Neurochemical changes in rat brain amines after short- and long-term inhibition of monoamine oxidase by a low dose of tranylcypromine

[Psychopharmacotherapy with the MAO-inhibitor Tranylcypromine Key Aspects and Trends in Theory and Practice]

The irreversible monoamine oxidase inhibitor tranylcypromine has been known as an antidepressant drug for more than 60 years. The aim of this review was to make an assessment of the state of the art and therapy of tranylcypromine. The recent medical-scientific literature is analyzed and discussed with respect to key aspects of and general trends in practical psychopharmacotherapy. Meta-analyses of controlled clinical studies have shown that tranylcypromine is an established approach to treatment-resistant depression. Doses (maximum dose, maintenance dose) are increasingly adapted to the requirements of treatment-resistant depression. Monoamine oxidase is not only the primary pharmacological target of tranylcypromine but determines for the first doses also the pharmacokinetics of tranylcypromine because monoamine oxidase is also an enantioselective drug-metabolizing enzyme of the monoamine oxidase inhibitor. An increased diversity of the antidepressant pharmacotherapy suggests the need to rethink the continuing assessment of tranylcypromine as a therapeutic "ultima ratio" in depression. In conclusion, tranylcypromine as a drug of second choice remains a valuable option in antidepressant treatment. Criteria of a switch from other antidepressant drugs to tranylcypromine should be better defined.

The trace amine theory of spontaneous hypertension as induced by classic monoamine oxidase inhibitors

The classic monoamine oxidase inhibitors (MAOIs) tranylcypromine (TCP) and phenelzine (PLZ) are powerful antidepressants that come with an equally powerful stigma, and are thus rarely prescribed-despite their well-established effectiveness. Some of these preconceptions appear to stem from unclarity, as the etiology of a rare but important side effect, 'spontaneous hypertension' (SH)-a significant increase in blood pressure absent dietary tyramine ingestion-remains improperly elucidated. This paper aims at uprooting some of the stigma surrounding MAOIs by advancing the trace amine (TA) theory as the causative underpinning of SH. This theory posits that SH results from the considerable influx of TAs observed following TCP- or PLZ-administration. TAs are known, albeit at greatly supraphysiological levels, to raise blood pressure on account of their propensity to exert potent indirect sympathomimetic effects; additionally, some research posits that TAs may induce vasoconstrictive effects partly or wholly separate therefrom, which would then constitute a second hypertensive mechanism. TAs are endogenous to the human body in low quantities. Both TCP and PLZ cause marked elevations of 2-phenylethylamine (PEA), meta- and para-tyramine (m-/p-TYR), octopamine (OA), and tryptamine (TRYP), following both acute and (sub)chronic administration. This paper holds that TYR plays a pivotal role in causing SH, due to its strong pressor effect. Cautious treatment of SH is advised, given its typically self-limiting nature. The risk of hypotensive overshoots must be taken into account. For severe cases, this paper urges reconsideration, following suitable confirmation trials, of antipsychotics (notably risperidone) as these agents may reduce striatal p-TYR levels.

Review and meta-analysis of add-on tranylcypromine with antipsychotic drugs for the treatment of schizophrenia with predominant negative symptoms: a restoration of evidence

BACKGROUND

Treatment using add-on antidepressants with antipsychotic drugs in negative symptoms of schizophrenia has been reviewed recently in comprehensive meta-analyses. Tranylcypromine (TCP), an irreversible monoamine oxidase (MAO)-A/B inhibitor applied in treatment resistant depression, was not included because of strict requirements for quality of study design. To get a clear picture of available evidence for this resource in the treatment of schizophrenia, we conducted a review and meta-analysis of add-on TCP in the treatment of predominant negative symptoms of schizophrenia (negative schizophrenia).

METHODS

Seven controlled studies of add-on TCP in schizophrenia with predominant negative symptoms were found in a search of multiple databases. A subset of four studies of the prospective and parallel comparison of add-on TCP with antipsychotic drugs vs. antipsychotic drug monotherapy and meeting minimum quality criteria formed the primary meta-analysis. The effect size was calculated as the natural logarithm of the odds ratio (logOR) of responders and non-responders.

RESULTS

In the primary meta-analysis, a pooled logOR = 1.092 with 95%CI 0.410-1.774 (I² = 43.4%, moderate heterogeneity) was calculated according to a fixed-effect model. Heterogeneity was reduced for three double-blind studies of add-on TCP with trifluoperazine (TFP) vs. TFP-monotherapy and resulted a pooled logOR = 0.916 with 95%CI 0.216-1.616 (I² negative, no heterogeneity). A significant logOR = 1.558 with 95%CI 0.340-2.776 was found for TCP/TFP compared to placebo in one study. In a meta-analysis of extrapyramidal adverse effects, studies were very heterogeneous and revealed no significant differences between treatments. The risk of exacerbation of positive symptoms with add-on TCP was found to be very low for a duration of treatment of 12-16 weeks. No cases of hypertensive crisis were reported. The main methodical limitations were insufficient description of randomization or matching of patients without randomization. The main clinical limitation is a gap of data for add-on TCP with second-generation antipsychotics.

