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Deligiannidis KM, Meltzer-Brody S, Gunduz-Bruce H, Doherty J, Jonas J, Li S, Sankoh AJ, Silber C, Campbell AD, Werneburg B, Kanes SJ, Lasser R. Effect of Zuranolone vs Placebo in Postpartum Depression: A Randomized Clinical Trial. JAMA Psychiatry 2021; 78:951-959. [PMID: 34190962 PMCID: PMC8246337 DOI: 10.1001/jamapsychiatry.2021.1559] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 05/05/2021] [Indexed: 12/28/2022]
Abstract
Importance Postpartum depression (PPD) is one of the most common medical complications during and after pregnancy, negatively affecting both mother and child. Objective To demonstrate the efficacy and safety of zuranolone, a neuroactive steroid γ-aminobutyric acid receptor-positive allosteric modulator, in PPD. Design, Setting, and Participants This phase 3, double-blind, randomized, outpatient, placebo-controlled clinical trial was conducted between January 2017 and December 2018 in 27 enrolling US sites. Participant were women aged 18 to 45 years, 6 months or fewer post partum, with PPD (major depressive episode beginning third trimester or ≤4 weeks postdelivery), and baseline 17-item Hamilton Rating Scale for Depression (HAMD-17) score of 26 or higher. Analysis was intention to treat and began December 2018 and ended March 2019. Interventions Randomization 1:1 to placebo:zuranolone, 30 mg, administered orally each evening for 2 weeks. Main Outcomes and Measures Primary end point was change from baseline in HAMD-17 score for zuranolone vs placebo at day 15. Secondary end points included changes from baseline in HAMD-17 total score at other time points, HAMD-17 response (≥50% score reduction) and remission (score ≤7) rates, Montgomery-Åsberg Depression Rating Scale score, and Hamilton Rating Scale for Anxiety score. Safety was assessed by adverse events and clinical assessments. Results Of 153 randomized patients, the efficacy set comprised 150 patients (mean [SD] age, 28.3 [5.4] years), and 148 (98.7%) completed treatment. A total of 76 patients were randomized to placebo, and 77 were randomized to zuranolone, 30 mg. Zuranolone demonstrated significant day 15 HAMD-17 score improvements from baseline vs placebo (-17.8 vs -13.6; difference, -4.2; 95% CI, -6.9 to -1.5; P = .003). Sustained differences in HAMD-17 scores favoring zuranolone were observed from day 3 (difference, -2.7; 95% CI, -5.1 to -0.3; P = .03) through day 45 (difference, -4.1; 95% CI, -6.7 to -1.4; P = .003). Sustained differences at day 15 favoring zuranolone were observed in HAMD-17 response (odds ratio, 2.63; 95% CI, 1.34-5.16; P = .005), HAMD-17 score remission (odds ratio, 2.53; 95% CI, 1.24-5.17; P = .01), change from baseline for Montgomery-Åsberg Depression Rating Scale score (difference, -4.6; 95% CI, -8.3 to -0.8; P = .02), and Hamilton Rating Scale for Anxiety score (difference, -3.9; 95% CI, -6.7 to -1.1; P = .006). One patient per group experienced a serious adverse event (confusional state in the zuranolone group and pancreatitis in the placebo group). One patient in the zuranolone group discontinued because of an adverse event vs none for placebo. Conclusions and Relevance In this randomized clinical trial, zuranolone improved the core symptoms of depression as measured by HAMD-17 scores in women with PPD and was generally well tolerated, supporting further development of zuranolone in the treatment of PPD. Trial Registration ClinicalTrials.gov Identifier: NCT02978326.
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Affiliation(s)
- Kristina M. Deligiannidis
- Department of Psychiatry, Zucker Hillside Hospital, Glen Oaks, New York
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | | | | | | | | | - Sigui Li
- Sage Therapeutics, Inc, Cambridge, Massachusetts
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von Blomberg A, Kay L, Knake S, Fuest S, Zöllner JP, Reif PS, Herrmann E, Balaban Ü, Schubert-Bast S, Rosenow F, Strzelczyk A. Efficacy, Tolerability, and Safety of Concentrated Intranasal Midazolam Spray as Emergency Medication in Epilepsy Patients During Video-EEG Monitoring. CNS Drugs 2020; 34:545-553. [PMID: 32219682 PMCID: PMC7198639 DOI: 10.1007/s40263-020-00720-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND An efficient, well tolerated, and safe emergency treatment with a rapid onset of action is needed to prevent seizure clusters and to terminate prolonged seizures and status epilepticus. OBJECTIVES This study aimed to examine the efficacy, tolerability, and safety of intranasal midazolam (in-MDZ) spray in clinical practice. METHODS In this retrospective, multicenter observational study, we evaluated all patients with peri-ictal application of in-MDZ during video-EEG monitoring at the epilepsy centers in Frankfurt and Marburg between 2 014 and 2017. For every patient, we analyzed the recurrence of any seizure or generalized tonic-clonic seizures after index seizures with and without in-MDZ administration. Treatment-emergent adverse events (TEAEs) were also evaluated. RESULTS In-MDZ was used in 243 patients with epilepsy (mean age 35.5 years; range 5-76 years; 46.5% female) for treatment of 459 seizures. A median dose of in-MDZ 5 mg (i.e., two puffs; range 2.5-15 mg) was administered within a median time from EEG seizure onset until in-MDZ application of 1.18 min [interquartile range (IQR) 1.27], while median time from clinical seizure onset until in-MDZ administration was 1.08 min (IQR 1.19). In-MDZ was given within 1 min after EEG seizure onset in 171 seizures. An intraindividual comparison of seizures with and without application of in-MDZ was feasible in 171 patients, demonstrating that in-MDZ reduced the occurrence of any (Cox proportional-hazard model p < 0.001) and generalized tonic-clonic seizure (Cox proportional-hazard model p = 0.0167) over a period of 24 h. The seizure-free timespan was doubled from a median of 5.0 h in controls to a median of 10.67 h after in-MDZ administration. We additionally clustered in-MDZ administrations for the 119 patients who received in-MDZ more than once, comparing them with the index cases without in-MDZ. Even when considering subsequent seizures with in-MDZ administration, a patient receiving in-MDZ is still half as likely to incur another seizure in the upcoming 24 h as compared with when the same patient does not receive in-MDZ (hazard ratio 0.50; 95% CI 0.42-0.60; p < 0.01). In-MDZ was well tolerated without major adverse events. The most common side effects were irritation of the nasal mucosa [37 cases (8.1%)], prolonged sedation [26 cases (5.7%)], and nausea and vomiting [12 cases (2.6%)]. A decline in oxygen saturation was measured after 78 seizures (17%). CONCLUSION We conclude that in-MDZ is a safe and efficient treatment option to prevent short-term recurrence of seizures. In-MDZ can be administered very quickly by trained staff within 1-2 min after seizure onset. No major cardiocirculatory or respiratory adverse events were observed.
