Tolerability of moclobemide, a new reversible inhibitor of monoamine oxidase-A, compared with other antidepressants and placebo

Comparison of the efficacy of moclobemide and fluvoxamine in elderly patients with a severe depressive episode

In a double-blind study carried out on elderly patients (older than 65 years) the efficacy and tolerability of the new antidepressant moclobemide was compared. Moclobemide belongs to a new class of substances called RIMA (Reversible inhibitor of the monoamine oxidase type A). Fluvoxamine, a selective reuptake-inhibitor of 5-HT, belongs to a class of antidepressants known for their better tolerability compared to tricyclic especially with elderly patients. Forty elderly patients (mean age 75 years) with major depression (according to DSM III) were randomized to receive either moclobemide (300 mg) or fluvoxamine (100 mg) twice daily. Dosages were increased when necessary on day 8, to a maximum of 450 mg moclobemide or 200 mg fluvoxamine and in most cases were maintained at these levels for the remainder of the study period (four weeks). Moclobemide was more effective than fluvoxamine showing a marked antidepressant effect and an earlier effect on psychomotor retardation. The two drugs were well tolerated showing a low incidence of side effects.

Side effects of moclobemide in depressed patients refractory to other treatments

Fifteen consecutive cases of moderate and severe depression were treated with moclobemide in recommended dosage and followed for six months. Eleven developed excitatory side effects including agitation, insomnia, restlessness and aggressivity; five patients reported unreality experiences. Subject to confirmation, these findings, together with indications of similar side effects in published studies and in non fatal overdose, raise the possibility that the potential of moclobemide to cause excitation in depressed patients refractory to other treatments may have been hitherto underestimated.

Monoamine oxidase inhibitors (MAOIs) for fibromyalgia syndrome

BACKGROUND

Fibromyalgia (FM) syndrome is a chronic condition of unknown aetiology characterised by musculoskeletal pain that often co-exists with sleep disturbance, cognitive dysfunction and fatigue. Patients often report high disability levels and poor quality of life. Since there is no specific treatment that alters the pathogenesis of FM, drug therapy focuses on pain reduction and improvement of other bothersome symptoms.

OBJECTIVES

The objective of this review was to assess the effectiveness and safety of monoamine oxidase inhibitors (MAOIs) in the treatment of FM syndrome.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 10), MEDLINE (1966 to November 2010), EMBASE (1980 to November 2010) and the reference lists of reviewed articles.

SELECTION CRITERIA

We selected all randomised, double-blind trials of MAOIs used for the treatment of FM pain in adult participants.

DATA COLLECTION AND ANALYSIS

Two authors assessed risk of bias and extracted data independently onto a specially designed pro forma and a third review author cross-checked them.

MAIN RESULTS

We included two studies of inconsistent risk of bias with a total of 230 patients diagnosed with FM. We evaluated two MAOIs: pirlindole and moclobemide. Pirlindole showed statistically significant results compared with placebo for several outcomes (pain, tender points and overall assessment by the patient and the physician), whereas moclobemide did not show statistically significant differences between groups. Pooled results of the two studies displayed a modest effect size in pain (mean difference (MD) -1.45 (121 patients; 95% confidence interval (CI) -2.71 to -0.20; number needed to treat (NNT) 2 (95% CI 1 to 12); I(2) = 59%)), implying a minimal clinically important difference (MCID) and a small effect on tender points (standardised mean difference (SMD) -0.36 (121 patients; 95% CI -0.72 to -0.00; I(2) = 31%)). No effect was seen on global assessment by patient. Physical function and sleep disturbance were not measured. The most frequent adverse events were nausea and vomiting, with statistically significant differences between groups (risk ratio (RR) 7.82 (89 patients; 95% CI 1.02 to 59.97; NNT 7 (95% CI 4 to 33)).

AUTHORS' CONCLUSIONS

Data suggest that the effectiveness of MAOIs for the treatment of FM symptoms is limited. Although we observed a moderate effect size on pain and a small one on tender points, these results should be taken with caution as they are only based on two studies with a small number of patients and inconsistent risk of bias among them.

