manifestation of citalopram toxicity, and cannot be explained solely by electrolyte disturbances or co-ingestion of other drugs or ethanol. The strongest predictors of seizures in this patient series were ingestion of high citalopram dosages and co-ingestion of drugs capable of lowering seizure threshold.

Corrected QT interval prolongation after an overdose of escitalopram, morphine, oxycodone, zopiclone and benzodiazepines

Escitalopram is the recently marketed S-enantiomer of the widely used antidepressant citalopram. Data from intentional overexposure to this medication are limited. Twelve-lead electrocardiogram (ECG) effects from racemic citalopram have been described; however, the present report is the first, to the best of the authors' knowledge, that describes all the reported abnormalities in a single patient receiving escitalopram. A 52-year-old man with a history of depression treated with escitalopram 10 mg/day, extended-release morphine 30 mg/day and zopiclone 15 mg/day was found unconscious at his home. He was known to have attempted suicide three weeks previously. Partially emptied bottles of escitalopram, morphine, oxycodone, zopiclone, lorazepam and diazepam were found close to the patient. He was transferred to the emergency department, where airway management and other supportive care were initiated. The patient was transferred to the intensive care unit. The initial 12-lead ECG demonstrated junctional rhythm at 48 beats/min, a wide complex escape (145 ms) with right bundle branch morphology and a prolonged corrected QT interval at 650 ms. Cardiac monitoring was undertaken. No ventricular arrhythmias or torsade de pointes were detected. No specific treatment for shortening the QT was implemented. Another 12-lead ECG performed 48 h later demonstrated sinus tachycardia with a normal corrected QT, normal PR interval and normal QRS duration. The effects of the overdose of escitalopram on the ECG and its interactions with other drugs are reviewed.

Escitalopram for the treatment of major depression and anxiety disorders

Escitalopram is the S-enantiomer of the selective serotonin reuptake inhibitor (SSRI) citalopram, which contains equal amounts of the S- and R-forms in a racemic mixture. Escitalopram is the most selective SSRI, with almost no significant affinity to other tested receptors. It has been demonstrated that it is escitalopram that carries the therapeutic potential of citalopram, and has statistically superior and clinically relevant properties compared with citalopram. Escitalopram is at least as effective in the treatment of depression and anxiety as other SSRIs, as well as venlafaxine, bupropion and duloxetine. Owing to multiple metabolic degrading pathways, the clinically relevant interactions of escitalopram with other drugs are minimal. Compared with other antidepressants, escitalopram is generally better tolerated, its onset of action is relatively fast, and its use may have cost-effectiveness and cost-utility advantages. Escitalopram is an effective first-line option in the management of patients with major depression, including severe forms, and various anxiety disorders.

From the selective serotonin transporter inhibitor citalopram to the selective norepinephrine transporter inhibitor talopram: synthesis and structure-activity relationship studies

Citalopram and talopram are structurally closely related, but they have very distinct pharmacological profiles as selective inhibitors of the serotonin and norepinephrine transporters, respectively. A systematic structure-activity relationship study was performed, in which each of the four positions distinguishing the two compounds were varied. The inhibitory potencies of the resulting 16 compounds were tested at both serotonin and norepinephrine transporters. This showed that particularly two of the four positions are determinants for the biological activity.

Escitalopram and duloxetine in major depressive disorder: a pharmacoeconomic comparison using UK cost data

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) are approved for the treatment of major depressive disorder (MDD). The allosteric SSRI escitalopram has been shown to be at least as clinically effective as the SNRIs venlafaxine and duloxetine in MDD, with a better tolerability profile. In addition, escitalopram has been shown to be cost saving compared with venlafaxine.

OBJECTIVE

To evaluate the cost effectiveness of escitalopram versus duloxetine in the treatment of MDD, and to identify key cost drivers.