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Affiliation(s)
- Anemone von Blomberg
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, University Hospital Frankfurt, Schleusenweg 2-16, Haus 95, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Lara Kay
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, University Hospital Frankfurt, Schleusenweg 2-16, Haus 95, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Susanne Knake
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Sven Fuest
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Johann Philipp Zöllner
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, University Hospital Frankfurt, Schleusenweg 2-16, Haus 95, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Philipp S Reif
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, University Hospital Frankfurt, Schleusenweg 2-16, Haus 95, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Eva Herrmann
- Institute for Biostatistics and Mathematical Modeling, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Ümniye Balaban
- Institute for Biostatistics and Mathematical Modeling, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, University Hospital Frankfurt, Schleusenweg 2-16, Haus 95, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, University Hospital Frankfurt, Schleusenweg 2-16, Haus 95, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, University Hospital Frankfurt, Schleusenweg 2-16, Haus 95, 60528, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany.
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Gunduz-Bruce H, Silber C, Kaul I, Rothschild AJ, Riesenberg R, Sankoh AJ, Li H, Lasser R, Zorumski CF, Rubinow DR, Paul SM, Jonas J, Doherty JJ, Kanes SJ. Trial of SAGE-217 in Patients with Major Depressive Disorder. N Engl J Med 2019; 381:903-911. [PMID: 31483961 DOI: 10.1056/nejmoa1815981] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Altered neurotransmission of γ-aminobutyric acid (GABA) has been implicated in the pathogenesis of depression. Whether SAGE-217, an oral, positive allosteric modulator of GABA type A receptors, is effective and safe for the treatment of major depressive disorder is unknown. METHODS In this double-blind, phase 2 trial, we enrolled patients with major depression and randomly assigned them in a 1:1 ratio to receive 30 mg of SAGE-217 or placebo once daily. The primary end point was the change from baseline to day 15 in the score on the 17-item Hamilton Depression Rating Scale (HAM-D; scores range from 0 to 52, with higher scores indicating more severe depression). Secondary efficacy end points, which were assessed on days 2 through 8 and on days 15, 21, 28, 35, and 42, included changes from baseline in scores on additional depression and anxiety scales, a reduction from baseline of more than 50% in the HAM-D score, a HAM-D score of 7 or lower, and a Clinical Global Impression of Improvement score of 1 (very much improved) or 2 (much improved) (on a scale of 1 to 7, with a score of 7 indicating that symptoms are very much worse). RESULTS A total of 89 patients underwent randomization: 45 patients were assigned to the SAGE-217 group, and 44 to the placebo group. The mean baseline HAM-D score was 25.2 in the SAGE-217 group and 25.7 in the placebo group. The least-squares mean (±SE) change in the HAM-D score from baseline to day 15 was -17.4±1.3 points in the SAGE-217 group and -10.3±1.3 points in the placebo group (least-squares mean difference in change, -7.0 points; 95% confidence interval, -10.2 to -3.9; P<0.001). The differences in secondary end points were generally in the same direction as those of the primary end point. There were no serious adverse events. The most common adverse events in the SAGE-217 group were headache, dizziness, nausea, and somnolence. CONCLUSIONS Administration of SAGE-217 daily for 14 days resulted in a reduction in depressive symptoms at day 15. Adverse events were more common in the SAGE-217 group than in the placebo group. Further trials are needed to determine the durability and safety of SAGE-217 in major depressive disorder and to compare SAGE-217 with available treatments. (Funded by Sage Therapeutics; ClinicalTrials.gov number, NCT03000530.).
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Affiliation(s)
- Handan Gunduz-Bruce
- From Sage Therapeutics, Cambridge (H.G.-B., C.S., A.J.S., H.L., R.L., S.M.P., J.J., J.J.D., S.J.K.), Kaul Consulting, Concord (I.K.), and the University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester (A.J.R.) - all in Massachusetts; the Atlanta Center for Medical Research, Atlanta (R.R.); Washington University School of Medicine, St. Louis (C.F.Z., S.M.P.); and the University of North Carolina School of Medicine, Chapel Hill (D.R.R.)
| | - Christopher Silber
- From Sage Therapeutics, Cambridge (H.G.-B., C.S., A.J.S., H.L., R.L., S.M.P., J.J., J.J.D., S.J.K.), Kaul Consulting, Concord (I.K.), and the University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester (A.J.R.) - all in Massachusetts; the Atlanta Center for Medical Research, Atlanta (R.R.); Washington University School of Medicine, St. Louis (C.F.Z., S.M.P.); and the University of North Carolina School of Medicine, Chapel Hill (D.R.R.)
| | - Inder Kaul
- From Sage Therapeutics, Cambridge (H.G.-B., C.S., A.J.S., H.L., R.L., S.M.P., J.J., J.J.D., S.J.K.), Kaul Consulting, Concord (I.K.), and the University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester (A.J.R.) - all in Massachusetts; the Atlanta Center for Medical Research, Atlanta (R.R.); Washington University School of Medicine, St. Louis (C.F.Z., S.M.P.); and the University of North Carolina School of Medicine, Chapel Hill (D.R.R.)
| | - Anthony J Rothschild
- From Sage Therapeutics, Cambridge (H.G.-B., C.S., A.J.S., H.L., R.L., S.M.P., J.J., J.J.D., S.J.K.), Kaul Consulting, Concord (I.K.), and the University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester (A.J.R.) - all in Massachusetts; the Atlanta Center for Medical Research, Atlanta (R.R.); Washington University School of Medicine, St. Louis (C.F.Z., S.M.P.); and the University of North Carolina School of Medicine, Chapel Hill (D.R.R.)
| | - Robert Riesenberg
- From Sage Therapeutics, Cambridge (H.G.-B., C.S., A.J.S., H.L., R.L., S.M.P., J.J., J.J.D., S.J.K.), Kaul Consulting, Concord (I.K.), and the University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester (A.J.R.) - all in Massachusetts; the Atlanta Center for Medical Research, Atlanta (R.R.); Washington University School of Medicine, St. Louis (C.F.Z., S.M.P.); and the University of North Carolina School of Medicine, Chapel Hill (D.R.R.)
| | - Abdul J Sankoh
- From Sage Therapeutics, Cambridge (H.G.-B., C.S., A.J.S., H.L., R.L., S.M.P., J.J., J.J.D., S.J.K.), Kaul Consulting, Concord (I.K.), and the University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester (A.J.R.) - all in Massachusetts; the Atlanta Center for Medical Research, Atlanta (R.R.); Washington University School of Medicine, St. Louis (C.F.Z., S.M.P.); and the University of North Carolina School of Medicine, Chapel Hill (D.R.R.)
