Subgroup analysis of the non-interventional study VIVALDI: agomelatine in treatment-naïve patients, in combination therapy and after treatment switch

Experimental Therapeutics in Treatment-Resistant Major Depressive Disorder

Treatment-Resistant Depression (TRD) patients remain a challenging sub-division of patients with Major Depressive Disorder (MDD) in day to day clinical practice. As with any diagnostic condition, comprehensive evaluation, exclusion of other psychiatric conditions, assessment of co-morbid medical and psychiatric illnesses and psychosocial stressors are the keys to appropriate diagnosis and subsequent management. There are various management options available for the treatment of MDD, however, about 30% of the patients fail to achieve full remission of symptoms despite multiple trials and belong to this sub-category of MDD. This article brings forth discussion of other non-conventional medication and non-medication treatment alternatives that merit exploration of their efficacy in TRD. Many of the proposed novel medications and other treatment modalities such as Deep Brain Stimulation, exercise, yoga are already used for other medical and psychiatric disorders and have some evidence suggesting their potential benefits in TRD in conjunction with conventional medications or even as monotherapy. Nevertheless, more research is needed in this direction to establish effectiveness.

What combinations of agomelatine with other antidepressants could be successful during the treatment of major depressive disorder or anxiety disorders in clinical practice?

Even with many antidepressant and anxiolytic drugs available on the market, there are still patients who do not respond well to the standard first or second line treatments for affective or anxiety disorders. The antidepressant agomelatine has been used in Europe for several years. Agomelatine, an agonist at melatonin receptors and an antagonist at serotonin receptors, can be particularly useful in patients suffering from a major depressive disorder associated with insomnia. Some clinical data have shown a limited effect for agomelatine in a subset of patients with major depression. A number of case reports published in 2011-2016 describe the effect of agomelatine in combination with an established antidepressant, such as escitalopram, venlafaxine, duloxetine, moclobemide or bupropion. A successful combination of agomelatine was reported after adjunctive use of agomelatine combined with clomipramine, escitalopram, and venlafaxine in patients with major depression or obsessive-compulsive disorder. Moreover, bupropion or moclobemide augmentation with agomelatine in patients with major depressive disorder led to a significant improvement. Other supportive data have been published, such as analysis of the VIVALDI study, although it should be noted that the study was supported by the manufacturer of agomelatine. In this study, agomelatine in combination with other antidepressants was shown to be effective and well tolerated in practice, although the most effective antidepressant treatment in the study consisted of agomelatine alone and not in combination with other antidepressants. There have also been two published case reports about the concomitant use of duloxetine and agomelatine which were not efficacious. The positive results of agomelatine augmentation with other antidepressants should be confirmed through randomized, double-blind clinical trials.

Pooled Analysis of Four Non-Interventional Studies: Effectiveness and Tolerability of the Antidepressant Agomelatine in Daily Practice

INTRODUCTION

Meta-analyses are useful to increase knowledge and strengthen evidence about antidepressant treatment supplementary to individual studies.

METHODS

A pooled analysis of four multicenter, open-label, prospective, non-interventional studies (2009-2013) was performed to provide further evidence about the antidepressant effectiveness and tolerability of agomelatine (25-50 mg/day) in a large number of non-selected German outpatients with major depressive disorder. The main analysis was performed after 12 weeks (n = 9601) and in subpopulations after 24 and 52 weeks by descriptive statistical methods.

RESULTS

Overall, 60.1% of patients were pretreated with antidepressants. Concomitant psychiatric diseases (71.9%), co-medication with antidepressants (18.9%) and/or psychotropic medication (31.9%) were observed. Depressive symptoms improved according to the Clinical Global Impression (CGI) in 81% after 12 weeks, a response was observed in 78.7% (CGI-I ≤2), and remission in 34.5% of patients (CGI-S = 1 or 2). In subpopulations, response was documented in 79.3% (W24) and 75.9% (W52) and remission in 38.1% (W24) and 47.5% (W52), respectively. Over 12 weeks, adverse drug reactions (ADRs) were reported for 511 patients (5.32%), most frequently headache (0.92%) and nausea (0.75%), and serious adverse drug reactions (sADR) for 18 patients (0.19%). Between W12-W24 and W24-W52, ADRs were reported for 0.49%/0.99% and sADRs for 0.05%/0%, respectively. Overall, 49 patients (0.5%) showed clinically relevant transaminase elevations (AST/ALT >3 times upper normal value), with 19 patients (0.2%) showing preexisting elevations at the study start. One patient (0.03%) developed hepatitis with reversible symptoms after treatment discontinuation. ADR predominantly occurred within the first weeks of treatment. Mean weight and body mass index (BMI) remained unchanged over 24 weeks.

CONCLUSION

In this pooled data analysis, 9601 depressed patients of clinical practice were evaluated over 12 weeks and subpopulations were also analyzed over 24 and 52 weeks. Agomelatine effectively reduced depressive symptoms (CGI-response and remission) with good general tolerability.