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Mehrotra R, Cukor D, McCurry SM, Rue T, Roumelioti ME, Heagerty PJ, Unruh M. Effectiveness of Existing Insomnia Therapies for Patients Undergoing Hemodialysis : A Randomized Clinical Trial. Ann Intern Med 2024; 177:177-188. [PMID: 38224591 DOI: 10.7326/m23-1794] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Chronic insomnia is common in patients undergoing in-center hemodialysis, yet there is limited evidence on effective treatments for this population. OBJECTIVE To compare the effectiveness of cognitive behavioral therapy for insomnia (CBT-I), trazodone, and placebo for insomnia in patients undergoing long-term hemodialysis. DESIGN Randomized, multicenter, double-blinded, placebo-controlled trial. (ClinicalTrials.gov: NCT03534284). SETTING 26 dialysis units in Albuquerque, New Mexico, and Seattle, Washington. PARTICIPANTS Patients with Insomnia Severity Index (ISI) score of 10 or greater, with sleep disturbances on 3 or more nights per week for 3 or more months. INTERVENTION Participants were randomly assigned to 6 weeks of CBT-I, trazodone, or placebo. MEASUREMENTS The primary outcome was the ISI score at 7 and 25 weeks from randomization. RESULTS A total of 923 patients were prescreened, and of the 411 patients with chronic insomnia, 126 were randomly assigned to CBT-I (n = 43), trazodone (n = 42), or placebo (n = 41). The change in ISI scores from baseline to 7 weeks with CBT-I or trazodone was no different from placebo: CBT-I, -3.7 (95% CI, -5.5 to -1.9); trazodone, -4.2 (CI, -5.9 to -2.4); and placebo, -3.1 (CI, -4.9 to -1.3). There was no meaningful change in ISI scores from baseline to 25 weeks: CBT-I, -4.8 (CI, -7.0 to -2.7); trazodone, -4.0 (CI, -6.0 to -1.9); and placebo, -4.3 (CI, -6.4 to -2.2). Serious adverse events (SAEs), particularly serious cardiovascular events, were more frequent with trazodone (annualized cardiovascular SAE incidence rates: CBT-I, 0.05 [CI, 0.00 to 0.29]; trazodone, 0.64 [CI, 0.34 to 1.10]; and placebo, 0.21 [CI, 0.06 to 0.53]). LIMITATION Modest sample size and most participants had mild or moderate insomnia. CONCLUSION In patients undergoing hemodialysis with mild or moderate chronic insomnia, there was no difference in the effectiveness of 6 weeks of CBT-I or trazodone compared with placebo. The incidence of SAEs was higher with trazodone. PRIMARY FUNDING SOURCE National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- Rajnish Mehrotra
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington (R.M.)
| | - Daniel Cukor
- The Rogosin Institute, New York, New York (D.C.)
| | - Susan M McCurry
- School of Nursing, University of Washington, Seattle, Washington (S.M.M.)
| | - Tessa Rue
- Center for Biomedical Statistics, University of Washington School of Public Health, Seattle, Washington (T.R., P.J.H.)
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Medicine, University of New Mexico, Albuquerque, New Mexico (M.-E.R., M.U.)
| | - Patrick J Heagerty
- Center for Biomedical Statistics, University of Washington School of Public Health, Seattle, Washington (T.R., P.J.H.)
| | - Mark Unruh
- Division of Nephrology, Department of Medicine, University of New Mexico, Albuquerque, New Mexico (M.-E.R., M.U.)
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Yokohara S, Hashiguchi M, Shiga T. Psychotherapeutic drug-induced life-threatening arrhythmias: A retrospective analysis using the Japanese adverse drug event report database. J Arrhythm 2023; 39:928-936. [PMID: 38045460 PMCID: PMC10692844 DOI: 10.1002/joa3.12936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 12/05/2023] Open
Abstract
Background Drug-induced life-threatening ventricular arrhythmias including torsade de pointes (TdP), ventricular tachycardia (VT), and ventricular fibrillation (VF) are serious cardiac side effects. Psychotherapeutic drugs are known to be risk factors for arrhythmias. The aim of this study was to evaluate psychotherapeutic drugs associated with life-threatening ventricular arrhythmias using the Japanese Adverse Drug Event Report (JADER) database. Methods From the JADER database (April 2004 to September 2022), cases of TdP, VT, VF, and QT prolongation in patients taking psychotherapeutic drugs as 'suspected drugs' were extracted. The adjusted reported odds ratio (aROR) was calculated to identify potential drugs involved in combined TdP/VF/VT or combined QT prolongation/TdP. Results Of the 4,530,772 cases reported, life-threatening arrhythmia-related adverse events were reported in 1760 cases (QT prolongation 1261, TdP 192, VF 108, VT 199) among 909 patients; 58.9% of patients were female, and the highest incidence was among patients aged 80-89 years (18.6%), followed by patients aged 70-79 years (15.4%). The highest aROR for TdP/VF/VT was found for trazodone (17.1), followed by sulpiride (10.8), haloperidol (9.8), donepezil (9.1), and fluvoxamine (7.9). The highest aROR for QT prolongation/TdP was found for guanfacine (87.8), followed by sultopride (60.1), escitalopram (21.0), trazodone (12.8), and donepezil (9.3). Conclusions This study showed that typical antipsychotics, antidepressants, and antidementia drugs were associated with life-threatening arrhythmia-related adverse events in a Japanese clinical setting. These events were more frequent in women and elderly individuals.
