Immediate switching of antidepressant therapy: results from a clinical trial of duloxetine

Oral Anticancer Therapy: Management of Drug Interactions

Oral anticancer therapy is increasingly integrated into the care of patients with cancer. Recognition and management of drug-drug interactions (DDIs) is critical to providing efficacious and safe anticancer treatment. DDIs with QTc-prolonging agents, anticoagulants, enzyme inducers and inhibitors, antidepressants, and acid suppressants are commonly encountered with anticancer therapies. Here, we review frequently observed DDIs and outline literature-supported suggestions for their management.

Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines

A revision of the 2008 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken in order to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in September 2012. Key areas in treating depression were reviewed and the strength of evidence and clinical implications were considered. The guidelines were then revised after extensive feedback from participants and interested parties. A literature review is provided which identifies the quality of evidence upon which the recommendations are made. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse and stopping treatment. Significant changes since the last guidelines were published in 2008 include the availability of new antidepressant treatment options, improved evidence supporting certain augmentation strategies (drug and non-drug), management of potential long-term side effects, updated guidance for prescribing in elderly and adolescent populations and updated guidance for optimal prescribing. Suggestions for future research priorities are also made.

Duloxetine-mirtazapine combination in depressive illness: The case for Limerick 'rocket fuel'

The use of complex psychopharmacological regimens is increasingly advocated in more difficult to treat depressive illness. The combination of venlafaxine with mirtazapine - 'California rocket fuel' is one such example involving an SNRI combined with a NaSSA. We describe two cases that highlight the potential usefulness of duloxetine used in combination with mirtazapine that also emphasise the danger of drug-induced hypomanic switching. This combination may have a specific role for carefully selected patients but caution is needed given the potential to induce profound alterations in mental state.

RESEARCH: Validation of the Massachusetts General Hospital Antidepressant Treatment History Questionnaire (ATRQ)

The low rate of response to antidepressants in treatment resistant depression (TRD) justifies studies of next-step therapies following a treatment failure. In TRD clinical trials, it is important to verify the accurate diagnosis of treatment resistance for all enrolled subjects using a reliable and valid instrument. Self-rated scales can reduce the impact of investigator bias and reduce the time burden for clinical researchers. The Massachusetts General Hospital (MGH) Antidepressant Treatment Response Questionnaire (ATRQ) is a self-rated scale used to determine treatment resistance in major depressive disorder (MDD). The ADAPT-A study is a multi-center double-blind, placebo-controlled study of low-dose aripiprazole adjunctive to ADT among outpatients with TRD. At the screening assessment, potential subjects completed the MGH ATRQ. The ADAPT-A medical monitors subsequently performed remote patient interviews and obtained detailed medication histories. The data obtained from the MGH ATRQ and by the medical monitors were compared for congruency. Of the 186 patients enrolled by the local sites, no subjects deemed treatment resistant by the MGH ATRQ were found to be nonresistant by the medical monitors. In 76.3% (n = 142) of the subjects, the number of failed adequate antidepressant trials reported by the MGH ATRQ was concordant with the data collected by medical monitors. In 16.1% (n = 30) of all cases, the medical monitors found a greater number of failed trials; in 7.5% (n = 14) of cases, the medical monitors found fewer failed medication trials. The discrepancy was by more than one medication trial in only 4.0% (n = 7) of cases. We found the MGH ATRQ to be relatively concordant in its assessment of treatment resistance in depression compared with independent clinical researchers. Although the MGH ATRQ tended to underreport the number of unsuccessful treatment trials relative to the clinical interviews, its accuracy in cases it detected was confirmed by raters.

Healthcare utilization and costs incurred by patients with major depression after being switched from escitalopram to another SSRI for non-medical reasons

OBJECTIVE

To compare healthcare utilization and costs for major depressive disorder (MDD) patients treated with escitalopram and who were switched to another SSRI for non-medical reasons versus those who did not switch.

RESEARCH DESIGN AND METHODS

Patients were identified in the Ingenix Impact Database (2003-2006). The analysis group included patients who remained on escitalopram for ≥ 90 days and switched to another SSRI within 45 days of end of supply days for non-medical reasons; the control group included matched individuals who did not switch within 45 days. Switching for medical reasons was defined as switching within 7 days after having a hospitalization, an emergency room (ER) visit, or a psychotherapy visit. Outcomes (all-cause and MDD-related) were analyzed over 3 months and included use of hospital, ER, outpatient visits and professional services, and healthcare costs. Outcomes were compared between the two groups using descriptive statistics and regression analyses controlling for differences in baseline characteristics. Costs were inflation adjusted to 2006 US dollars.

RESULTS

The study included 2,805 matched pairs. Compared to controls, switchers had higher rates of all-cause and MDD-related hospitalizations (relative risk [RR] = 1.4 and 2.0, respectively) and all-cause and MDD-related ER visits (RR = 1.2 and 1.6, respectively, all p ≤ 0.05). Results from multivariate analyses show that switchers had higher medical costs (+$138), drug costs (+$149) and total healthcare costs (+$322) compared to patients in the control group (all p < 0.0001).

LIMITATIONS

This study's limitations include its short observational period and definition of switching for non-medical reasons.