METHODS

The pharmacoeconomic evaluation was conducted alongside a 24-week, double-blind, multinational randomized study (escitalopram 20 mg/day and duloxetine 60 mg/day) in outpatients with MDD, aged 18-65 years, with Montgomery-Asberg Depression Rating Scale (MADRS) score >or=26 and Clinical Global Impression Severity (CGI-S) score >or=4, and baseline duration of the current depressive episode of 12 weeks to 1 year.The analysis was conducted on the full analysis set (FAS), which included all patients with >or=1 valid post-baseline health economic assessment. Effectiveness outcomes of the cost-effectiveness analyses (CEA) included the change in Sheehan Disability Scale (SDS) score (primary CEA), treatment response (MADRS score decrease >or=50%) and remission (MADRS score <or=12) rates at week 24. Cost outcomes were assessed from the societal perspective. Healthcare resource use and sick leave were evaluated using a health economic assessment questionnaire. Unit costs of healthcare services were obtained from standard UK sources ( pound, year 2006 values).

RESULTS

Over the total 24-week study period, escitalopram was associated with significant cost savings compared with duloxetine (total per-patient monthly cost pound 188 vs pound 334, respectively). In the primary CEA, escitalopram dominated duloxetine (i.e. was more effective on the disability scale and less costly). Treatment with escitalopram resulted in significantly lower mean sick leave duration per patient over 24 weeks than duloxetine (30.7 days vs 62.2 days).In multivariate analyses, escitalopram as a treatment choice was associated with a 54% reduction in sick leave duration (p < 0.001). Treatment with escitalopram also resulted in 49% lower total costs than treatment with duloxetine (p = 0.002). Absenteeism accounted for about two-thirds of the overall cost. Early clinical improvement (mean change in MADRS total score, response and remission) had an independent significant impact on the sick leave duration, after controlling for key co-variates.

CONCLUSIONS

Escitalopram was associated with significantly lower duration of sick leave and significant savings in the total cost compared with duloxetine; it dominated duloxetine when effectiveness was assessed on the SDS scale. Indirect costs due to sick leave accounted for the most substantial portion of the total cost and should, therefore, be an important consideration when pharmacoeconomic comparisons between treatments are made from the societal perspective. The link between decrease in absenteeism and early (8-week) clinical improvement suggested in the additional analyses may explain the reduced sick leave observed with escitalopram, given its superior short-term efficacy compared with duloxetine (demonstrated in the underlying clinical trial).

Depressive Störungen

Das Spektrum depressiver Erkrankungen macht den Hauptteil affektiver Störungen aus und gehört mit einer Inzidenz von ca. 8–20% zu den häufigsten psychischen Erkrankungen. Depressionen werden nach wie vor zu selten einer adäquaten Therapie (Antidepressiva, störungsspezifische Psychotherapie wie z. B. kognitive Verhaltenstherapie) zugeführt.

Escitalopram in the treatment of major depressive disorder: clinical efficacy, tolerability and cost-effectiveness vs. venlafaxine extended-release formulation

Major depressive disorder (MDD), a prevalent and serious mental illness, is associated with a substantial disease and economic burden. Long-term pharmacotherapy is often necessary; selective serotonin reuptake inhibitors (SSRIs) or the serotonin-noradrenaline reuptake inhibitor venlafaxine are the most frequently prescribed medications in patients with moderate-to-severe depressive symptoms. This article reviews head-to-head clinical studies and health economic models comparing the efficacy, tolerability and cost-effectiveness of escitalopram, a dual-action selective inhibitor of serotonin reuptake, and the extended-release (XR) formulation of venlafaxine. While there has been some evidence that conventional SSRIs are inferior to venlafaxine in terms of efficacy, escitalopram was at least as effective as venlafaxine XR in reducing Montgomery-Asberg Depression Rating Scale scores from baseline in two short-term (8-week) comparative studies. Furthermore, escitalopram had potentially important advantages over venlafaxine XR in terms of time to remission, tolerability and discontinuation (withdrawal) symptoms. The results of economic evaluations, including a 'gold standard' prospective study conducted alongside one of the studies are consistent in suggesting that escitalopram offers a more cost-effective alternative to venlafaxine XR for the treatment of MDD, both from a healthcare and societal perspective. Based on this evidence, it is concluded that escitalopram is at least as effective as venlafaxine XR in the treatment of MDD, but is better tolerated and may also have cost advantages.