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Affiliation(s)
| | - Masayuki Hashiguchi
- Department of Clinical Pharmacology and TherapeuticsThe Jikei University School of MedicineTokyoJapan
| | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and TherapeuticsThe Jikei University School of MedicineTokyoJapan
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Benjamin EJ, Nelson OL, Baumwart R, Haines J. Adverse effects of trazodone in dogs on primary hemostasis and electrocardiogram: A single-blinded placebo-controlled crossover study. J Vet Intern Med 2023; 37:2131-2136. [PMID: 37807949 PMCID: PMC10658541 DOI: 10.1111/jvim.16841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 08/21/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND Trazodone is a serotonin antagonist/reuptake inhibitor medication commonly used for anxiety in dogs. Therapy with selective serotonin reuptake inhibitors in humans is associated with bleeding disorders and increased arrhythmogenesis. HYPOTHESIS/OBJECTIVES To evaluate markers of primary hemostasis and corrected QT (cQT) interval in dogs before and after oral administration of standard dosages of trazodone or placebo. ANIMALS Fifteen apparently healthy, client-owned dogs. METHODS A single-blinded, randomized placebo-controlled crossover study was performed. Dogs were administered trazodone (5 to 7.5 mg/kg PO Q12h) or placebo. [Correction added after first online publication on 14 October 2023. In the abstract (methods) section (57.5 mg/kg PO Q12h) changed as (5 to 7.5 mg/kg PO Q12h).] Buccal mucosal bleeding time (BMBT), platelet count, platelet aggregation via Plateletworks, PFA-100 closure time and cQT interval were measured. A Shapiro-Wilk test was performed followed by either a paired t test or a Wilcoxon signed-rank test. RESULTS No significant difference was detected in the BMBT, PFA-100 closure times, platelet counts, and cQT interval between trazodone or placebo. However, using Plateletworks, there was a significant decrease in platelet aggregation after administration of trazodone (95%; 81-97 vs 62%; 39-89, P = .002) and not placebo (95%; 81-97 vs 91%; 81-96, P = .21). CONCLUSIONS It is unknown if this represents a clinically relevant change or if dogs with preexisting impairment in primary hemostasis or receiving higher dosages or longer durations of trazodone could have a more substantial change in hemostatic variables.
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Fagiolini A, González-Pinto A, Miskowiak KW, Morgado P, Young AH, Vieta E. Role of trazodone in treatment of major depressive disorder: an update. Ann Gen Psychiatry 2023; 22:32. [PMID: 37660092 PMCID: PMC10474647 DOI: 10.1186/s12991-023-00465-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/22/2023] [Indexed: 09/04/2023] Open
Abstract
Major depressive disorder (MDD) is the most common mood disorder and a leading cause of disability worldwide. Trazodone, a triazolopyridine serotonin receptor antagonist and reuptake inhibitor (SARI) antidepressant approved for major depressive disorder (MDD) in adults, has established efficacy that is comparable to other available antidepressants, and is effective for a range of depression symptoms, including insomnia, which is one of the most common and bothersome symptoms of depression. Also, trazodone's pharmacodynamic properties allow it to avoid the side effects of insomnia, anxiety and sexual dysfunction often associated with selective serotonin reuptake inhibitor antidepressants. In this narrative review, we have summarized recent clinical trials and real-world data on trazodone, including the recently introduced once-daily formulation, which has single dose pharmacokinetic properties that maintain effective blood trazodone levels for 24 h, while avoiding concentration peaks associated with side effects. This, combined with a low incidence of weight gain, and sexual dysfunction, may improve adherence to treatment. The most common adverse effects of trazodone are somnolence, headache, dizziness and xerostomia. It has minimal anticholinergic activity but may be associated infrequently with orthostatic hypotension (especially in patients with cardiovascular disease or older adults), QT interval prolongation, cardiac arrhythmias, and rare episodes of priapism. The low liability for activating side effects, the efficacy on symptoms such as insomnia and psychomotor agitation and the rapid onset of action make it useful for many depressed patients, both in monotherapy at nominal dosages of 150-300 mg/day, and in combination with other antidepressants at lower dosages.