| | - Haihong Li
- From Sage Therapeutics, Cambridge (H.G.-B., C.S., A.J.S., H.L., R.L., S.M.P., J.J., J.J.D., S.J.K.), Kaul Consulting, Concord (I.K.), and the University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester (A.J.R.) - all in Massachusetts; the Atlanta Center for Medical Research, Atlanta (R.R.); Washington University School of Medicine, St. Louis (C.F.Z., S.M.P.); and the University of North Carolina School of Medicine, Chapel Hill (D.R.R.)
| | - Robert Lasser
- From Sage Therapeutics, Cambridge (H.G.-B., C.S., A.J.S., H.L., R.L., S.M.P., J.J., J.J.D., S.J.K.), Kaul Consulting, Concord (I.K.), and the University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester (A.J.R.) - all in Massachusetts; the Atlanta Center for Medical Research, Atlanta (R.R.); Washington University School of Medicine, St. Louis (C.F.Z., S.M.P.); and the University of North Carolina School of Medicine, Chapel Hill (D.R.R.)
| | - Charles F Zorumski
- From Sage Therapeutics, Cambridge (H.G.-B., C.S., A.J.S., H.L., R.L., S.M.P., J.J., J.J.D., S.J.K.), Kaul Consulting, Concord (I.K.), and the University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester (A.J.R.) - all in Massachusetts; the Atlanta Center for Medical Research, Atlanta (R.R.); Washington University School of Medicine, St. Louis (C.F.Z., S.M.P.); and the University of North Carolina School of Medicine, Chapel Hill (D.R.R.)
| | - David R Rubinow
- From Sage Therapeutics, Cambridge (H.G.-B., C.S., A.J.S., H.L., R.L., S.M.P., J.J., J.J.D., S.J.K.), Kaul Consulting, Concord (I.K.), and the University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester (A.J.R.) - all in Massachusetts; the Atlanta Center for Medical Research, Atlanta (R.R.); Washington University School of Medicine, St. Louis (C.F.Z., S.M.P.); and the University of North Carolina School of Medicine, Chapel Hill (D.R.R.)
| | - Steven M Paul
- From Sage Therapeutics, Cambridge (H.G.-B., C.S., A.J.S., H.L., R.L., S.M.P., J.J., J.J.D., S.J.K.), Kaul Consulting, Concord (I.K.), and the University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester (A.J.R.) - all in Massachusetts; the Atlanta Center for Medical Research, Atlanta (R.R.); Washington University School of Medicine, St. Louis (C.F.Z., S.M.P.); and the University of North Carolina School of Medicine, Chapel Hill (D.R.R.)
| | - Jeffrey Jonas
- From Sage Therapeutics, Cambridge (H.G.-B., C.S., A.J.S., H.L., R.L., S.M.P., J.J., J.J.D., S.J.K.), Kaul Consulting, Concord (I.K.), and the University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester (A.J.R.) - all in Massachusetts; the Atlanta Center for Medical Research, Atlanta (R.R.); Washington University School of Medicine, St. Louis (C.F.Z., S.M.P.); and the University of North Carolina School of Medicine, Chapel Hill (D.R.R.)
| | - James J Doherty
- From Sage Therapeutics, Cambridge (H.G.-B., C.S., A.J.S., H.L., R.L., S.M.P., J.J., J.J.D., S.J.K.), Kaul Consulting, Concord (I.K.), and the University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester (A.J.R.) - all in Massachusetts; the Atlanta Center for Medical Research, Atlanta (R.R.); Washington University School of Medicine, St. Louis (C.F.Z., S.M.P.); and the University of North Carolina School of Medicine, Chapel Hill (D.R.R.)
| | - Stephen J Kanes
- From Sage Therapeutics, Cambridge (H.G.-B., C.S., A.J.S., H.L., R.L., S.M.P., J.J., J.J.D., S.J.K.), Kaul Consulting, Concord (I.K.), and the University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester (A.J.R.) - all in Massachusetts; the Atlanta Center for Medical Research, Atlanta (R.R.); Washington University School of Medicine, St. Louis (C.F.Z., S.M.P.); and the University of North Carolina School of Medicine, Chapel Hill (D.R.R.)
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Abstract
Postpartum depression is one of the most common complications of childbirth. Untreated postpartum depression can have substantial adverse effects on the well-being of the mother and child, negatively impacting child cognitive, behavioral, and emotional development with lasting consequences. There are a number of therapeutic interventions for postpartum depression including pharmacotherapy, psychotherapy, neuromodulation, and hormonal therapy among others, most of which have been adapted from the treatment of major depressive disorder outside of the peripartum period. Current evidence of antidepressant treatment for postpartum depression is limited by the small number of randomized clinical trials, underpowered samples, and the lack of long-term follow-up. The peripartum period is characterized by rapid and significant physiological change in plasma levels of endocrine hormones, peptides, and neuroactive steroids. Evidence supporting the role of neuroactive steroids and γ-aminobutyric acid (GABA) in the pathophysiology of postpartum depression led to the investigation of synthetic neuroactive steroids and their analogs as potential treatment for postpartum depression. Brexanolone, a soluble proprietary intravenous preparation of synthetic allopregnanolone, has been developed. A recent series of open-label and placebo-controlled randomized clinical trials of brexanolone in postpartum depression demonstrated a rapid reduction in depressive symptoms, and has led to the submission for regulatory approval to the US Food and Drug Administration (decision due in March 2019). SAGE-217, an allopregnanolone analog, with oral bioavailability, was recently tested in a randomized, double-blind, placebo-controlled phase III study in severe postpartum depression, with reportedly positive results. Finally, a 3β-methylated synthetic analog of allopregnanolone, ganaxolone, is being tested in both intravenous and oral forms, in randomized, double-blind, placebo-controlled phase II studies in severe postpartum depression.
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Affiliation(s)
- Ariela Frieder
- Department of Psychiatry, Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, 75-59 263rd Street, New York, NY, 11004, USA
| | - Madeleine Fersh
- Department of Psychiatry, Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, 75-59 263rd Street, New York, NY, 11004, USA
| | - Rachel Hainline
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Kristina M Deligiannidis
- Department of Psychiatry, Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, 75-59 263rd Street, New York, NY, 11004, USA.
- Departments of Psychiatry and Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
- Feinstein Institute for Medical Research, Manhasset, NY, USA.