Pharmacotherapy of dysthymia: review and new findings

Open trials with tricyclics, classical monoamine oxidase inhibitors (MAOIs) or lithium in dysthymia yielded a response rate in 45% of subjects. A long-term treatment of dysthymia with 276 patients treated during 4 years with either moclobemide, tranylcypromine or a combination of amitryptiline plus chlordiazepoxide is described. After discontinuation there was a relapse rate of 89.1%. The controlled studies with tricyclics, MAOIs, reversible inhibitors of monoamine oxidase (RIMAs), specific serotonin reuptake inhibitor (SSRIs) or benzamides showed that drugs well-tolerated work better in dysthymia, due to the fact that the treatment must be long-term. Sertraline was studied vs placebo or imipramine in primary dysthymia. Moclobemide, imipramine and placebo were also studied in 315 patients. Mean doses were 650 mg/d of moclobemide and 203.2 mg/d of imipramine. Moclobemide and sertraline were both efficacious and well tolerated. In a long term treatment the clinician should assess the risk-benefit ratio. Dysthymic patients are very sensitive to unwanted effects and compliance is a serious issue.

MAO-inhibitors in Parkinson's Disease

Monoamine oxidase inhibitors (MAO-I) belong to the earliest drugs tried in Parkinson's disease (PD). They have been used with or without levodopa (L-DOPA). Non-selective MAO-I due to their side-effect/adverse reaction profile, like tranylcypromine have limited use in the treatment of depression in PD, while selective, reversible MAO-A inhibitors are recommended due to their easier clinical handling. For the treatment of akinesia and motor fluctuations selective irreversible MAO-B inhibitors selegiline and rasagiline are recommended. They are safe and well tolerated at the recommended daily doses. Their main differences are related to (1) metabolism, (2) interaction with CYP-enzymes and (3) quantitative properties at the molecular biological/genetic level. Rasagiline is more potent in clinical practise and has a hypothesis driven more favourable side effect/adverse reaction profile due to its metabolism to aminoindan. Both selegiline and rasagiline have a neuroprotective and neurorestaurative potential. A head-to head clinical trial would be of utmost interest from both the clinical outcome and a hypothesis-driven point of view. Selegiline is available as tablet and melting tablet for PD and as transdermal selegiline for depression, while rasagiline is marketed as tablet for PD. In general, the clinical use of MAO-I nowadays is underestimated. There should be more efforts to evaluate their clinical potency as antidepressants and antidementive drugs in addition to the final proof of their disease-modifying potential. In line with this are recent innovative developments of MAO-I plus inhibition of acetylcholine esterase for Alzheimer's disease as well as combined MAO-I and iron chelation for PD.