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Affiliation(s)
- Andrea Fagiolini
- Department of Molecular and Developmental Medicine, Division of Psychiatry, University of Siena School of Medicine, Viale Bracci 12, 53100, Siena, Italy.
| | - Ana González-Pinto
- Bioaraba Research Institute, Department of Psychiatry, Araba University Hospital, 01004, Vitoria, Spain
- CIBERSAM. University of the Basque Country, Vitoria, Spain
| | - Kamilla Woznica Miskowiak
- Psychiatric Centre, Copenhagen Affective Disorder Research Centre (CADIC), Rigshospitalet, Copenhagen, Denmark
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Pedro Morgado
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, 4710-057, Braga/Guimarães, Portugal
- Clinical Academic Center-Braga (2CA), 4710-243, Braga, Portugal
| | - Allan H Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London Strand, London, UK
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Kent, UK
| | - Eduard Vieta
- Bipolar and Depressive Disorders Unit, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
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Hobbs K, Luethy D, Davis J, Mallicote M, Torcivia C, Kulp J, Stefanovski D, Futterman C, Cooper F, van Eps A. The effects of orally administered trazodone on ambulation and recumbency in healthy horses. J Vet Intern Med 2023; 37:1899-1906. [PMID: 37489582 PMCID: PMC10472990 DOI: 10.1111/jvim.16821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 07/07/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Trazodone, a serotonin receptor antagonist and reuptake inhibitor, might be a useful adjunctive treatment in the initial management of horses with acute laminitis if it minimizes ambulation or encourages recumbency. OBJECTIVES (1) Evaluate the effects of PO trazodone on ambulatory activity and recumbency in healthy horses; and (2) assess the pharmacokinetics of multiple PO doses of trazodone. ANIMALS/METHODS In a randomized cross-over design, 8 healthy horses received placebo or trazodone at 2 doses (2.5 and 7.5 mg/kg) PO q12h for 48 hours with a 14-day washout period between treatments. Forelimb step frequency was measured using a hoof-mounted accelerometer and continuous video monitoring was used to detect recumbency. Groups were compared using repeated measures analysis of variance with Tukey's post hoc test. Trazodone and m-chlorophenylpiperazine (m-CPP) plasma concentrations were determined by ultra-high performance liquid chromatography-tandem mass spectrometry and pharmacokinetics were analyzed using noncompartmental methods. RESULTS Step frequency was lower in horses receiving 7.5 mg/kg trazodone than in the control group (mean step reduction: 44% ± 11%). Steps-area under the curve were significantly lower in the 7.5 mg/kg group (mean ± SD: 3375 ± 525 steps × hour) as compared to the 2.5 mg/kg group (mean ± SD: 5901 ± 2232; P = .02) and compared to control (mean ± SD: 6590 ± 1241; P = .001). No difference was found in the number of recumbent episodes (P = .92) or total duration of recumbency (P = .9). Trazodone and m-CPP achieved steady-state concentrations, with an accumulation ratio of 1.45 ± 0.2. CONCLUSIONS AND CLINICAL IMPORTANCE Although it did not affect recumbency, trazodone at 7.5 mg/kg q12h decreased step frequency by approximately 44%.