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Reddy MSS, Achary U, Harbishettar V, Sivakumar PT, Varghese M. Paradoxical reaction to benzodiazepines in elderly - Case series. Asian J Psychiatr 2018; 35:8-10. [PMID: 29723722 DOI: 10.1016/j.ajp.2018.04.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 04/23/2018] [Indexed: 01/10/2023]
Affiliation(s)
- Mukku Shiva Shanker Reddy
- Geriatric Clinic & Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
| | - Umesh Achary
- Geriatric Clinic & Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
| | - Vijaykumar Harbishettar
- Geriatric Clinic & Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
| | - Palanimuthu T Sivakumar
- Geriatric Clinic & Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
| | - Mathew Varghese
- Geriatric Clinic & Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
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Abstract
BACKGROUND Hepatic encephalopathy is a common complication of cirrhosis which results in poor brain functioning. The spectrum of changes associated with hepatic encephalopathy ranges from the clinically 'indiscernible' or minimal hepatic encephalopathy to the clinically 'obvious' or overt hepatic encephalopathy. Flumazenil is a synthetic benzodiazepine antagonist with high affinity for the central benzodiazepine recognition site. Flumazenil may benefit people with hepatic encephalopathy through an indirect negative allosteric modulatory effect on gamma-aminobutyric acid receptor function. The previous version of this review, which included 13 randomised clinical trials, found no effect of flumazenil on all-cause mortality, based on an analysis of 10 randomised clinical trials, but found a beneficial effect on hepatic encephalopathy, based on an analysis of eight randomised clinical trials. OBJECTIVES To evaluate the beneficial and harmful effects of flumazenil versus placebo or no intervention for people with cirrhosis and hepatic encephalopathy. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, and LILACS; meeting and conference proceedings; and bibliographies in May 2017. SELECTION CRITERIA We included randomised clinical trials regardless of publication status, blinding, or language in the analyses of benefits and harms, and observational studies in the assessment of harms. DATA COLLECTION AND ANALYSIS Two review authors extracted data independently. We undertook meta-analyses and presented results using risk ratios (RR) with 95% confidence intervals (CI) and I2 values as a marker of heterogeneity. We assessed bias control using the Cochrane Hepato-Biliary Group domains; determined the quality of the evidence using GRADE; evaluated the risk of small-study effects in regression analyses; and conducted trial sequential, subgroup, and sensitivity analyses. MAIN RESULTS We identified 14 eligible randomised clinical trials with 867 participants, the majority of whom had an acute episode of overt hepatic encephalopathy. In addition, we identified one ongoing randomised clinical trial. We were unable to gather outcome data from two randomised clinical trials with 25 participants. Thus, our analyses include 842 participants from 12 randomised clinical trials comparing flumazenil versus placebo. We classified one randomised clinical trial at low risk of bias in the overall assessment and the remaining randomised clinical trials at high risk of bias. The duration of follow-up ranged from a few minutes to two weeks, but it was less than one day in the majority of the trials.In total, 32/433 (7.4%) participants allocated to flumazenil versus 38/409 (9.3%) participants allocated to placebo died (RR 0.75, 95% CI 0.48 to 1.16; 11 randomised clinical trials; low quality evidence). The Trial Sequential Analysis and the one randomised clinical trial assessed as low risk of bias (RR 0.76, 95% CI 0.37 to 1.53) found no beneficial or harmful effects of flumazenil on all-cause mortality. The methods used to evaluate hepatic encephalopathy included several different clinical scales, electrophysiological variables, and psychometric tests. Flumazenil was associated with a beneficial effect on hepatic encephalopathy when including all randomised clinical trials (RR 0.75, 95% CI 0.71 to 0.80; 824 participants; nine randomised clinical trials; low quality evidence), or just the trial at low risk of bias (RR 0.78, 95% CI 0.72 to 0.84; 527 participants). The Trial Sequential Analysis supported a beneficial effect of flumazenil on hepatic encephalopathy. The randomised clinical trials included little information about causes of death and little information on non-fatal serious adverse events. AUTHORS' CONCLUSIONS We found low quality evidence suggesting a short-term beneficial effect of flumazenil on hepatic encephalopathy in people with cirrhosis, but no evidence of an effect on all-cause mortality. Additional evidence from large, high quality randomised clinical trials is needed to evaluate the potential benefits and harms of flumazenil in people with cirrhosis and hepatic encephalopathy.
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Affiliation(s)
- Ee Teng Goh
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthRowland Hill StreetHampsteadLondonUKNW3 2PF
| | - Mette L Andersen
- RigshospitaletDepartment of HepatologyBlegdamsvej 9Dept. 2121CopenhagenDenmark2100
| | - Marsha Y Morgan
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthRowland Hill StreetHampsteadLondonUKNW3 2PF
| | - Lise Lotte Gluud
- Copenhagen University Hospital HvidovreGastrounit, Medical DivisionKettegaards AlleHvidovreDenmark2650
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Hertle DN, Beynon C, Neumann JO, Santos E, Sánchez-Porras R, Unterberg AW, Sakowitz OW. Use of GABAergic sedatives after subarachnoid hemorrhage is associated with worse outcome-preliminary findings. J Clin Anesth 2016; 35:118-122. [PMID: 27871507 DOI: 10.1016/j.jclinane.2016.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 06/21/2016] [Accepted: 07/05/2016] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE Recent experimental evidence identified GABAergic sedation as a possible cause for deprived neuroregeneration and poor outcome after acute brain injury. Patients with aneurysmal subarachnoid hemorrhage are often sedated, and GABAergic sedation, such as midazolam and propofol, is commonly used. DESIGN Retrospective cohort study based on a prospectively established database. SETTING Single-center neurointensive care unit. PATIENTS Twenty-nine patients after subarachnoid hemorrhage. INTERVENTION Noninterventional study. MEASUREMENTS The relationship between mean GABAergic sedative dose during the acute phase and outcome after 6 months according to the Glasgow Outcome Scale, and initial Glasgow Coma Scale was investigated. MAIN RESULTS Use of GABAergic sedatives was negatively correlated with Glasgow Outcome Scale (r2=0.267; P=.008). Administration of sedatives was independent of the initial Glasgow Coma Scale. GABAergic sedatives flunitrazepam, midazolam, and propofol were used differently during the first 10 days after ictus. CONCLUSION Administration of GABAergic sedation was associated with an unfavorable outcome after 6 months. To avoid bias (mainly through the indication to use sedation), additional experimental and comparative clinical investigation of, for example, non-GABAergic sedation, and clinical protocols of no sedation is necessary.