Moclobemide: therapeutic use and clinical studies

Moclobemide is a reversible inhibitor of monoamine-oxidase-A (RIMA) and has been extensively evaluated in the treatment of a wide spectrum of depressive disorders and less extensively studied in anxiety disorders. Nearly all meta-analyses and most comparative studies indicated that in the acute management of depression this drug is more efficacious than placebo and as efficacious as tricyclic (or some heterocyclic) antidepressants or selective serotonin reuptake inhibitors (SSRIs). There is a growing evidence that moclobemide is not inferior to other antidepressants in the treatment of subtypes of depression, such as dysthymia, endogenous (unipolar and bipolar), reactive, atypical, agitated, and retarded depression as with other antidepressants limited evidence suggests that moclobemide has consistent long-term efficacy. However, more controlled studies addressing this issue are needed. For patients with bipolar depression the risk of developing mania seems to be not higher with moclobemide than with other antidepressants. The effective therapeutic dose range for moclobemide in most acute phase trials was 300 to 600 mg, divided in 2 to 3 doses. While one controlled trial and one long-term open-label study found moclobemide to be efficacious in social phobia, three controlled trials subsequently revealed either no effect or less robust effects with the tendency of higher doses (600 - 900 mg/d) to be more efficacious. Two comparative trials demonstrated moclobemide to be as efficacious as fluoxetine or clomipramine in patients suffering from panic disorder. Placebo-controlled trials in this indication are, however, still lacking. A relationship between the plasma concentration of moclobemide and its therapeutic efficacy is not apparent but a positive correlation with adverse events has been found. Dizziness, nausea and insomnia occurred more frequently on moclobemide than on placebo. Due to negligible anticholinergic and antihistaminic actions, moclobemide has been better tolerated than tri- or heterocyclic antidepressants. Gastrointestinal side effects and, especially, sexual dysfunction were much less frequent with moclobemide than with SSRIs. Unlike irreversible MAO-inhibitors, moclobemide has a negligible propensity to induce hypertensive crisis after ingestion of tyramine-rich food ("cheese-reaction"). Therefore, dietary restrictions are not as strict. However, with moclobemide doses above 900 mg/d the risk of interaction with ingested tyramine might become clinically relevant. After multiple dosing the oral bioavailability of moclobemide reaches almost 100%. At therapeutic doses, moclobemide lacks significant negative effects on psychomotor performance, cognitive function or cardiovascular system. Due to the relative freedom from these side effects, moclobemide is particularly attractive in the treatment of elderly patients. Moclobemide is a substrate of CYP2C19. Although it acts as an inhibitor of CYP1A2, CYP2C19, and CYP2D6, relatively few clinically important drug interactions involving moclobemide have been reported. It is relatively safe even in overdose. The drug has a short plasma elimination half-life that allows switching to an alternative agent within 24 h. Since it is well tolerated, therapeutic doses can often be reached rapidly upon onset of treatment. Steady-state plasma levels are reached approximately at one week following dose adjustment. Patients with renal dysfunction require no dose reduction in contrast to patients with severe hepatic impairment. Cases of refractory depression might improve with a combination of moclobemide with other antidepressants, such as clomipramine or a SSRI. Since this combination has rarely been associated with a potentially lethal serotonin syndrome, it requires lower entry doses, a slower dose titration and a more careful monitoring of patients. Combination therapy with moclobemide and other serotonergic agents, or opioids, should be undertaken with caution, although no serious adverse events have been published with therapeutic doses of moclobemide to date. On the basis of animal data the combined use of moclobemide with pethidine or dextropropoxyphene should be avoided. There is no evidence that moclobemide would increase body weight or produce seizures. Some preclinical data suggest that moclobemide may have anticonvulsant property.

Moclobemide is effective and well tolerated in the long-term pharmacotherapy of social anxiety disorder with or without comorbid anxiety disorder

Social phobia (social anxiety disorder) is a highly prevalent and chronic disorder that is associated with significant comorbidity and disability. Despite recent advances in the pharmacotherapy of the disorder, there is a paucity of randomized controlled trials on patients with comorbid disorders and on maintenance treatment. A randomized placebo-controlled, double-blind multi-site trial of moclobemide, a reversible inhibitor of monoamine oxidase A, was undertaken with 390 subjects. After an initial 12 weeks, there was the option of continuing for an additional 6 months of treatment. The primary efficacy parameter chosen was responder status as defined by the Clinical Global Impression scale change item. From week 4 onwards, there was a significantly higher response rate on moclobemide than on placebo. Superiority of medication over placebo was similar in patients with comorbid anxiety disorders (33% of subjects) and without, as well as in patients with different subtypes of social anxiety disorder; indeed, treatment with moclobemide rather than placebo was the strongest predictor of response. Adverse events were similar across treatment groups, and were typically mild and transient. In the extension phase, response rates remained higher in the moclobemide group, and ratings of tolerability were equally high in both groups. Thus, in a large sample of social anxiety disorder patients with and without comorbid anxiety disorders, moclobemide was both effective and well-tolerated in the short as well as long-term. These data confirm and extend previous findings on the value of moclobemide in the treatment of social anxiety disorder, and strengthen the range of therapeutic options for managing this important disorder.

