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D'Onofrio G, Kuchenbuch M, Hachon-Le Camus C, Desnous B, Staath V, Napuri S, Ville D, Pedespan JM, Lépine A, Cances C, de Saint-Martin A, Teng T, Chemaly N, Milh M, Villeneuve N, Nabbout R. Slow Titration of Cannabidiol Add-On in Drug-Resistant Epilepsies Can Improve Safety With Maintained Efficacy in an Open-Label Study. Front Neurol 2020; 11:829. [PMID: 32903409 PMCID: PMC7434926 DOI: 10.3389/fneur.2020.00829] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/02/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: To assess adverse events (AEs) and efficacy of add-on cannabidiol (CBD) with a slower titration protocol in pediatric clinical practice. Methods: We conducted a prospective, open-label, multicenter study in seven French reference centers for rare epilepsies. Patients had slow titration to reach a target dose of 10 mg/kg/day within at least 1 month and then gradually increased to a maximum dose of 20 mg/kg/day. We analyzed AEs and efficacy at M1 (month 1), M2, and M6, comparing two sets of subgroups: Dravet syndrome (DS) vs. Lennox-Gastaut (LGS) and patients with clobazam (CLB+) vs. patients without (CLB-). Results: One hundred and twenty-five patients were enrolled (62 LGS, 48 DS, 5 Tuberous sclerosis, and 10 other etiologies). Median concomitant antiepileptic drugs (AEDs) was three (25th percentile: 3, 75th percentile: 4). Patients received a dose of 10 (10-12), 14 (10-20), and 15.5 mg/kg/day (10-20) at M1, M2, and M6, respectively. Twenty-six patients discontinued CBD, 19 due to lack of efficacy, 2 due to AEs, 4 for both, and 1 had a sudden unexpected death in epilepsy. AEs were reported in 61 patients (48.8%), mainly somnolence (n = 26), asthenia (n = 20), and behavior disorders (n = 16). Abnormal transaminases (≥3 times) were reported in 11 patients receiving both valproate and clobazam. AEs were significantly higher at M2 (p = 0.03) and increased with the number of AEDs (p = 0.03). At M6, total seizure frequency change from baseline was -41% ± 37.5% (mean ± standard deviation), and 28 patients (37.8%) had a reduction ≥50%. AE and efficacy did not differ between DS vs. LGS and CLB+ vs. CLB- patients. Significance: A slower titration of CBD dose delivered better tolerance with comparable efficacy to previous trials. Concomitant CLB did not increase efficacy rates but in a few cases increased AEs. This slow titration scheme should help guide clinicians prescribing CBD and allow patients to benefit from its potential efficacy.
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Affiliation(s)
- Gianluca D'Onofrio
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Hôpital Necker-Enfants Malades, APHP, Paris, France.,Pediatric Residency, Department of Women and Child Health, University of Padua, Padua, Italy
| | - Mathieu Kuchenbuch
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Hôpital Necker-Enfants Malades, APHP, Paris, France.,Laboratory of Translational Research for Neurological Disorders, INSERM UMR 1163, Imagine Institute, Université de Paris, Paris, France
| | - Caroline Hachon-Le Camus
- Department of Pediatric Neurology, Hôpital des Enfants, Toulouse University Hospital, Toulouse, France
| | - Béatrice Desnous
- AP-HM, Pediatric Neurology Department, Timone Children Hospital, Marseille, France
| | - Véronique Staath
- Department of Pediatric Neurology, Strasbourg University Hospital, Hopital de Hautepierre, Strasbourg, France
| | - Sylvia Napuri
- Department of Pediatrics, Rennes University Hospital, University Rennes, Rennes, France
| | - Dorothée Ville
- Department of Pediatric Neurology, CNRS UMR 5304, Bron, France
| | | | - Anne Lépine
- AP-HM, Pediatric Neurology Department, Timone Children Hospital, Marseille, France
| | - Claude Cances
- Department of Pediatric Neurology, Hôpital des Enfants, Toulouse University Hospital, Toulouse, France
| | - Anne de Saint-Martin
- Department of Pediatric Neurology, Strasbourg University Hospital, Hopital de Hautepierre, Strasbourg, France
| | - Théo Teng
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Hôpital Necker-Enfants Malades, APHP, Paris, France
| | - Nicole Chemaly