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Affiliation(s)
- Daniel N Hertle
- Department of Neurosurgery, University of Heidelberg, 69120 Heidelberg, Germany.
| | - Christopher Beynon
- Department of Neurosurgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Jan O Neumann
- Department of Neurosurgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Edgar Santos
- Department of Neurosurgery, University of Heidelberg, 69120 Heidelberg, Germany
| | | | - Andreas W Unterberg
- Department of Neurosurgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Oliver W Sakowitz
- Department of Neurosurgery, University of Heidelberg, 69120 Heidelberg, Germany
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Blau PA, Schwade N, Roland P. Diazepam Tolerance Effects on Vestibular Function Testing, Part I: Saccadic Parameters during Electronystagmography. Ann Otol Rhinol Laryngol 2016; 114:621-8. [PMID: 16190095 DOI: 10.1177/000348940511400807] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Benzodiazepines, particularly diazepam (DZ), are used in clinical practice to suppress acute vestibular symptoms. There have been limited studies looking at the effects of tolerance to DZ on parameters designed to measure the integrity of the vestibular system and its interaction with the oculomotor and balance systems. Methods: In a double-blinded, repeated-measures design, we randomized 30 young healthy men into one of two treatment groups (diazepam and placebo) and assessed with electro-oculography the effects of clinical divided doses of DZ on saccadic eye movements and sedation over 16 days. Results: Only sedation and saccadic latency were significant (p < .05) for treatment group, indicating selective effects on different central nervous system mechanisms. No significant effect for time was seen in any of the variables measured. Bonferroni t-test comparisons of the DZ group among 3 days were significant (p < .017) between baseline and day 3 for saccadic latency and accuracy and between day 3 and day 16 for self-ratings of sedation. Conclusions: Saccadic latency and accuracy and sedation ratings appear to be more sensitive to changes over time and less affected by subject variability than saccadic eye velocity. It remains questionable whether patients who have been on DZ for acute or extended periods of time need to discontinue the drug 48 hours before testing.
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Affiliation(s)
- Patricia A Blau
- Dept of Otorhinolaryngology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas, TX 75390-8876, USA
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Abstract
Clonazepam is long-acting benzodiazepine agonist used in short-acting benzodiazepine withdrawal; however, recent observations suggest the existence of its abuse. We demonstrate a 40-year-old man with a 20-year history of psychiatric care with recently benzodiazepine dependence (daily intake of ∼60 mg of clonazepam and 10 mg of alprazolam). High serum levels of both drugs were analyzed 3 weeks before admission to hospitalization (clonazepam 543.9 ng/mL, alprazolam 110 ng/mL) and at the time of admission (clonazepam 286.2 ng/mL, alprazolam 140 ng/mL) without any signs of benzodiazepine intoxication. Gradual withdrawal of clonazepam with monitoring of its serum levels and increase of gabapentin dose were used to minimize physical signs and symptoms of clonazepam withdrawal. Alprazolam was discontinued promptly. Clinical consequences of the treatment were controllable tension, intermittent headache, and rarely insomia. It is the first case report showing utilization of therapeutic drug monitoring during withdrawal period in the patient with extreme toleration to severe benzodiazepine dependence.
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Affiliation(s)
- Ivana Kacirova
- From the Department of Clinical Pharmacology (IK, MG, HB), Faculty of Medicine, University of Ostrava; Department of Clinical Pharmacology (IK, HB), Department of Laboratory Diagnostics; and Department of Psychiatry (PS), University Hospital Ostrava, Czech Republic
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Jago BJ. My sleep fest: an autoethnographic short story. Health Commun 2014; 30:96-99. [PMID: 25072670 DOI: 10.1080/10410236.2014.891453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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11
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Wolter DK. [Alzheimer's disease--treatment with and without drugs]. MMW Fortschr Med 2012; 154:85-90. [PMID: 22558882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Dirk K Wolter
- Inn-Salzach-Klinikum, Fachbereich Gerontopsychiatrie und Geriatrie, Wasserburg a Inn.
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Ramdas S, Riesenberg LA, Jasani N. Drug overdose with refractory bradycardia and hypotension. Del Med J 2011; 83:169-172. [PMID: 21882496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND In the emergency department physicians are often called upon to make decisions with limited information. Often the correct diagnosis and treatment hinge on one piece of information, which may be the key to the entire presentation. OBJECTIVE We present a case report of a patient who presented with refractory bradycardia and hypotension who had over-dosed on calcium channel blockers as well as beta blockers. The underlying cause however was myxedema. Were it not for the presence of hypothermia, the correct diagnosis of myxedema secondary to severe hypothyroidism could have been missed. We also briefly review the pathophysiology and treatment of myxedema. CONCLUSION We present a case of refractory bradycardia and hypotension in a patient who had overdosed on calcium channel blockers as well as beta blockers. Paying close attention to all the details of the case eventually uncovered the underlying severe hypothyroidism and myxedema. In the emergency department we are always called upon to make decisions with limited information. It is also paying close attention to all of the information presented that allows one to not miss any key pieces central to the final diagnosis.
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Affiliation(s)
- Shyamkrishnan Ramdas
- Department of Internal Medicine at Christiana Care Health System, Newark, Del, USA
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Kovacs N, Herold R, Janszky J, Komoly S, Nagy F. Tics status: a movement disorder emergency: observations. J Neurol 2010; 258:143-5. [PMID: 20658244 DOI: 10.1007/s00415-010-5680-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Accepted: 07/14/2010] [Indexed: 11/28/2022]
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14
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Aurora RN, Zak RS, Maganti RK, Auerbach SH, Casey KR, Chowdhuri S, Karippot A, Ramar K, Kristo DA, Morgenthaler TI. Best practice guide for the treatment of REM sleep behavior disorder (RBD). J Clin Sleep Med 2010; 6:85-95. [PMID: 20191945 PMCID: PMC2823283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Modifying the sleep environment is recommended for the treatment of patients with RBD who have sleep-related injury. Level A Clonazepam is suggested for the treatment of RBD but should be used with caution in patients with dementia, gait disorders, or concomitant OSA. Its use should be monitored carefully over time as RBD appears to be a precursor to neurodegenerative disorders with dementia in some patients. Level B Clonazepam is suggested to decrease the occurrence of sleep-related injury caused by RBD in patients for whom pharmacologic therapy is deemed necessary. It should be used in caution in patients with dementia, gait disorders, or concomitant OSA, and its use should be monitored carefully over time. Level B Melatonin is suggested for the treatment of RBD with the advantage that there are few side effects. Level B Pramipexole may be considered to treat RBD, but efficacy studies have shown contradictory results. There is little evidence to support the use of paroxetine or L-DOPA to treat RBD, and some studies have suggested that these drugs may actually induce or exacerbate RBD. There are limited data regarding the efficacy of acetylcholinesterase inhibitors, but they may be considered to treat RBD in patients with a concomitant synucleinopathy. Level C.