Antidepressants in social anxiety disorder

Social anxiety disorder (SAD) is a marked and persistent fear of doing almost everything in front of people due to concerns about being judge by others. An up-to-date review is needed in order to reach a practical judgement of all psychopharmacological data. Case reports, open and double-blind trials with SAD were described and commented upon from a clinical point of view. The MEDLINE system was searched from 1975 to 2001. The references from the selected papers were also used as a source. MAOIs (fenelzine, tranylcypromine), reversible monoamino oxidase-A inhibitors (moclobemide, brofaromine), SSRIs (paroxetine, sertraline, fluoxetine, fluvoxamine) and some other antidepressants (venlafaxine, nefazodone) have proven effective in several studies with various methodologies. The MAOIs have more serious adverse effects and the SSRIs have the best tolerance. SSRIs are efficacious and the first choice of treatment.

Antidepressants, old and new. A review of their adverse effects and toxicity in overdose

The newer antidepressants are as efficacious as the older agents in the treatment of depression. They have a side effect profile that is different from the older drugs and are generally better tolerated. Drug-drug interactions do exist with some of these agents and can usually be predicted from knowledge of their metabolism. When taken in overdose as the sole agents they are rarely fatal; seizures, nausea, vomiting, decreased level of consciousness, and tachycardia are common. In combination with other drugs, toxicity can be more severe. The serotonin syndrome can occur with many of these drugs, and the emergency physician must be vigilant in the evaluation of the overdose patient. CAs and older MAOIs are still in use and remain dangerous when taken in overdose. Patients asymptomatic after a period of observation in the ED usually can be discharged after psychiatric evaluation, when it is required.

Behavioral and biochemical studies of dichloromethane fraction from the Areca catechu nut

The dichloromethane fraction from Areca catechu was found to inhibit monoamine oxidase type A isolated from the rat brain with an IC50 of 665 +/- 65.1 microg/ml. Studies with pharmacological models of depression, i.e., forced swim and tail-suspension tests, indicated that it caused significant reduction in the immobility time similar to that of moclobemide (a selective inhibitor of MAO-A) without causing a significant change in motor performance. Alkaloids such as arecaidine, arecoline, and a few other constituents, reported to be present in Areca catechu were also tested, but none of them were found to inhibit MAO. Present study suggests that the dichloromethane fraction from A. catechu possesses antidepressant property via MAO-A inhibition.

Depression in epilepsy: etiology, phenomenology, and treatment

A history of depression or depressive symptomatology has been reported in up to two-thirds of patients with medically intractable epilepsy, whereas community studies have demonstrated affective disorder only in a quarter of these patients. Depression has been reported peri- and interictally. However, differentiation may be difficult in patients with frequent seizures. Most authors have found no correlation between depression and epilepsy variables. However, complex partial seizures, especially of temporal lobe origin, appear to be etiologic factors, particularly in men with left-sided foci. Depression is also more common in patients treated with polytherapy especially with barbiturates, phenytoin, and vigabatrin. Depression has also been described de novo after temporal lobectomy. Psychosocial factors also play a part, but underlying risk factors (e.g., genetic, endocrine and metabolic) may explain the increased rates of depression in people with epilepsy compared to those with other neurologic and chronic medical conditions. The depression appears to be endogenous. Patients tend to exhibit fewer neurotic traits and more psychotic symptoms such as paranoia, delusions, and persecutory auditory hallucinations. Treatment approaches include psychotherapy, rationalization of antiepileptic drug medication, antidepressant treatment, and ECT. The tricyclic and related antidepressants appear to be epileptogenic, especially in people at high risk (personal or family history of seizures, abnormal pretreatment EEG, brain damage, alcohol or substance abuse/withdrawal and concurrent use of CNS-active medication). Seizures tend to occur early in treatment or after dose increments, especially if rapidly titrated. There is little evidence that the newer antidepressants, e.g., selective serotonin reuptake inhibitors, moclobemide, venlafaxine, or nefazodone are more epileptogenic than placebo.

