Reboxetine plus citalopram for refractory depression not responding to venlafaxine: possible mechanisms

A case of social phobia and avoidant personality disorder with erectile dysfunction successfully treated with venlafaxine and add-on reboxetine

A 25-year-old man with DSM-IV-TR Axis I social phobia and Axis II avoidant personality disorder and erectile dysfunction, presenting with depression, anxiety and insomnia, responded partially to extended release oral venlafaxine (75 mg/die for 6 weeks), but developed side effects and worsening symptoms when dose was increased to 150 mg/die; he responded to a combination of 75 mg/die venlafaxine and 4 mg/die reboxetine and improved on most of his symptoms.

Clinical effect of nemifitide, a novel pentapeptide antidepressant, in the treatment of severely depressed refractory patients

Clinical data were evaluated from an open-label, single-center, pilot study in patients with chronic refractory depression. The primary efficacy criterion was the change from baseline using the Montgomery-Asberg Depression Rating Scale. The secondary efficacy criteria were the 17-item Hamilton Depression Rating Scale and the Clinical Global Impression-Improvement scale. Response to treatment (40-240 mg once per day by subcutaneous injection for 10-20 doses) was defined as more than 50% improvement in the Montgomery-Asberg Depression Rating Scale from baseline or Clinical Global Impression-Improvement < or =2 and lasting for at least two sequential weeks. Patients with a sustained response at the end point in the acute main treatment phase were enrolled for up to 2 years in a maintenance phase of the study to determine duration of response and to initiate retreatments upon relapse. Of the 25 patients with chronic refractory depression, 11 patients showed a response for Montgomery-Asberg Depression Rating Scale and one responded according to the secondary criterion Hamilton Depression Rating Scale. In seven of the 11 responders to Montgomery-Asberg Depression Rating Scale the effects were sustained for the remainder of the acute phase. Two additional sustained responders identified according to secondary criteria (Hamilton Depression Rating Scale or Clinical Global Impression-Improvement) were also enrolled in the maintenance phase. All nine sustained responders were retreated, as needed, in the maintenance phase of the study, ranging from 71 to 660 days. Mean duration of response following initial treatment and between retreatments was around 2 months. Pharmacokinetic data indicated dose-proportional systemic exposure to the drug.

A Critical Overview of the Pharmacologic Management of Treatment-Resistant Depression

Major depressive disorder is a frequent, serious disorder that usually responds partially to treatment and leaves many patients with treatment resistance. This article reviews and critically evaluates the evidence for the management of treatment-resistant depression and examines pharmacologic approaches to alleviate the suffering of patients who benefit insufficiently from initial treatment.

A comparison of the efficacy and tolerability of reboxetine and sertraline versus venlafaxine in major depressive disorder: a randomized, open-labeled clinical trial

The aim of the study was to compare the efficacy and tolerability of the combination of reboxetine and sertraline to venlafaxine XR (extended release) in major depressive disorder (MDD). The study consisted of 40 patients with MDD, aged 18-65 years. Patients were evaluated six times during a 10-week period. Treatment was started as venlafaxine XR 75 mg/day once a day (od) or reboxetine 4 mg/day twice a day (bid)+sertraline 50 mg/day od. In the second week, venlafaxine XR was increased to 150 mg/day od and reboxetine 8 mg/day bid while sertraline was kept at the same dose. The Hamilton Depression Rating Scale (HDRS), Montgomery and Asberg Depression Rating Scale, Clinical Global Impressions-Severity of Illness and Clinical Global Impressions-Global Improvement Scale were applied on each visit. Beginning from the second visit, both groups showed significant declines in each scale. There were no significant differences between treatment response rates. Remission rates defined as HDRS<or=10 were significantly higher in the venlafaxine XR group at visit 4 only. However, when remission was accepted as HDRS<or=7, no significant difference was observed. Side effect frequency was similar between the treatment groups. We may suggest that the reboxetine+sertraline combination is not superior to venlafaxine treatment.

Multi-target strategies for the improved treatment of depressive states: Conceptual foundations and neuronal substrates, drug discovery and therapeutic application

Major depression is a debilitating and recurrent disorder with a substantial lifetime risk and a high social cost. Depressed patients generally display co-morbid symptoms, and depression frequently accompanies other serious disorders. Currently available drugs display limited efficacy and a pronounced delay to onset of action, and all provoke distressing side effects. Cloning of the human genome has fuelled expectations that symptomatic treatment may soon become more rapid and effective, and that depressive states may ultimately be "prevented" or "cured". In pursuing these objectives, in particular for genome-derived, non-monoaminergic targets, "specificity" of drug actions is often emphasized. That is, priority is afforded to agents that interact exclusively with a single site hypothesized as critically involved in the pathogenesis and/or control of depression. Certain highly selective drugs may prove effective, and they remain indispensable in the experimental (and clinical) evaluation of the significance of novel mechanisms. However, by analogy to other multifactorial disorders, "multi-target" agents may be better adapted to the improved treatment of depressive states. Support for this contention is garnered from a broad palette of observations, ranging from mechanisms of action of adjunctive drug combinations and electroconvulsive therapy to "network theory" analysis of the etiology and management of depressive states. The review also outlines opportunities to be exploited, and challenges to be addressed, in the discovery and characterization of drugs recognizing multiple targets. Finally, a diversity of multi-target strategies is proposed for the more efficacious and rapid control of core and co-morbid symptoms of depression, together with improved tolerance relative to currently available agents.