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Paciullo C. Comparing dexmedetomidine with midazolam for sedation of patients in the ICU. JAMA 2009; 301:2440; author reply 2441-2. [PMID: 19531779 DOI: 10.1001/jama.2009.838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Rady MY, Patel BM, Larson JS. Comparing dexmedetomidine with midazolam for sedation of patients in the ICU. JAMA 2009; 301:2439-40; author reply 2441-2. [PMID: 19531776 DOI: 10.1001/jama.2009.837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Anderson KN, Shneerson JM. Drug treatment of REM sleep behavior disorder: the use of drug therapies other than clonazepam. J Clin Sleep Med 2009; 5:235-239. [PMID: 19960644 PMCID: PMC2699168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
STUDY OBJECTIVES REM sleep behavior disorder (RBD) is characterized by loss of the normal muscle atonia during REM sleep associated with disruptive motor activity related to the acting out of dreams. There is frequently injury to the patient or bed partner, and treatment is usually required. Clonazepam has been the first-line therapy for many years, with 2 large case series reporting efficacy with few side effects in the majority of patients. However, long-acting hypnotics in the elderly or those with cognitive impairment can be associated with adverse events especially unacceptable daytime sedation, confusion, and exacerbation of existing sleep apnea. METHODS We reviewed 39 patients with confirmed RBD who were treated within our regional sleep center, assessing both efficacy and side effects of drug therapies. RESULTS Adverse effects were reported by 58% of the patients using clonazepam, with 50% either discontinuing the drug or reducing the dose. This prompted us review the side effects of clonazepam in detail and to look for alternative therapies. We report several novel and effective therapies, in particular zopiclone, in a series of patients under long-term follow-up for RBD. CONCLUSIONS There are alternatives to clonazepam therapy for RBD which can be as effective and may be better tolerated.
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Affiliation(s)
- Kirstie N Anderson
- Regional Centre for Neurosciences, Newcastle General Hospital, Newcastle upon Tyne, UK.
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Abstract
Clinically used anesthetics show amnestic, sedative, hypnotic and immobilizing properties. On a molecular level these drugs affect several receptors in the cell membrane of neurons. By using genetically engineered mice a linkage can now be made between actions on certain receptors and clinically desired and undesired effects. Experiments show that a certain GABA(A) receptor subtype mediates hypnosis and immobility, whereas another subtype is involved in side-effects like sedation and hypothermia. These findings form the basis for the development of new drugs, acting highly specific and with fewer side-effects.
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Affiliation(s)
- B Drexler
- Abteilung für Anaesthesiologie und Intensivmedizin, Universitätsklinikum, Tübingen.
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Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, Whitten P, Margolis BD, Byrne DW, Ely EW, Rocha MG. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA 2009; 301:489-99. [PMID: 19188334 DOI: 10.1001/jama.2009.56] [Citation(s) in RCA: 1043] [Impact Index Per Article: 69.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CONTEXT Gamma-aminobutyric acid receptor agonist medications are the most commonly used sedatives for intensive care unit (ICU) patients, yet preliminary evidence indicates that the alpha(2) agonist dexmedetomidine may have distinct advantages. OBJECTIVE To compare the efficacy and safety of prolonged sedation with dexmedetomidine vs midazolam for mechanically ventilated patients. DESIGN, SETTING, AND PATIENTS Prospective, double-blind, randomized trial conducted in 68 centers in 5 countries between March 2005 and August 2007 among 375 medical/surgical ICU patients with expected mechanical ventilation for more than 24 hours. Sedation level and delirium were assessed using the Richmond Agitation-Sedation Scale (RASS) and the Confusion Assessment Method for the ICU. INTERVENTIONS Dexmedetomidine (0.2-1.4 microg/kg per hour [n = 244]) or midazolam (0.02-0.1 mg/kg per hour [n = 122]) titrated to achieve light sedation (RASS scores between -2 and +1) from enrollment until extubation or 30 days. MAIN OUTCOME MEASURES Percentage of time within target RASS range. Secondary end points included prevalence and duration of delirium, use of fentanyl and open-label midazolam, and nursing assessments. Additional outcomes included duration of mechanical ventilation, ICU length of stay, and adverse events. RESULTS There was no difference in percentage of time within the target RASS range (77.3% for dexmedetomidine group vs 75.1% for midazolam group; difference, 2.2% [95% confidence interval {CI}, -3.2% to 7.5%]; P = .18). The prevalence of delirium during treatment was 54% (n = 132/244) in dexmedetomidine-treated patients vs 76.6% (n = 93/122) in midazolam-treated patients (difference, 22.6% [95% CI, 14% to 33%]; P < .001). Median time to extubation was 1.9 days shorter in dexmedetomidine-treated patients (3.7 days [95% CI, 3.1 to 4.0] vs 5.6 days [95% CI, 4.6 to 5.9]; P = .01), and ICU length of stay was similar (5.9 days [95% CI, 5.7 to 7.0] vs 7.6 days [95% CI, 6.7 to 8.6]; P = .24). Dexmedetomidine-treated patients were more likely to develop bradycardia (42.2% [103/244] vs 18.9% [23/122]; P < .001), with a nonsignificant increase in the proportion requiring treatment (4.9% [12/244] vs 0.8% [1/122]; P = .07), but had a lower likelihood of tachycardia (25.4% [62/244] vs 44.3% [54/122]; P < .001) or hypertension requiring treatment (18.9% [46/244] vs 29.5% [36/122]; P = .02). CONCLUSIONS There was no difference between dexmedetomidine and midazolam in time at targeted sedation level in mechanically ventilated ICU patients. At comparable sedation levels, dexmedetomidine-treated patients spent less time on the ventilator, experienced less delirium, and developed less tachycardia and hypertension. The most notable adverse effect of dexmedetomidine was bradycardia. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00216190 Published online February 2, 2009 (doi:10.1001/jama.2009.56).
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23
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Spaeth GL, Mantravadi AV. Topiramate as treatment for alcohol dependence. JAMA 2008; 299:405; author reply 406-7. [PMID: 18230775 DOI: 10.1001/jama.299.4.405-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Reder LM, Oates JM, Dickison D, Anderson JR, Gyula F, Quinlan JJ, Ferris JL, Dulik M, Jefferson BF. Retrograde facilitation under midazolam: the role of general and specific interference. Psychon Bull Rev 2007; 14:261-9. [PMID: 17694911 PMCID: PMC2533051 DOI: 10.3758/bf03194062] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In a double-blind, placebo-controlled experiment that used midazolam, a benzodiazepine that creates temporary amnesia, we compared acquisition and retention of paired associates of different types. Some word pairs were studied before the injection of saline or midazolam, and two lists of word pairs were studied after the injection. Critical comparisons involved retention of pairs that were practiced on all three lists, pairs studied on only one list, and pairs that involved recombining cue and response terms from one list to the next, as a function of drug condition. Previous research with benzodiazepines had found retrograde facilitation for material acquired prior to injection, compared with the control condition. One explanation for this facilitation is that the anterograde amnesia produced by the benzodiazepine frees up the hippocampus to better consolidate previously learned material (Wixted, 2004, 2005). We accounted for a rich data set using a simple computational model that incorporated interference effects (cue overload) at retrieval for both general (experimental context) interference and specific (stimulus term) interference without the need to postulate a role for consolidation. The computational model as an Excel spreadsheet may be downloaded from www.psychonomic.org/archive.