Higher serotonin transporter occupancy after multiple dose administration of escitalopram compared to citalopram: an [123I]ADAM SPECT study

OBJECTIVES

Previous studies have investigated the occupancy of the serotonin reuptake transporter (SERT) after clinical doses of citalopram and other selective serotonin reuptake inhibitors. In the present study, the occupancies of SERT after multiple doses of escitalopram and citalopram were compared using the radioligand [(123)I]ADAM and single photon emission computed tomography (SPECT).

METHODS

Fifteen healthy subjects received escitalopram 10 mg/day (n = 6) or citalopram 20 mg/day (n = 9) for a total of 10 days. SERT occupancies in midbrain were determined with SPECT and [(123)I]ADAM at three different time points: at baseline (no medication) and at 6 and 54 h after last drug intake.

RESULTS

At 6 h after the last dose, mean SERT occupancies were 81.5 +/- 5.4% (mean+/-SD) for escitalopram and 64.0 +/- 12.7% for citalopram (p < 0.01). At 54 h after the last dose, mean SERT occupancies were 63.3 +/- 12.1% for escitalopram and 49.0 +/- 11.7% for citalopram (p < 0.05). The plasma concentrations of the S-enantiomer were of the same magnitude in both substances. For both drugs, the elimination rate of the S-enantiomer in plasma was markedly higher than the occupancy decline rate in the midbrain.

CONCLUSION

The significantly higher occupancy of SERT after multiple doses of escitalopram compared to citalopram indicates an increased inhibition of SERT by escitalopram. The results can also be explained by an attenuating effect of R-citalopram on the occupancy of S-citalopram at the SERT.

New treatment options for OCD

Pharmacological management of obsessive-compulsive disorder (OCD) is achieved using drugs that inhibit the synaptic uptake of serotonin, such as clomipramine, a tricyclic antidepressant, and the selective serotonin reuptake inhibitors (SSRIs). Recent studies suggest that the improved tolerability profile of the SSRIs relative to clomipramine may offer a more suitable treatment choice. Escitalopram, the therapeutically active S-enantiomer of citalopram, is the most selective SSRI currently available. In a 24-week randomized, placebo-controlled, double-blind study, escitalopram (20 mg) was associated with significantly lower symptom scores at 12 weeks (P<0.01) and increased response rate (Yale-Brown Obsessive-compulsive Scale [Y-BOCS]) (70.2%) compared with placebo (50.4%). Escitalopram (10 mg) was more effective in reducing symptom scores than placebo at 24 weeks (P=0.052). Escitalopram 20 mg was also associated with improved remitter status (Y-BOCS total score ≤10) compared with paroxetine (40 mg) or placebo from week 12. In a relapse-prevention study, 10 and 20 mg escitalopram showed a statistically significant superior effect relative to placebo on time to relapse of OCD with a hazard ratio of 2.74. Escitalopram was well-tolerated by patients with OCD. In conclusion, escitalopram provides significant symptom relief and prevention of relapse during long-term use and deserves consideration as a first-line agent in the long-term pharmacotherapy of OCD.