Efficacy and tolerability of reboxetine compared with citalopram: a double-blind study in patients with major depressive disorder

The objective of this study was to compare efficacy and tolerability of the selective noradrenaline reuptake inhibitor reboxetine with the selective serotonin reuptake inhibitor citalopram, in the treatment of major depressive disorder (MDD). In total, 357 outpatients with MDD were randomized to treatment with reboxetine 8-10 mg or citalopram 20-40 mg per day during 24 weeks. Primary end-point was change from baseline in the Hamilton Depression Rating Scale (HAM-D, 21 items). Sexual function/dysfunction was measured by the Sexual Function scale (SF). Observed case analysis showed that both treatments yielded a gradual reduction of HAM-D scores: reboxetine with -21.4 and citalopram with -22.1 points (NS). LOCF analysis showed a greater reduction of the HAM-D scores with citalopram compared with reboxetine (-19.6 vs. -17.8; P = 0.034). The response rate was 90.3% for reboxetine and 92.7% for citalopram (NS). The most common side effect in the reboxetine group was dry mouth, and in the citalopram group sexual dysfunction. At week 24, anorgasmia was reported by 5.9% of the sexually active women in the reboxetine group vs 39% in the citalopram group. The dropout number was 91 in the reboxetine group, and 54 in the citalopram group. To summarize, both treatments gave a satisfactory antidepressant effect. The side effect profile differed between the groups, with a notably high prevalence of sexual dysfunctions in the citalopram group. The high number of dropouts in the reboxetine group, is considered as a result of the non-titration starting dose of 8 mg reboxetine per day, which gave a high incidence of early side-effects.

To combine or not to combine? A literature review of antidepressant combination therapy

OBJECTIVE

Treatment resistant depression is a common clinical problem and a major public health concern. The use of antidepressant combinations to overcome treatment resistance, while somewhat controversial, is a popular strategy in practice. This paper reviews published trials on combination antidepressants with a view to inform clinical practice.

METHOD

A systematic but selective review of the published literature was conducted using EMBASE, PSYCHLIT and MEDLINE with relevant search terms.

RESULTS

A number of trials suggesting efficacy of combination antidepressants were found. These are incorporated into a number of treatment guidelines for the management of treatment refractory depression. Clinicians should be cautious regarding pharmacokinetic and pharmacodynamic interactions, including the serotonin syndrome, however combination strategies are an effective option.

CONCLUSIONS

Many antidepressants can be usefully combined especially if they engage separate mechanisms of action. Clinically, antidepressant combinations provide a useful resort in otherwise treatment resistant individuals. However, much further research is needed to determine relative efficacy and determine long term outcome.

Escitalopram/reboxetine combination in depressed patients with substance use disorder

Acting pharmacologically on different transmitter systems has been suggested to have some advantages in patients with substance abuse and may possibly address a larger spectrum of symptoms. One major drawback of using antidepressants addressing several neurotransmitters is that the relative activities on the different neurotransmitters cannot individually be adjusted. Combining antidepressants targeting different neurotransmitter systems may allow adapting the effect on each neurotransmitter system corresponding to patients' response and tolerance. Three cases of patients presenting a substance use disorder with comorbid major depression episodes are presented, who were treated with a reboxetine/escitalopram combination and who showed a rapid response of their depressive syndrome.

Toward optimal treatments for major depression

The treatment of major depression remains problematic for several reasons. In particular, the therapeutic response to medications usually does not manifest itself until a week after administration has begun, and more than half the patients will not experience a full recovery with the first antidepressant drug administration. There are, however, some pharmacologic strategies that can accelerate antidepressant response. When facing a treatment-resistant depression, combination therapy offers a more time-efficient approach to achieve remission than drug substitution. These interventions have been devised on a better understanding of the basis for the therapeutic response obtained with the first- and second-generation antidepressants, and evidence derived from controlled clinical trials of their superior effectiveness is growing. The rationale for such approaches will be described in this article, as well as their advantages and potential inconveniences. Ongoing research in this field continues to fuel the development of novel, better-tolerated, and more effective pharmacotherapies for depression.