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Affiliation(s)
- Lynne M Reder
- Department of Psychology, Carnegie Mellon University, Pittsburgh, Pennsylvania 15213, USA.
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Hayashi K, Osawa M, Aihara M, Izumi T, Ohtsuka Y, Haginoya K, Kato I, Kaneko K, Sugai K, Takahashi T, Hamano SI, Matsukura M, Miura H, Minagawa K, Yamano T, Yamamoto H, Yamanouchi H, Yoshikawa H. Efficacy of intravenous midazolam for status epilepticus in childhood. Pediatr Neurol 2007; 36:366-72. [PMID: 17560497 DOI: 10.1016/j.pediatrneurol.2007.02.012] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2006] [Revised: 07/14/2006] [Accepted: 02/26/2007] [Indexed: 10/23/2022]
Abstract
A retrospective multicenter study was conducted, designed to evaluate the efficacy and safety of midazolam for the treatment of status epilepticus. The subjects were 358 inpatients who received intravenous midazolam therapy for status epilepticus. The mean age was 48.6 +/- 46.5 months. The underlying disorder was epilepsy in 195 cases, and acute symptomatic diseases in 163 (encephalitis or encephalopathy in 88 cases). Midazolam was administered as a bolus dose (0.25 +/- 0.21 mg/kg), followed if necessary by continuous infusion (0.26 +/- 0.25 mg/kg/hr). The bolus injection was effective in 162 (56.6%) of the 286 cases. In the end, seizure suppression was obtained in 231 cases (64.5% of the total). The effectiveness of midazolam was lower in patients in whom midazolam was initiated more than 3 hours after seizure onset, and this tendency was particularly marked in the epilepsy group. During the treatment period, 10 patients died, but none of these deaths were associated with midazolam therapy. The incidence and types of adverse events were consistent with previously reported data. The present results indicate that midazolam is highly effective for the management of status epilepticus, if used sufficiently early after seizure onset.
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Affiliation(s)
- Kitami Hayashi
- Department of Pediatrics, Tokyo Women's Medical University, School of Medicine, Tokyo, Japan.
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Krupitsky EM, Rudenko AA, Burakov AM, Slavina TY, Grinenko AA, Pittman B, Gueorguieva R, Petrakis IL, Zvartau EE, Krystal JH. Antiglutamatergic strategies for ethanol detoxification: comparison with placebo and diazepam. Alcohol Clin Exp Res 2007; 31:604-11. [PMID: 17374039 DOI: 10.1111/j.1530-0277.2007.00344.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Benzodiazepines are the standard pharmacotherapies for ethanol detoxification, but concerns about their abuse potential and negative effects upon the transition to alcohol abstinence drive the search for new treatments. Glutamatergic activation and glutamate receptor up-regulation contribute to ethanol dependence and withdrawal. This study compared 3 antiglutamatergic strategies for ethanol detoxification with placebo and to the benzodiazepine, diazepam: the glutamate release inhibitor, lamotrigine; the N-methyl-D-aspartate glutamate receptor antagonist, memantine; and the AMPA/kainite receptor inhibitor, topiramate. METHODS This placebo-controlled randomized single-blinded psychopharmacology trial studied male alcohol-dependent inpatients (n=127) with clinically significant alcohol withdrawal symptoms. Subjects were assigned to 1 of 5 treatments for 7 days: placebo, diazepam 10 mg TID, lamotrigine 25 mg QID, memantine 10 mg TID, or topiramate 25 mg QID. Additional diazepam was administered when the assigned medication failed to suppress withdrawal symptoms adequately. RESULTS All active medications significantly reduced observer-rated and self-rated withdrawal severity, dysphoric mood, and supplementary diazepam administration compared with placebo. The active medications did not differ from diazepam. CONCLUSIONS This study provides the first systematic clinical evidence supporting the efficacy of a number of antiglutamatergic approaches for treating alcohol withdrawal symptoms. These data support the hypothesis that glutamatergic activation contributes to human alcohol withdrawal. Definitive studies of each of these medications are now needed to further evaluate their effectiveness in treating alcohol withdrawal.
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Affiliation(s)
- Evgeny M Krupitsky
- St. Petersburg Regional Center of Addictions and Psychopharmacology, Pavlov State Medical University, St. Petersburg, Russia
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N-Wihlbäck AC, Sundström-Poromaa I, Bäckström T. Action by and sensitivity to neuroactive steroids in menstrual cycle related CNS disorders. Psychopharmacology (Berl) 2006; 186:388-401. [PMID: 16362406 DOI: 10.1007/s00213-005-0185-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2005] [Accepted: 08/27/2005] [Indexed: 12/11/2022]
Abstract
Neuroactive steroids are a large group of substances having effect in the brain and on brain function. The steroids most studied are allopregnanolone (ALLO), tetrahydrodesoxycorticosterone (THDOC), pregnenolone sulfate (PS) dihydroepiandrosteronesulfate (DHEAS), and estradiol (E2). ALLO and THDOC are called gamma-aminobutyric acid (GABA) steroids as they are positive modulators of the GABAA receptor in a similar way as benzodiazepines, barbiturates, and alcohol. GABA steroids not only have similar behavioral effects as benzodiazepines and barbiturates but, possibly, also similar adverse effects as well. This review aims to elucidate the possible role that neuroactive steroids play in the development of mood disorders in women. One of the most clear-cut examples of the interaction between mood, neuroactive steroids, and the GABA system is premenstrual dysphoric disorder (PMDD), which is a cluster of negative mood symptoms occurring during the luteal phase of the menstrual cycle in 2-6% of reproductive women. Furthermore, certain women also experience adverse mood effects during sequential progestin addition to postmenopausal estrogen treatment, which is why the role of neuroactive steroids in postmenopausal women is also addressed in this review.