CONCLUSION

New studies are needed for add-on TCP with antipsychotic drugs in schizophrenia with predominant negative symptoms. Trials of this treatment may be possible in rare and selected cases. The therapeutic effect of add-on TCP may be explained by a strong dopaminergic activity.

Tranylcypromine in mind (Part I): Review of pharmacology

It has been over 50 years since a review has focused exclusively on the monoamine oxidase (MAO) inhibitor tranylcypromine (TCP). A new review has therefore been conducted for TCP in two parts which are written to be read preferably in close conjunction: Part I - pharmacodynamics, pharmacokinetics, drug interactions, toxicology; and Part II - clinical studies with meta-analysis of controlled studies in depression, practice of TCP treatment, place in therapy. Pharmacological data of this review part I characterize TCP as an irreversible and nonselective MAO-A/B inhibitor at low therapeutic doses of 20mg/day with supplementary norepinephrine reuptake inhibition at higher doses of 40-60mg/day. Serotonin, norepinephrine, dopamine, and trace amines, such as the "endogenous amphetamine" phenylethylamine, are increased in brain, which leads to changes in neuroplasticity by e.g. increased neurotrophic growth factors and translates to reduced stress-induced hypersecretion of corticotropin releasing factor (CRF) and positive testing in animal studies of depression. TCP has a pharmacokinetic half-life (t_1/2) of only 2h which is considerably lower than for most other antidepressant drugs. However, a very long pharmacodynamic half-life of about one week is found because of the irreversible MAO inhibition. New studies show that, except for cytochrome P450 (CYP) 2A6, no other drug metabolizing CYP-enzymes are inhibited by TCP at therapeutic doses which defines a low potential of pharmacokinetic interactions in the direction from TCP to other drugs. Insufficient information is available, however, for plasma concentrations of TCP influenced by comedication. More quantitative data are also needed for TCP metabolites such as p-hydroxytranylcypromine and N-acetyltranylcypromine. Pharmacodynamic drug interactions comprise for instance severe serotonin toxicity (SST) with serotonergic drugs and hypertensive crisis with indirect sympathomimetics. Because of the risk of severe food interaction, TCP treatment remains beset with the need for a mandatory tyramine-restricted diet. Toxicity in overdose is similar to amitriptyline and imipramine according to the distance of therapeutic to toxic doses. In conclusion, TCP is characterized by an exceptional pharmacology which is different to most other antidepressant drugs, and a more special evaluation of clinical efficacy and safety may therefore be needed.

Regulation of corticotropin-releasing factor neuronal systems and hypothalamic-pituitary-adrenal axis activity by stress and chronic antidepressant treatment

In a series of experiments, we tested the hypothesis that chronic antidepressant drug administration reduces the synaptic availability of corticotropin-releasing factor (CRF) through one or more effects on CRF gene expression or peptide synthesis. We also determined whether effects of acute or chronic stress on CRF gene expression or peptide concentration are influenced by antidepressant drug treatment. Four-week treatment with venlafaxine, a dual serotonin (5-HT)/norepinephrine (NE) reuptake inhibitor, and tranylcypromine, a monoamine oxidase inhibitor, resulted in an attenuation of acute stress-induced increases in CRF heteronuclear RNA (hnRNA) synthesis in the paraventricular nucleus (PVN). Trends toward the same effect were observed after treatment with the 5-HT reuptake inhibitor fluoxetine, or the NE reuptake inhibitor reboxetine. CRF mRNA accumulation in the PVN during exposure to chronic variable stress was attenuated by concurrent antidepressant administration. Basal CRF hnRNA and mRNA expression were not affected by antidepressant treatment in the PVN or in other brain regions examined. Chronic stress reduced CRF concentrations in the median eminence, but there were no consistent effects of antidepressant drug treatment on CRF, serum corticotropin, or corticosterone concentrations. CRF receptor expression and basal and stress-stimulated HPA axis activity were unchanged after antidepressant administration. These results suggest that chronic antidepressant administration diminishes the sensitivity of CRF neurons to stress rather than alters their basal activity. Additional studies are required to elucidate the functional consequences and mechanisms of this interaction.

Time-dependent changes in brain monoamine oxidase activity and in brain levels of monoamines and amino acids following acute administration of the antidepressant/antipanic drug phenelzine

Phenelzine (PLZ) is a non-selective monoamine oxidase (MAO) inhibitor commonly used to treat depression and panic disorder. Acute administration of PLZ produces several neurochemical changes, including an increase in brain levels of the catecholamines norepinephrine (NE) and dopamine (DA), of 5-hydroxytryptamine (5-HT), and of the amino acids alanine and gamma-aminobutyric acid (GABA). The goal of the present series of experiments was to characterize the time course of these PLZ-induced changes. Male Sprague-Dawley rats were sacrificed 6, 24, 48, 96, 168, or 336 hr after acute PLZ administration (15 or 30 mg/kg, i.p., based on free base weight). Whole brain levels of monoamines and amino acids were determined using HPLC, and MAO A and B activities were determined using a radiochemical procedure. The results indicated that PLZ changed amino acid levels 6 and 24 hr after injection, but not 48 hr later. In contrast, the effects of PLZ on MAO activity and monoamines were longer-lasting. For example, PLZ-induced increases in dopamine and 5-HT were observed 1 week after injection, and PLZ-induced inhibition of MAO activity persisted for 2 weeks. Thus, in addition to demonstrating that the effects of PLZ on MAO activity and monoamines were long-lasting, these results indicate that the effects of PLZ on MAO activity and on brain levels of monoamines and amino acids are temporally dissociated. These findings regarding the long-term effects of PLZ on neurochemistry will have considerable critical implications for the design and interpretation of behavioral studies of the acute effects of PLZ.