CONCLUSION

Patients who were switched to another SSRI for non-medical reasons after being stabilized on escitalopram used more resources and had higher healthcare costs within 3 months of switching than patients who did not switch.

Switching to duloxetine from selective serotonin reuptake inhibitors in non- or partial responders: Results from a Spanish sample

Objectives. To evaluate the efficacy and safety of switching from a selective serotonin reuptake inhibitor (SSRI) to duloxetine in non- or partial responders. Methods. This is a post-hoc analysis of the pooled data of the Spanish sample from an open-label, multicentre study. Additionally, a 6-month continuation safety phase was performed. Results. A total of 156 patients were switched to duloxetine from SSRIs. More than 83% completed the acute phase, of whom 75% went into the continuation phase. At baseline, the mean duration of SSRI treatment was 71.2 weeks and the HAM-D17 mean score was 22.4. In the acute-phase, symptoms severity significantly improved after 10 weeks of duloxetine treatment as measured by mean change from baseline in HAM-D17 total score (-10.5; P<0.001) and all secondary efficacy measures, including painful symptoms. Response (≥50% decrease in HAM-D17 total score) and remission rates (HAM-D17 total score ≤ 7) were 52.9 and 27.7%, respectively. The most common adverse events reported in both phases were headache (11.5% [acute]; 6.1% [continuation]) and nausea (6.4% [acute]; 5.1% [continuation]). Conclusions. In a population of Spanish SSRI non- and partial responders, switch to duloxetine was associated with significant improvement in emotional and painful symptoms of depression. Duloxetine was well tolerated and safe during both phases.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines

A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.

Treatment of SSRI-resistant depression: a meta-analysis comparing within- versus across-class switches

BACKGROUND

Two broad treatment options exist for switching antidepressants for depressed patients who fail to respond to a selective serotonin reuptake inhibitor (SSRI): either a second course of SSRI therapy or a different class of antidepressants. The goal of the present work was to conduct a meta-analysis of studies comparing these two switch strategies.

METHODS

Several sources were searched for randomized clinical trials comparing these two switch strategies.

RESULTS

Data from four clinical trials (n = 1496) were combined using a random-effects model. Patients randomized to switch to a non-SSRI antidepressant (bupropion, mirtazapine, venlafaxine) were more likely to experience remission than patients switched to a second SSRI (risk ratio = 1.29, p = .007). Pooled remission rates were 28% (for non-SSRIs) and 23.5% (for SSRIs). There was also a nonsignificant trend (p = .1) in the rate of discontinuation due to intolerance favoring the within-class switch strategy (risk ratio = 1.23). There was no difference in response rates between the two treatment groups.

CONCLUSIONS

These results suggest a modest yet statistically significant advantage in remission rates when switching patients with SSRI-resistant depression to a non-SSRI rather than an SSRI antidepressant. With the number needed to treat (NNT) statistic as one indicator of clinical significance, nearly 22 SSRI nonresponders would need to be switched to a non-SSRI rather than a second SSRI antidepressant to obtain one additional remitter. This difference falls well below the mark of NNT = 10 suggested by the United Kingdom's National Institute of Clinical Excellence but nonetheless might be of public health relevance given the large number of SSRI-resistant patients switched to an SSRI versus a non-SSRI antidepressant.

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.

Duloxetine for patients with diabetic peripheral neuropathic pain: a 6-month open-label safety study

OBJECTIVE

Duloxetine is a relatively balanced and potent reuptake inhibitor of both serotonin and norepinephrine. Because these neurotransmitters play a role in pain inhibition, duloxetine was considered a possible treatment for diabetic peripheral neuropathic pain (DPNP). This study assessed the 6-month safety and tolerability of duloxetine in patients with DPNP; evaluation of efficacy was a secondary objective.

DESIGN

In this 28-week, open-label study, in the clinical setting, 449 patients with DPNP were randomized (3:1) to receive duloxetine 60 mg twice daily (BID) (N = 334) or duloxetine 120 mg once daily (QD) (N = 115). Comprehensive safety evaluations including laboratory analyses and electrocardiograms were performed for all patients. Efficacy measures included the Brief Pain Inventory (BPI) and Clinical Global Impression of Severity (CGI-S) scales.

RESULTS

Protocol completion rates were 63.8% and 62.6% for the 60 mg BID and 120 mg QD groups, respectively (P = 0.823). Discontinuations were primarily due to adverse events, 20.1% for 60 mg BID and 27.0% for 120 mg QD (P = 0.149). Heart rate increased slightly in both treatment groups (P </= 0.02 in both groups). Systolic blood pressure was unaffected, while diastolic blood pressure decreased slightly in the 120 mg QD group (P = 0.04). Sustained elevation in blood pressure was reported for 18 (5.5%) patients in the 60 mg BID group and six (5.4%) in the 120 mg QD group. Duloxetine treatment was not associated with significant QTc prolongation. There was significant improvement at endpoint on all subscales of the BPI and CGI-S (P < 0.001 in both groups).

CONCLUSIONS

In this study, duloxetine 60 mg BID and 120 mg QD were safely administered and well tolerated in patients with DPNP for up to 28 weeks. There were few differences in safety or tolerability between the two dosages. At both doses, duloxetine provided clinically significant pain relief.