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Affiliation(s)
- Kallie Hobbs
- Department of Large Animal Clinical SciencesUniversity of Florida College of Veterinary MedicineGainesvilleFloridaUSA
| | - Daniela Luethy
- Department of Large Animal Clinical SciencesUniversity of Florida College of Veterinary MedicineGainesvilleFloridaUSA
| | - Jennifer Davis
- Department of Biomedical Sciences and PathobiologyVirginia‐Maryland College of Veterinary MedicineBlacksburgVirginiaUSA
| | - Martha Mallicote
- Department of Large Animal Clinical SciencesUniversity of Florida College of Veterinary MedicineGainesvilleFloridaUSA
| | - Catherine Torcivia
- Department of Clinical Studies‐New Bolton Center, School of Veterinary MedicineUniversity of PennsylvaniaKennett SquarePennsylvaniaUSA
| | - Jeaneen Kulp
- Department of Clinical Studies‐New Bolton Center, School of Veterinary MedicineUniversity of PennsylvaniaKennett SquarePennsylvaniaUSA
| | - Darko Stefanovski
- Department of Clinical Studies‐New Bolton Center, School of Veterinary MedicineUniversity of PennsylvaniaKennett SquarePennsylvaniaUSA
| | - Catherine Futterman
- Department of Large Animal Clinical SciencesUniversity of Florida College of Veterinary MedicineGainesvilleFloridaUSA
| | - Freya Cooper
- Department of Large Animal Clinical SciencesUniversity of Florida College of Veterinary MedicineGainesvilleFloridaUSA
| | - Andrew van Eps
- Department of Clinical Studies‐New Bolton Center, School of Veterinary MedicineUniversity of PennsylvaniaKennett SquarePennsylvaniaUSA
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Sidhom E, O’Brien JT, Butcher AJ, Smith HL, Mallucci GR, Underwood BR. Targeting the Unfolded Protein Response as a Disease-Modifying Pathway in Dementia. Int J Mol Sci 2022; 23:2021. [PMID: 35216136 PMCID: PMC8877151 DOI: 10.3390/ijms23042021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/19/2022] [Accepted: 01/26/2022] [Indexed: 01/27/2023] Open
Abstract
Dementia is a global medical and societal challenge; it has devastating personal, social and economic costs, which will increase rapidly as the world's population ages. Despite this, there are no disease-modifying treatments for dementia; current therapy modestly improves symptoms but does not change the outcome. Therefore, new treatments are urgently needed-particularly any that can slow down the disease's progression. Many of the neurodegenerative diseases that lead to dementia are characterised by common pathological responses to abnormal protein production and misfolding in brain cells, raising the possibility of the broad application of therapeutics that target these common processes. The unfolded protein response (UPR) is one such mechanism. The UPR is a highly conserved cellular stress response to abnormal protein folding and is widely dysregulated in neurodegenerative diseases. In this review, we describe the basic machinery of the UPR, as well as the evidence for its overactivation and pathogenicity in dementia, and for the marked neuroprotective effects of its therapeutic manipulation in murine models of these disorders. We discuss drugs identified as potential UPR-modifying therapeutic agents-in particular the licensed antidepressant trazodone-and we review epidemiological and trial data from their use in human populations. Finally, we explore future directions for investigating the potential benefit of using trazodone or similar UPR-modulating compounds for disease modification in patients with dementia.
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Affiliation(s)
- Emad Sidhom
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0AH, UK; (E.S.); (A.J.B.); (H.L.S.); (G.R.M.)
- Department of Clinical Neurosciences, UK Dementia Research Institute, University of Cambridge, Cambridge CB2 0AH, UK
- Cambridgeshire and Peterborough NHS Foundation Trust, Windsor Research Unit, Fulbourn Hospital, Cambridge CB21 5EF, UK
- Gnodde Goldman Sachs Translational Neuroscience Unit, Windsor Research Unit, University of Cambridge, Cambridge CB2 1TN, UK
| | - John T. O’Brien
- Department of Psychiatry, University of Cambridge, Herchel Smith Building, Forvie Site, Cambridge CB2 0SZ, UK;
| | - Adrian J. Butcher
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0AH, UK; (E.S.); (A.J.B.); (H.L.S.); (G.R.M.)
- Department of Clinical Neurosciences, UK Dementia Research Institute, University of Cambridge, Cambridge CB2 0AH, UK
| | - Heather L. Smith
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0AH, UK; (E.S.); (A.J.B.); (H.L.S.); (G.R.M.)
- Department of Clinical Neurosciences, UK Dementia Research Institute, University of Cambridge, Cambridge CB2 0AH, UK
| | - Giovanna R. Mallucci
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0AH, UK; (E.S.); (A.J.B.); (H.L.S.); (G.R.M.)
- Department of Clinical Neurosciences, UK Dementia Research Institute, University of Cambridge, Cambridge CB2 0AH, UK
| | - Benjamin R. Underwood
- Cambridgeshire and Peterborough NHS Foundation Trust, Windsor Research Unit, Fulbourn Hospital, Cambridge CB21 5EF, UK
- Gnodde Goldman Sachs Translational Neuroscience Unit, Windsor Research Unit, University of Cambridge, Cambridge CB2 1TN, UK
- Department of Psychiatry, University of Cambridge, Herchel Smith Building, Forvie Site, Cambridge CB2 0SZ, UK;
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