Effects of tranylcypromine on thyroid hormone metabolism and concentrations in rat brain

The effect of 14 days administration of the anti-depressant tranylcypromine (TCP) on iodothyronine deiodinase activities and the concentrations of thyroxine (T4) and triiodothyronine (T3) were investigated in homogenates of up to nine regions of the rat brain. The activity of the 5III deiodinase isoenzyme, which catalyses the inactivation of T3 to 3,3'-diiodothyronine (3,3'-T2), was enhanced in eight brain regions. However, the brain levels of T4 were completely unchanged and the T3 concentrations were significantly reduced in the frontal cortex only. Therefore, we also measured the T3 concentrations of three subcellular fractions (nuclei, synaptosomes and mitochondria) of six brain regions. TCP induced a significant reduction in T3 levels in the synaptosomes of the frontal cortex and significant increases in the mitochondrial T3 concentrations in the amygdala. The latter effect was replicated after 14 days administration of 5 mg/kg desipramine. No effects of either drug on nuclear concentrations of T3 were seen in any brain region. As the amygdala is critically involved in the affective coloring of sensory stimuli, the increase in T3 concentrations in the mitochondria of this brain region may be of relevance for the mechanism of action of anti-depressant drugs.

Tranylcypromine does not enhance the effects of amitriptyline on 5-HT2 receptors in rat cerebral cortex

The combination of amitriptyline (a tricyclic antidepressant) and tranylcypromine (a monoamine oxidase inhibitor) has been reported to be effective for treatment of refractory depressed patients. In the study reported here, this drug combination was compared with amitriptyline administered alone on the number and affinity of 5-HT2 receptors in rat brain. Male Sprague-Dawley rats were given vehicle (distilled water), amitriptyline (3.5 mg/kg/day), or tranylcypromine and amitriptyline (0.5 and 3.5 mg/kg/day, respectively) in combination subcutaneously via osmotic minipumps for 4, 10, or 28 days. A membrane fraction prepared from whole cortex was employed for studying binding to 5-HT2 receptors ([3H]ketanserin as the radioligand). The combination of amitriptyline and tranylcypromine produced a small but significantly greater down-regulation (decrease in number) of 5-HT2 sites than did amitriptyline alone after 10 days of administration; at 4 and 28 days, both amitriptyline and the drug combination had produced down-regulation, but there was not a significant difference between the two treatments. These data suggest that the antidepressant efficacy observed with this combination is not likely due to an enhanced effect on 5-HT2 receptors.

Chronic effects of tranylcypromine and 4-fluorotranylcypromine on regional brain monoamine metabolism in rats: a comparison with clorgyline

A regional analysis of brain amine and acid metabolite levels was conducted after chronic administration of the antidepressant tranylcypromine (0.5 mg/kg/day), of a novel fluorinated analog of this compound, and of clorgyline (1.0 mg/kg/day). These compounds were administered to male Sprague-Dawley rats for 28 days by subcutaneous infusion using osmotic minipumps (Alzet 2002). Levels of noradrenaline, 5-hydroxytryptamine, dopamine, and of the acid metabolites 5-hydroxyindole-3-acetic acid, 3,4-dihydroxyphenylacetic acid, and homovanillic acid were measured in the frontal cortex, nucleus accumbens, caudate nucleus, hippocampus, and hypothalamus. After 28 days of drug administration, sustained increases in amines and decreases in their acid metabolites were observed. Regional differences in these effects were minimal. These results are consistent with reports of sustained increases in brain amine concentrations following prolonged administration of other monoamine oxidase inhibitors.

Chronic tranylcypromine treatment induces functional alpha 2-adrenoceptor down-regulation in rats

The effects of chronic (28 d Alzet 2002 osmotic mini-pumps) administration of antidepressant drugs on the functional sensitivity of alpha 2-adrenoceptors and on monoamine oxidase activity has been assessed. Tranylcypromine, 4-fluorotranylcypromine and clorgyline (0.5-1.0 mg kg-1) induced a decrease in the motor-suppressant effects of clonidine (50 micrograms kg-1) observed at 9-10 and 23-24 days of drug administration. These effects were associated with marked decreases in type A (clorgyline) or type A and B monoamine oxidase activity (tranylcypromine and 4-fluorotranylcypromine). The results indicate that alpha 2-adrenoceptor down-regulation is an early emergent feature of adaptive changes in noradrenaline systems induced by prolonged exposure to tranylcypromine.