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Hôpital Necker-Enfants Malades, APHP, Paris, France.,Laboratory of Translational Research for Neurological Disorders, INSERM UMR 1163, Imagine Institute, Université de Paris, Paris, France
| | - Mathieu Milh
- AP-HM, Pediatric Neurology Department, Timone Children Hospital, Marseille, France
| | - Nathalie Villeneuve
- AP-HM, Pediatric Neurology Department, Timone Children Hospital, Marseille, France
| | - Rima Nabbout
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Hôpital Necker-Enfants Malades, APHP, Paris, France.,Laboratory of Translational Research for Neurological Disorders, INSERM UMR 1163, Imagine Institute, Université de Paris, Paris, France
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Is trazodone more effective than clomipramine in major depressed outpatients? A single-blind study with intravenous and oral administration. CNS Spectr 2019; 24:258-264. [PMID: 29081313 DOI: 10.1017/s1092852917000773] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Some antidepressants, such as trazodone or clomipramine, can be administered intravenously in patients with major depressive disorder (MDD), with potential benefits compared to the standard oral treatment, but available data about their efficacy are limited. The present study was aimed to compare the effectiveness of trazodone and clomipramine (intravenous [i.v.] followed by oral administration). METHODS Some 42 patients with a diagnosis of MDD according to the DSM-5 were selected and treated with i.v. trazodone or clomipramine according to clinical judgment. The Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, and the Montgomery-Åsberg Depression Rating Scale were administered at baseline, after 2 weeks, and after 6 weeks, as well as after 1 week of intravenous antidepressant administration. Raters were blinded to type of treatment. RESULTS No significant differences were found between treatment groups in terms of effectiveness at endpoint. Borderline statistical significance was found in terms of number of responders in favor of trazodone. In addition, patients treated with trazodone reported fewer total side effects than those treated with clomipramine. CONCLUSION Both i.v. trazodone and clomipramine are rapid and effective options for improving depressive symptoms, although trazodone appears to be tolerated better. Further studies with larger samples and double-blind conditions are warranted to confirm our results.
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Zugliani MM, Cabo MC, Nardi AE, Perna G, Freire RC. Pharmacological and Neuromodulatory Treatments for Panic Disorder: Clinical Trials from 2010 to 2018. Psychiatry Investig 2019; 16:50-58. [PMID: 30696238 PMCID: PMC6354041 DOI: 10.30773/pi.2018.12.21.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/29/2018] [Accepted: 12/21/2018] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Treatment for panic disorder (PD) have evolved, although there is still a strong unmet need for more effective and tolerable options. The present study summarizes and discusses recent evidence regarding the pharmacological and neuromodulatory treatment of PD. METHODS MEDLINE, Cochrane Library, PsycINFO and Thomson Reuters's Web of Science were searched for clinical trials published between 2010 and 2018. We included all prospective experimental studies including randomized controlled trials (RCT) and other clinical trials with more than 10 patients. RESULTS Only 11 articles met the inclusion criteria, including 4 RCT, 3 open clinical trials and 5 comparative clinical trials. RCT demonstrated efficacy of transcranial magnetic stimulation (TMS) in only one of two trials. Neither pindolol nor d-fenfluramine were effective in blocking flumazenil-induced panic attacks. Augmentation with quetiapine was not superior to placebo. Open trials indicated that escitalopram, vortioxetine and TMS may be effective. Comparative trials did not demonstrate superiority from any drug, but confirmed tranylcypromine, paroxetine, clonazepam and alprazolam as effective options. CONCLUSION The current study confirmed the efficacy of tranylcypromine, paroxetine, clonazepam, alprazolam and escitalopram. Vortioxetine and TMS, with duration of 4 or more weeks, also seems to be effective. Quetiapine, pindolol and d-fenfluramine were not considered effective compounds.