O tratamento farmacológico da fobia social

A fobia social é o medo acentuado e persistente de comer, beber, tremer, enrubescer, falar, escrever, enfim, de agir de forma ridícula ou inadequada na presença de outras pessoas. A fobia social apresenta-se em dois tipos básicos: a circunscrita, restrita a apenas um tipo de situação social, e a generalizada, caracterizada pelo temor a todas ou quase todas situações sociais. As características clínicas da fobia social são a ansiedade antecipatória, os sintomas físicos, a esquiva e a baixa auto-estima. Conforme o rigor diagnóstico, estima-se que 5% a 13% da população geral apresentem sintomas fóbicos sociais que resultem em diferentes graus de incapacitação e limitações sociais e ocupacionais. O tratamento médico de escolha é o uso de medicamentos associados à psicoterapia cognitivo-comportamental. Beta-bloqueadores (atenolol, propranolol), antidepressivos inibidores da monoamino oxidase (IMAO) (fenelzine, tanilcipromina), inibidores reversíveis da monoamino oxidase tipo-A (RIMA) (moclobemida, brofaromina), benzodiazepínicos (clonazepam, bromazepam, alprazolam) e antidepressivos inibidores seletivos de serotonina (ISRS) (paroxetina, sertralina, fluoxetina e fluvoxamina) e alguns outros (venlafaxina, nefazodone, gabapentina, clonidina) têm demonstrado eficácia em inúmeros estudos com diferentes metodologias. Os antidepressivos tricíclicos (imipramina, clomipramina), o ácido valproico e a buspirona têm apresentado resultados negativos. A paroxetina é o medicamento mais estudado com metodologia duplo-cega, com melhores resultados e com boa tolerância. Atualmente, os indivíduos que têm sua vida prejudicada pela fobia social podem, com o tratamento eficaz, adquirir uma postura mais segura em situações sociais.

Pharmacotherapy of dysthymic and chronic depressive disorders: overview with focus on moclobemide

Chronic depression was once considered untreatable pharmacologically. Open studies conducted around 1980 demonstrated efficacious results with tricyclics, classical MAOIs and lithium in 45% of cases. The subsequent delineation of dysthymia in DSM-III and its future editions as well as ICD.10, facilitated controlled trials in subjects with "pure dysthymia" and those with superimposed major depression (so-called "double-depression"). TCAs, SSRIs, RIMA, and benzamides have all proven effective in an average of 65% vs. an average of 25% with placebo. Well tolerated compounds--e.g. moclobemide, sertraline and desipramine--may permit the long-term clinical management of this spectrum of dysthymic and related conditions. Patients with "lifetime pure dysthymia" tend to respond more slowly to antidepressants than those with concurrent major depression ("double-depression") or those with "pure dysthymia" but with history of major depressive episodes. Chronicity is now well established: indeed discontinuation of antidepressants in a 4-year maintenance study has resulted in 89% rate of relapse. Dysthymia is a disabling condition and high doses of antidepressants are needed to achieve full recovery.

Pharmacokinetic and pharmacodynamic interactions between fluoxetine and moclobemide in the investigation of development of the "serotonin syndrome"

OBJECTIVE

To assess the tolerability, safety, pharmacokinetics, and pharmacodynamics of combined treatment with fluoxetine and moclobemide in healthy subjects.

METHODS

Fluoxetine (20 to 40 mg/day) was administered for 23 days to 18 subjects. At (nor)fluoxetine steady state, subjects were randomized in a 2:1 ratio to receive in addition either moclobemide (ascending doses up to 600 mg/day) of placebo. A single 300 mg dose of moclobemide was administered before and at the end of the fluoxetine regimen to assess the effects of the latter on the pharmacokinetics and pharmacodynamics of moclobemide. Adverse events and vital signs were recorded and pharmacokinetic parameters of fluoxetine and moclobemide were determined. Plasma concentrations of 3,4-dihydroxy-phenyl-glycol, 5-hydroxyindoleacetic acid, 3,4-dihydroxyphenylacetic acid, and serotonin uptake into platelets were assessed as pharmacodynamic measures.

RESULTS

The number, intensity, or type of adverse events did not change when moclobemide was added to fluoxetine. No clinically relevant changes in safety parameters occurred. Fluoxetine markedly inhibited the metabolism of moclobemide. However, multiple dosing of moclobemide did not lead the excessive accumulation. 3,4-Dihydroxyphenylglycol, 5-hydroxyindoleacetic acid, and 3,4-dihydroxyphenylacetic acid plasma levels and serotonin uptake did not reveal a pharmacodynamic interaction.