Escitalopram: a review of its use in the management of anxiety disorders

Escitalopram (Cipralex, Lexapro, Seroplex, Sipralexa), the therapeutically active S-enantiomer of racemic citalopram (RS-citalopram), is a potent and highly selective serotonin reuptake inhibitor. It is effective and generally well tolerated in the treatment of moderate to severe generalised anxiety disorder (GAD) or social anxiety disorder (SAD), panic disorder (with or without agoraphobia) as well as obsessive-compulsive disorder (OCD). Moreover, escitalopram is at least as effective as paroxetine for the treatment of GAD, SAD or OCD and appears to achieve a more rapid response than racemic citalopram in the management of panic disorder. Generally, it has a more favourable tolerability profile than paroxetine in terms of fewer discontinuation symptoms. In addition, a favourable pharmacokinetic profile permits once-daily administration of the drug. Additional comparative studies are required to definitively position escitalopram with respect to other SSRIs and venlafaxine. Nevertheless, available clinical data indicate that escitalopram is an effective first-line treatment option for the management of GAD, SAD, panic disorder and OCD.

Managing depressive and anxiety disorders with escitalopram

This article reviews escitalopram, the S-stereoisomer of the racemic compound citalopram, and a highly selective and potent member of the selective serotonin re-uptake inhibitor class of antidepressants. Escitalopram has a straightforward pharmacokinetic profile, little effect on hepatic metabolism, and is relatively safe in overdose. Similar to other members of the selective serotonin re-uptake inhibitor class, escitalopram (10-20 mg/day) is a well-tolerated and effective treatment of major depressive disorder. Although relatively few head-to-head comparative studies with other antidepressants have been published, pooled analyses of studies using citalopram as the active comparator suggest a modest advantage for the stereoisomer. This advantage, which is more apparent among patients with greater symptom levels, may be attributable to a greater than predicted potency compared with citalopram, presumably as a result of the greater effect of escitalopram at the allosteric binding site of the serotonin transporter. Results of two published studies versus venlafaxine also suggest better tolerability in the context of comparable efficacy. Escitalopram is also approved for the treatment of generalised anxiety disorder (in the US) and social anxiety disorder and panic disorder (in the EU). Pharmacoeconomic models suggest that the greater drug acquisition cost of this patent-protected compound may be offset by greater efficacy (relative to generic citalopram) and tolerability (compared with extended release venlafaxine).

Serotonin noradrenaline reuptake inhibitors: Logical evolution of antidepressant development

Although considerable progress has been made in improving the tolerability of antidepressant drugs, the classical tricyclic antidepressants (TCA) are still a standard for efficacy. The selective serotonin reuptake inhibitors (SSRI) are much better tolerated than the TCAs, but their antidepressant efficacy is, at best, equivalent and probably inferior to the TCA, clomipramine, in many situations. The introduction of the SSRIs naturally focussed both fundamental and clinical research effort on the role of serotonin (5-HT) in the pharmacogenesis and pharmacotherapy of depression. More recently the probable role of noradrenaline (NA) has been "rediscovered" and increasingly both 5-HT and NA dysfunctions are seen as fundamental to depressive illness. The therapeutic importance of this has been underlined by studies showing the increased antidepressant efficacy obtained when selective serotonergic drugs have been used in conjunction with selective noradrenergic drugs. The development of the new class of serotonin and noradrenaline reuptake inhibitors (SNRI) was a logical extension of these ideas. Compounds of this class, which currently comprises venlafaxine, milnacipran and duloxetine, act to inhibit the reuptake of both monoamines with no direct actions at postsynaptic receptors. Although, by definition all three SNRIs have actions on both 5-HT and NA neurotransmission, they do not all have equal potency for both transmitters. Venlafaxine has a 30-fold higher affinity for 5-HT than NA while duloxetine has a 10-fold selectivity for 5-HT. Only milnacipran is balanced between the two neurotransmitters with an approximately equal potency for the inhibition of reuptake of 5-HT and NA both in vitro and in vivo. At high doses venlafaxine and duloxetine appear to be superior to SSRIs but not at lower doses. Duloxetine is, however, not licensed in the EU at these higher doses. Milnacipran at usual doses appears more effective than SSRIs with efficacy which is similar to TCAs but with a lower side effect burden.