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Affiliation(s)
- Morena M. Zugliani
- Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mariana C. Cabo
- Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Antonio E. Nardi
- Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Giampaolo Perna
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
- Department of Clinical Neurosciences, Villa San Benedetto Menni, Hermanas Hospitalarias, FoRiPsi, Albese con Cassano, Italy
| | - Rafael C. Freire
- Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Gomez AF, Barthel AL, Hofmann SG. Comparing the efficacy of benzodiazepines and serotonergic anti-depressants for adults with generalized anxiety disorder: a meta-analytic review. Expert Opin Pharmacother 2018; 19:883-894. [PMID: 29806492 DOI: 10.1080/14656566.2018.1472767] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Generalized anxiety disorder (GAD) is a common form of anxiety disorder. Selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and benzodiazepines (BZs) are the most commonly prescribed medications for GAD, but little is known about the relative efficacy of these pharmacological treatments. Areas covered: This study provides a meta-analytic review of the efficacy of these medications in the treatment of adults with GAD. A comprehensive literature search yielded 54 articles reporting 56 unique studies with 12,655 participants treated with either pill placebo (6,191 participants), SSRIs (16 trials, 2,712 participants), SNRIs (17 trials, 2,603 participants), or BZs (23 trials, 1,149 participants). The overall combined effect size was modest to moderate (Hedges' g = 0.37, p < 0.0001). Effect sizes decreased significantly over time. SSRIs (Hedges' g = 0.33) and SNRIs (Hedges' g = 0.36) demonstrated significantly lower effect sizes than BZs (Hedges' g = 0.50). These findings were not due to differences in treatment length or publication year. Expert opinion: The results of this study suggest that the most common forms of pharmacotherapy for adult GAD are moderately effective, with BZs being the most effective drug.
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Affiliation(s)
- Angelina F Gomez
- a Department of Psychological and Brain Sciences , Boston University , Boston , MA , USA
| | - Abigail L Barthel
- a Department of Psychological and Brain Sciences , Boston University , Boston , MA , USA
| | - Stefan G Hofmann
- a Department of Psychological and Brain Sciences , Boston University , Boston , MA , USA
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Buoli M, Grassi S, Serati M, Altamura AC. Agomelatine for the treatment of generalized anxiety disorder. Expert Opin Pharmacother 2017; 18:1373-1379. [DOI: 10.1080/14656566.2017.1359257] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Massimiliano Buoli
- Department of Psychiatry, University of Milan, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Silvia Grassi
- Department of Psychiatry, University of Milan, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Marta Serati
- Department of Psychiatry, University of Milan, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - A. Carlo Altamura
- Department of Psychiatry, University of Milan, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico , Milan, Italy
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Buoli M, Serati M, Caldiroli A, Galimberti D, Scarpini E, Altamura AC. Pharmacological Management of Psychiatric Symptoms in Frontotemporal Dementia: A Systematic Review. J Geriatr Psychiatry Neurol 2017; 30:162-169. [PMID: 28351199 DOI: 10.1177/0891988717700506] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Psychiatric symptoms in patients with frontotemporal dementia (FTD) are highly prevalent and may complicate clinical management of these patients. Purpose of the present article is to present and discuss available data about the pharmacological treatment of psychiatric symptoms in patients with FTD. A research in the main database sources has been conducted to obtain an overview of the pharmacological management of psychiatric symptoms in patients with FTD. The search strategy included the following terms-"FTD and psychiatry," "FTD and behavioural disturbances," and "FTD and treatment". Pathophysiology of psychiatric symptoms in FTD is different from other types of dementia. Although drugs for Alzheimer disease appear to be ineffective for the treatment of psychiatric symptoms of FTD, preliminary evidence supports a possible usefulness of serotonergic antidepressants for these patients. Data are too scanty to draw definitive conclusions, but antidepressant treatment, particularly with serotonergic compounds, may improve psychiatric symptoms in patients with FTD. Large observational studies are needed to confirm this preliminary evidence, and a lot of effort and collaboration between neurologists and psychiatrists will be definitely crucial for future research of effective treatments for FTD.