CONCLUSIONS

Combination treatment with fluoxetine and moclobemide did not provide any indication of development of the "serotonin syndrome."

Double-blind randomized controlled study of the efficacy and tolerability of two reversible monoamine oxidase A inhibitors, pirlindole and moclobemide, in the treatment of depression

The aim of this double-blind randomized study was to compare the efficacy and the tolerability of moclobemide (300-600 mg daily) and pirlindole (150-300 mg daily), two reversible inhibitors of MAO-A (RIMAs), in the treatment of depression. In total 116 patients were included in the trial, 111 patients (52 patients on pirlindole and 59 patients on moclobemide) were evaluable for efficacy and safety, and 77 patients completed the whole study (42 days of administration). Both treatments produced highly significant improvements in the Hamilton Depression Rating Scale (HDRS) score, the Hamilton Anxiety Rating Scale (HARS) score and the Montgomery-Asberg Rating Scale (MADRS) score from day 7 to day 42. The pattern of development of the three scores in the two groups did not differ significantly. After 42 days of treatment, an improvement of > or = 50% in the HDRS score was noted in 80% and 67% of patients in the pirlindole and moclobemide groups, respectively. A total of 30 (58%) patients on pirlindole and 33 (56%) patients on moclobemide experienced side-effects that were considered to be possibly or probably related to the medication. The differences between the two drugs were non-significant for all types of side-effect, with the exception of dry mouth and tachycardia, which were significantly more frequent with moclobemide.

Three suicide attempts with moclobemide

OBJECTIVE

To report plasma moclobemide, course and outcome of two cases of overdose with moclobemide alone and one case of combined ingestion of moclobemide and clomipramide.

METHODS

Moclobemide identification and quantification was achieved by gas chromatography-mass spectrometry after alkaline extraction.

CASE REPORTS

In case 1, plasma moclobemide was 2.8 mg/L with 1.8 mg/L clomipramide; in case 2, 18 mg/L; in case 3 60.9 mg/L and 4.6 mg/L 12 hours later. None of the patients showed serious effects during 24 hours of observation. Plasma moclobemide at 10 to 30 times therapeutic was not associated with major toxic effects. Moclobemide seems to be considerably less toxic than tricyclic antidepressants.

Moclobemide safety: monitoring a newly developed product in the 1990s

Moclobemide is a reversible and selective inhibitor of monoamine oxidase subtype A with a wide spectrum of antidepressant activity. To fully evaluate product safety, Roche Drug Safety has collected data on adverse events (AEs), regardless of causality, from all sources worldwide through the product development phase and after launch. This effort has included analyses of reports from clinical trials, regulatory authorities, the literature, observational studies, and the marketplace. Roche Drug Safety has also carefully examined all cases where moclobemide was taken in overdose, whether with or without other substances. This article presents the safety profile of the product after 3 years on world markets. In clinical trials, moclobemide appeared only slightly less well tolerated than placebo. In comparative trials, moclobemide was largely devoid of the anticholinergic effects associated with tricyclic antidepressants. To the end of June 1993, with an estimated 780,000 subjects exposed, AEs had been reported by less than 0.2% of users. The most frequently reported AEs were psychiatric, neurologic, and gastrointestinal disorders. Hepatobiliary AEs were rare, suggesting that moclobemide is largely devoid of hepatotoxic potential. Cardiovascular AEs reflected the prevalence of cardiovascular disease in the population treated. This safety profile is largely unchanged from those observed at 1 and 2 years postlaunch, when the estimated exposed populations were 168,000 and 328,000, respectively. It is of great significance that the fatal toxicity index of moclobemide is zero. A review of single-drug intoxications with moclobemide at doses of up to 20.55 g revealed no deaths due solely to moclobemide overdose. All patients recovered fully within 1 to 7 days without residual hepatic or cardiovascular toxicity.(ABSTRACT TRUNCATED AT 250 WORDS)