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Affiliation(s)
- Massimiliano Buoli
- 1 Department of Psychiatry, University of Milan, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Serati
- 1 Department of Psychiatry, University of Milan, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alice Caldiroli
- 1 Department of Psychiatry, University of Milan, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniela Galimberti
- 2 Department of Neurology, University of Milan, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elio Scarpini
- 2 Department of Neurology, University of Milan, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alfredo Carlo Altamura
- 1 Department of Psychiatry, University of Milan, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
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Chen X, Broeyer F, de Kam M, Baas J, Cohen A, van Gerven J. Pharmacodynamic response profiles of anxiolytic and sedative drugs. Br J Clin Pharmacol 2017; 83:1028-1038. [PMID: 27922194 DOI: 10.1111/bcp.13204] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 11/21/2016] [Accepted: 11/22/2016] [Indexed: 02/04/2023] Open
Abstract
AIM Centrally-acting acutely anxiolytic drugs, such as benzodiazepines, barbiturates and gabapentinoids, affect various central nervous system (CNS) functions, which reflects not only their anxiolytic effects but also neuropsychological side-effects. To validate the pharmacodynamic biomarkers for GABA-ergic anxiolytics, this study determined the pharmacodynamics of two anxiolytics and a nonanxiolytic control, and linked them to their anxiolytic and sedative effects, during an anxiety-challenge study day. METHODS Twenty healthy volunteers were randomized in this placebo-controlled, double-blind, four-way cross-over study with single-dose alprazolam (1 mg), diphenhydramine (50 mg), pregabalin (200 mg) or placebo. The Neurocart was used between repeated fear-potentiated startle assessments. Thus, the potential influence of anxiety on CNS pharmacodynamic markers could be examined. RESULTS Compared to placebo, VAScalmness increased with alprazolam (2.0 mm) and pregabalin (2.5 mm) but not with diphenhydramine. Saccadic peak velocity (SPV) declined after alprazolam (-57 ° s-1 ) and pregabalin (-28 ° s-1 ), more than with diphenhydramine (-14 ° s-1 ); so did smooth pursuit. The average responses of SPV and smooth pursuit were significantly correlated with the drug-induced increases in VAScalmness . The SPV-relative responses of VASalertness , body-sway and adaptive-tracking also differed among alprazolam, pregabalin and diphenhydramine. CONCLUSIONS Compared with the antihistaminergic sedative diphenhydramine, alprazolam and pregabalin caused larger SPV reduction, which was correlated with simultaneous improvement of subjective calmness, during a study day in which anxiety was stimulated repeatedly. The different effect profiles of the three drugs are in line with their pharmacological distinctions. These findings corroborate the profiling of CNS effects to demonstrate pharmacological selectivity, and further support SPV as biomarker for anxiolysis involving GABA-ergic neurons. The study also supports the use of prolonged mild threat to demonstrate anxiolytic effects in healthy volunteers.
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Affiliation(s)
- Xia Chen
- Phase I Unit, Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Beijing, 100032, China.,Centre for Human Drug Research, Leiden, The Netherlands
| | | | | | - Joke Baas
- Department of Experimental Psychology, Faculty of Social Sciences, Utrecht University, The Netherlands
| | - Adam Cohen
- Centre for Human Drug Research, Leiden, The Netherlands
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Reinhold JA, Rickels K. Pharmacological treatment for generalized anxiety disorder in adults: an update. Expert Opin Pharmacother 2015; 16:1669-81. [PMID: 26159446 DOI: 10.1517/14656566.2015.1059424] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Modest response and remission rates for the selective serotonin reuptake inhibitors and the serotonin-norepinephrine reuptake inhibitors, coupled with mounting evidence that the tolerability of the antidepressants (ADs) may have been overstated in the literature, has contributed to changes in prescribing patterns for generalized anxiety disorder (GAD). New interest in the absence of evidence that supports these standard therapies as superior to benzodiazepines stimulated a review of the literature. AREAS COVERED A literature search was conducted in the MedLine database with search terms 'generalized anxiety disorder' and 'treatment' for purposes of including relevant literature related to pharmacologic treatment of GAD. Aside from a review of pivotal literature, the authors also included newer studies that evaluated novel drug treatments. Last, the database was searched for benzodiazepine comparisons to standard therapy secondary to concerns that such literature is sparse. The review of newer modalities and the decision to include related literature was also based on the strength of the evidence and the status of their approval for the treatment of GAD. EXPERT OPINION Although ADs remain the most frequently prescribed medications for GAD, alternative and off-label therapies such as pregabalin, the atypical antipsychotics and vortioxetine are garnering interest. Based on the evidence available to us, it is our recommendation that along with the ADs, benzodiazepines be considered a possible first-line therapy in eligible patients based on the discretion and clinical judgment of the treating physician.
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Affiliation(s)
- Jennifer A Reinhold
- University of the Sciences in Philadelphia, Department of Pharmacy Practice/Pharmacy Administration , 600 South 43rd Street, Philadelphia, PA 19104-4495 , USA
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Olgiati P, Serretti A. Persistent benefits of slow titration of paroxetine in a six-month follow-up. Hum Psychopharmacol 2015; 30:329-33. [PMID: 25900268 DOI: 10.1002/hup.2478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 02/16/2015] [Accepted: 03/03/2015] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Paroxetine titration may be difficult in older individuals as they are more sensitive to side effects. The current study extends to 6 months our previously published report in which paroxetine was started at 2.5 mg/day and slowly increased by 2.5 mg on alternate days (slow titration) or rapidly titrated to target dose from 10 mg/day (standard titration) in a naturalistic setting. METHODS Here, the follow-up period was extended to 26 weeks. We performed an intent-to-treat analysis of 47 subjects from the original sample (major depressive disorder and/or generalized anxiety disorder (GAD); >60 years of age). Missing evaluations were replaced by last observations carried forward. GAD was included as a stratification factor. RESULTS Patients in whom paroxetine was slowly up-titrated were more likely to remit (84.0% vs 54.5%; p = 0.028) and had lower core depression (p = 0.0015) and psychic anxiety levels (p = 0.006) after 26 weeks. Dropout rate was 20% in the slow titration group compared with 77.3% in the standard titration arm (p < 0.001). Patients with GAD accounted for all significant associations. No substantial differences were reported between slow and standard titration groups in the subsample without GAD. CONCLUSIONS Despite some limitations, these findings suggest that paroxetine treatment should be started at lower doses in older depressed patients and slowly up-titrated. This strategy would allow to increase antidepressant response and the likelihood of completing treatment cycle in patients with high anxiety levels and GAD comorbidity.
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Affiliation(s)
- Paolo Olgiati
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Alessandro Serretti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
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Altamura AC, Caldiroli A, Buoli M. Pharmacokinetic evaluation of fluvoxamine for the treatment of anxiety disorders. Expert Opin Drug Metab Toxicol 2015; 11:649-60. [DOI: 10.1517/17425255.2015.1021331] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Olgiati P, Bajo E, Serretti A. Benefit of slow titration of paroxetine to treat depression in the elderly. Hum Psychopharmacol 2014; 29:544-51. [PMID: 25363240 DOI: 10.1002/hup.2433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 05/13/2014] [Accepted: 07/07/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Paroxetine is commonly used to treat depression in the elderly; however, titration issues have been raised. Rapid titration may lead to increased anxiety and early dropout. The aim of this cost-utility analysis was to compare the potential benefit of standard (10 mg the first day) versus slow titration (2.5 mg gradually increased). METHODS Clinical analysis was based on a naturalistic trial integrated with a decision-analytic model representing second treatments for those who initially did not respond and for dropout cases. Treatment setting was a public outpatient center for mental disorders in Italy. Service use data were estimated from best practice guidelines, whereas costs (Euros; 2012) were retrieved from Italian official sources. RESULTS Slow titration approach produced 0.031 more quality-adjusted life years (remission rate: 57% vs 44% in standard titration group) at an incremental cost of €5.53 (generic paroxetine) and €54.54 (brand paroxetine syrup). Incremental cost-effectiveness ratio (ICER) values were €159 and €1768, respectively, in favor of slow titration approach. Cost-effectiveness threshold, defined as ICER < 1 GDP per capita according to World Health Organization criteria, is about €25 000 in Italy. CONCLUSIONS Our results are consistent with a superiority of slow titration of paroxetine in older depressed patients. However, these findings, in part based on simulated data, need to be replicated in clinical trials.