A double-blind comparison of moclobemide and doxepin in depressed general practice patients

A total of 56 patients attending a general practitioner for treatment of depression, most of whom met the criteria for major depression, were included in this double-blind, parallel group, 6-week study, in which the selective MAO-A inhibitor moclobemide (MOC; maximum dose 600 mg) was compared with the tricyclic antidepressant doxepin (DOX; maximum dose 250 mg). Thirty patients on MOC and 23 on DOX were assessed after treatment for at least 1 week and are included in the response evaluation. Improvement was assessed primarily with the Montgomery-Asberg Depression Rating Scale (MADRS). There were only 4 drop-outs in the MOC group and three in the DOX group after 1 week. Overall improvement measures showed a nonsignificant difference in favor of DOX. Two factors were found to have prognostic significance: (1) previous or present panic attacks (10 patients in the MOC group and--by chance--only one in the DOX group) were associated with significantly lower improvement within the MOC group. Since we had no a priori hypothesis about this effect, it could be a chance finding. (2) Improvement was negatively correlated with age; this was statistically significant in the total group as well as in the MOC group, with a nonsignificant trend in the same direction in the DOX group. Side effects differed little between the two groups; only dryness of mouth appeared with markedly higher frequency in the DOX group.

Moclobemide and fluoxetine in the prevention of relapses following acute treatment of depression

The efficacy of moclobemide (378 mg +/- 76 mg/day) and fluoxetine (36 mg +/- 8 mg/day) in preventing relapse was studied during 12 weeks of continuation treatment after a 6-week initial trial. Fifty-nine patients with Hamilton Depression Rating Scale (HDRS) scores of 16 or less were enrolled; 29 continued to receive moclobemide and 30 fluoxetine. Efficacy was measured using a 17-item HDRS, the Montgomery-Asberg Depression Rating Scale and the Clinical Global Impression. Improvement in quality of life was measured using a Medical Outcome Study Short-form General Health Survey and the 15D Measure of Quality of Life. Twenty-three per cent of the patients in the fluoxetine group dropped out of the study and 10% in the moclobemide group. Two patients (7%) in the moclobemide group and one (3%) in the fluoxetine group suffered a relapse. Health status and quality of life improved in both drug groups during a 12-week continuation period. The reports of adverse events fell to one third during the continuation phase. The results indicate that benefits may be gained from extending acute treatment.

Moclobemide versus fluoxetine for a major depressive episode

The efficacy and tolerability of moclobemide (300-600 mg daily) and fluoxetine (20-40 mg daily) were compared in a 6-week, double-blind study of 65 inpatients and 34 outpatients suffering from major depressive episodes (DSM III-R). No statistically significant differences between the two treatment groups were noted regarding efficacy (HDRS, CGI) or safety (adverse events, laboratory examination, vital signs). Moclobemide (300-600 mg daily) and fluoxetine (20-40 mg daily) would thus appear to be comparable both in antidepressant efficacy and tolerability. Doubling the low dosage in non-responders after 3 weeks resulted in a statistically significant improvement of CGI in the moclobemide group by comparison with the fluoxetine group at study end, suggesting that 600 mg moclobemide/day can still improve the patient's condition, while 40 mg fluoxetine/day does not. Sexual dysfunction was reported in two patients taking fluoxetine.

Moclobemide: a reversible MAO-A-inhibitor showing weaker antidepressant effect than clomipramine in a controlled multicenter study. Danish University Antidepressant Group

Antidepressant and unwanted effects of moclobemide (400 mg/day) and clomipramine (150 mg/day) were compared in a double-blind, randomised, in-patient, fixed-dose study with weekly ratings and drug level measurements. After 1 week of single-blind placebo treatment, 115 patients with major depression fulfilled the criterion of a Hamilton Depression Scale (17-item, HDS) score of > or = 18 and were started on active treatment for 6 weeks. Drop-outs on moclobemide (n = 20) were in particular due to worsening and suicidality (n = 9) whereas drop-outs on clomipramine (n = 12) in particular were due to side effects/adverse events (n = 6) and no drop-outs due to worsening. End-point analysis on the basis of different depression ratings showed consistently a significantly weaker effect of moclobemide (final median HDS: 15) compared with clomipramine (final median HDS: 11). The difference involved both sleep and depression symptoms. These results are generally at variance with the main body of literature on moclobemide, although a higher frequency of drop-out due to worsening in moclobemide-treated patients compared to tricyclic antidepressant-treated patients has been reported in several studies.