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Affiliation(s)
- Paolo Olgiati
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
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Buoli M, Mauri MC, Altamura AC. Pharmacokinetic evaluation of agomelatine for the treatment of generalised anxiety disorder. Expert Opin Drug Metab Toxicol 2014; 10:885-92. [PMID: 24717138 DOI: 10.1517/17425255.2014.907794] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Preliminary data indicate agomelatine as a promising molecule for both acute and long-term treatment of generalised anxiety disorder (GAD). AREAS COVERED The present review illustrates the pharmacokinetic properties of agomelatine and their implications for the management of GAD patients. A search of the main database sources (Medline, Isi Web of Knowledge and Medscape) was performed in order to obtain a complete and balanced evaluation of agomelatine pharmacokinetics for the treatment of GAD. The word 'agomelatine' was associated with 'pharmacokinetics', 'GAD', 'anxiety' and 'tolerability'. No restriction criteria were established in relation to methodology or year of publication. Only English-language articles were included. EXPERT OPINION Short half-life and 1-day administration make agomelatine an interesting molecule for GAD treatment. However, potential interactions with a number of compounds necessitate caution when prescribing and using agomelatine in patients with psychiatric (e.g., alcohol abuse) or medical comorbidities. Further data are necessary to define a precise risk/benefit ratio in special populations such as elderly patients suffering from GAD.
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Affiliation(s)
- Massimiliano Buoli
- University of Milan, Department of Psychiatry, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico , Milan , Italy
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Potential benefits of slow titration of paroxetine treatment in an elderly population: eight-week results from a naturalistic setting. J Clin Psychopharmacol 2013; 33:565-9. [PMID: 23764690 DOI: 10.1097/jcp.0b013e3182905967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Late-life depression, often in association with anxiety, affects approximately 15% of individuals older than 65 years. Selective serotonin reuptake inhibitors are the first-line treatment but could be responsible of an early exacerbation of anxiety, possibly reduced by a very gradual titration of drugs. The main aim of this study is to compare gradual and rapid (standard) titration of paroxetine in an elderly population. METHODS In a naturalistic setting, 50 elderly (≥60 years old) outpatients with unipolar mood disorder or anxiety disorder were naturalistically assigned to abrupt initiation of 10 mg of paroxetine or to a gradual increase with 2.5 mg on alternate days up to 10 mg in 7 days. Then dosage could be maintained at 10 mg or increased according to clinical response. Primary outcome was efficacy as assessed by the Hamilton Depression Rating Scale (HAM-D) 21, HAM-D symptom subscales (core, psychic anxiety, somatic anxiety cluster), and Hamilton Anxiety Rating Scale changes. Secondary outcome was evaluation of overall dropouts at eighth week and evaluation of most common adverse effects through the global judgment of the Dosage Record and Treatment Emergent Symptom Scale. All data were recorded weekly for the first 8 weeks of treatment (with 1 more evaluation after 3 days from the baseline). RESULTS Samples were comparable at baseline, with patients in gradual titration showing a higher level of psychic anxiety. During the first 3 days of treatment, a significant worsening in psychic anxiety was observed in patients treated abruptly with 10 mg of paroxetine (difference in HAM-D psychic anxiety subscale from baseline: 110.61% vs 89.38% with rapid and slow titration, respectively; t test P = 0.03). Overall, a significantly greater improvement in depressive and anxious symptoms favored gradual titration (HAM-D core cluster and HAM-D psychic anxiety cluster, respectively, P = 0.014 and P < 0.001, also when controlling for confounders). At the eighth week, significant higher dropouts in patients administered with abrupt dosage was observed (12.00% vs 40.91%, P = 0.02, respectively for slow and rapid titration). CONCLUSIONS Our results suggest that a gradual titration of paroxetine could avoid the initial treatment anxiety worsening and dropout at the beginning of the treatment.
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Buoli M, Caldiroli A, Caletti E, Paoli RA, Altamura AC. New approaches to the pharmacological management of generalized anxiety disorder. Expert Opin Pharmacother 2013; 14:175-84. [DOI: 10.1517/14656566.2013.759559] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Dobrea C, Buoli M, Arici C, Camuri G, Dell'Osso B, Altamura AC. Tolerability and use in co-administration of pregabalin in affective patients: a 6-month prospective naturalistic study. Expert Opin Drug Saf 2012; 11:893-9. [DOI: 10.1517/14740338.2012.720971] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Torta RGV. Antidepressant up-titration: pharmacological and psychological considerations. Expert Opin Drug Saf 2012; 11:685-8. [DOI: 10.1517/14740338.2012.712683] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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