Antidepressant treatments in children and adolescents. I. Affective disorders

Part I of this review critically evaluates antidepressants' benefits for children and adolescents with affective disorders. The effectiveness of antidepressants is characterized with specific references regarding diagnostic methodology, measurement characteristics, response definitions, recovery rates, length of treatment, and plasma level monitoring. Antidepressants' efficacy for depressed youths is quite circumscribed, and their superiority to placebo remains unproved. Their intriguing lack of efficacy in affective disorders is discussed based on methodological issues and from a theoretical perspective. Clinical and research implications are presented.

Pharmacotherapy of social phobia. A controlled study with moclobemide and phenelzine

In a double-blind, parallel group trial, 78 subjects with social phobia received moclobemide (a new reversible inhibitor of monoamine oxidase A) phenelzine, or placebo. After eight weeks, both active drugs-phenelzine somewhat more than moclobemide--were clinically and statistically significantly more effective than placebo, as assessed by rating scales. There was some further improvement between weeks 8 and 16, particularly in the moclobemide group; at week 16, 82% of the moclobemide and 91% of the phenelzine-treated patients were almost asymptomatic. Moclobemide was, however, much better tolerated than phenelzine. Patients withdrawn from active drugs had relapsed by week 24, providing additional support for the efficacy of the active drugs.

Effects of two different reversible monoamine oxidase-A inhibitors on nociceptive thresholds in the rat

The acute effect of two different reversible inhibitors of monoamine oxidase-A on nociceptive thresholds was evaluated in the rat by the tail-flick and hot-plate tests. CGP 11305-A, a monoamine oxidase-A inhibitor that also blocks serotonin reuptake, elicited an increase of latency in the tail-flick and the hot-plate test. Ineffective doses of CGP 11305-A increased nociceptive thresholds when administered in combination with other serotoninergic agents, i.e. chlorimipramine or 5-hydroxytryptophan, at doses that were ineffective alone. CGP 22364-A, a pure inhibitor of monoamine oxidase-A, increased latency only in the hot-plate test. Both compounds decreased spontaneous locomotor activity at the doses effective in the hot-plate test, suggesting that the responses observed in this test are not related to a pure effect on nociceptive thresholds. The data suggest that the increase in serotonin availability induced by monoamine oxidase-A inhibition alone is not sufficient to affect nociceptive thresholds.

Efficacy and tolerability of moclobemide compared with fluvoxamine in depressive disorder (DSM III). A French/Swiss double-blind trial

The efficacy and tolerability of moclobemide and fluvoxamine, two new types of antidepressant agents, were compared in a multicentre, double-blind prospective study of patients with a diagnosis of major depressive episode (DSM III). Patients were randomized to receive either moclobemide (150 mg) or fluvoxamine (50 mg) twice daily for 7 days, immediately following a washout period of at least 1 week. Dosages were increased where necessary on day 8, to a maximum of moclobemide 450 mg or fluvoxamine 200 mg and in most cases were maintained at these levels for the remainder of the study period (4-6 weeks). Both treatment groups showed a marked antidepressant effect. While both treatments were well tolerated, moclobemide showed a more favourable side-effect profile than fluvoxamine. Of the 126 patients eligible for evaluation, 34 withdrew from therapy, 22% in the moclobemide group and 30% in the fluvoxamine group. Adverse events were reported in 41.8% of patients treated with moclobemide compared to 60.3% of patients in the fluvoxamine group. Reports of dry mouth and other anticholinergic effects were more frequent among those treated with fluvoxamine. A greater number of gastrointestinal complaints, especially nausea, also occurred in the fluvoxamine-treated patients.