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Affiliation(s)
- Anna-Carin N-Wihlbäck
- Umeå Neurosteroid Research Center, Department of Clinical Sciences, University of Umeå, Norrlands University Hospital, Sweden
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Abstract
One hundred eighty-eight seizure episodes in 46 children were randomly assigned to receive treatment with rectal diazepam and intranasal midazolam with doses of 0.3 mg/kg body weight and 0.2 mg/kg body weight, respectively. Efficacy of the drugs was assessed by drug administration time and seizure cessation time. Heart rate, blood pressure, respiratory rate, and oxygen saturation were measured before and after 5, 10, and 30 minutes following administration of the drugs in both groups. Mean time from arrival of doctor to drug administration was 68.3 +/- 55.12 seconds in the diazepam group and 50.6 +/- 14.1 seconds in the midazolam group (P = 0.002). Mean time from drug administration to cessation of seizure was significantly less in the midazolam group than the diazepam group (P = 0.005). Mean heart rate and blood pressure did not vary significantly between the two drug groups. However, mean respiratory rate and oxygen saturation differed significantly between the two drug groups at 5, 10, and 30 minutes after drug administration. Intranasal midazolam is preferable to rectal diazepam in the treatment of acute seizures in children. Its administration is easy, it has rapid onset of action, has no significant effect on respiration and oxygen saturation, and is socially acceptable.
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Affiliation(s)
- Madhumita Bhattacharyya
- Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
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Merritt P, Hirshman E, Zamani S, Hsu J, Berrigan M. Episodic representations support early semantic learning: evidence from midazolam induced amnesia. Brain Cogn 2006; 61:219-23. [PMID: 16423438 DOI: 10.1016/j.bandc.2005.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2005] [Revised: 12/03/2005] [Accepted: 12/08/2005] [Indexed: 10/25/2022]
Abstract
Current controversy exists regarding the role of episodic representations in the formation of long-term semantic memories. Using the drug midazolam to induce temporary amnesia we tested participants' memories for newly learned facts in a semantic cue condition or an episodic and semantic cue condition. Following midazolam administration, memory performance was superior in the episodic and semantic condition, suggesting early semantic learning is supported by episodic representations.
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Affiliation(s)
- Paul Merritt
- Department of Psychology, Texas A&M University, Corpus Christi, USA.
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Swortfiguer D, Cissoko H, Giraudeau B, Jonville-Béra AP, Bensouda L, Autret-Leca E. Retentissement néonatal de l'exposition aux benzodiazépines en fin de grossesse. Arch Pediatr 2005; 12:1327-31. [PMID: 15894473 DOI: 10.1016/j.arcped.2005.03.055] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2004] [Accepted: 03/08/2005] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Since benzodiazepines (BZD) are largely prescribed during pregnancy, the Regional Pharmacovigilance Center (RPVC) of Tours regularly deals with questions about the risk of their administration to pregnant women and the monitoring of the newborns exposed in utero to these drugs. During the third trimester, we recommend a switch in the BZD maternal treatment to oxazepam, which has an intermediary half-life and no active metabolite, and a hospitalisation of the newborn in order to monitor his respiratory rate. The purpose of our study was to evaluate the neonatal consequences of BZD used at the end of pregnancy and to analysed if our recommendations were taken into account and if they were appropriate. METHODS From 1989 to the end of 2002, we studied the files in which women had received a BZD during the 30 days prior to delivery. We analysed maternal treatments, the outcome of pregnancy and the development of the newborn, the therapeutically attitude recommended and whether or not it was respected. RESULTS A total of 73 files were selected. Seventy neonates were born to 73 women. The newborns were hospitalised (73%) and they developed adverse reactions possibly related to the use of BZD (51,5%) : an impregnation syndrome (42%) characterized by hypotonia and hypoventilation, and a withdrawal syndrome (20%) with tremulations as the main symptom. CONCLUSION Considering the most frequent neonatal manifestations, hospitalization and the respiratory monitoring recommended by the RPVC seemed adequate. However, the switch to oxazepam was seldom done and its advantages should be pointed out.
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Affiliation(s)
- D Swortfiguer
- Centre régional de pharmacovigilance et d'information sur le médicament, service de pharmacologie
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Allison C, Pratt JA, Ripley TL, Stephens DN. alpha-Amino-3-hydroxy-5-methylisoxazole-4-propionate receptor autoradiography in mouse brain after single and repeated withdrawal from diazepam. Eur J Neurosci 2005; 21:1045-56. [PMID: 15787709 DOI: 10.1111/j.1460-9568.2005.03902.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Withdrawal from chronic treatment with benzodiazepines is associated with increased neuronal excitability leading to anxiety, aversive effects and increased seizure sensitivity. After repeated withdrawal experiences, seizure sensitivity increases while withdrawal-induced anxiety and aversion decrease. We used autoradiographical methods employing [(3)H]Ro48 8587, a selective ligand for glutamatergic alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate (AMPA) receptors, to study withdrawal-induced changes in AMPA receptor binding in areas of the mouse brain postulated to be involved in these responses. Mice were given 21 days treatment with diazepam (15 mg/kg, s.c. in sesame oil) followed by withdrawal (single withdrawal) or three blocks of 7 days treatment interspersed with 3-day periods to allow washout of drug (repeated withdrawal). In keeping with heightened excitability in withdrawal from chronic diazepam treatment, the single withdrawal group showed, 72 h after their final dose of diazepam, increased [(3)H]Ro48 8587 binding in several brain areas associated with emotional responses or seizure activity, including hippocampal subfields, amygdalar and thalamic nuclei and motor cortex. In contrast, the repeated withdrawal group showed no changes in [(3)H]Ro48 8587 binding in any brain area studied. These observations are consistent with up-regulation of AMPA receptor-mediated transmission being important in withdrawal-induced anxiety and aversion but not in increased seizure sensitivity associated with repeated withdrawal. As changes in AMPA receptor subunit expression alter the functionality of the receptor, future studies will address this possibility.
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Affiliation(s)
- C Allison
- Department of Pharmacology and Physiology, University of Strathclyde, 27 Taylor Street, Glasgow G4 ONR, UK
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Castro Conde JR, Hernández Borges AA, Doménech Martínez E, González Campo C, Perera Soler R. Midazolam in neonatal seizures with no response to phenobarbital. Neurology 2005; 64:876-9. [PMID: 15753426 DOI: 10.1212/01.wnl.0000152891.58694.71] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The outcome of 45 neonates with EEG-confirmed seizures (ESz) was analyzed with regard to treatment. ESz persisted in 17 of 32 neonates receiving phenobarbital/phenytoin (13 had a poor outcome, 4 died). In contrast, ESz were rapidly controlled in 13 of 13 nonresponders to phenobarbital/phenytoin treated with midazolam (4 had poor outcome, 2 died). Nonresponders to phenobarbital/phenytoin had a significantly worse outcome than responders did. Midazolam effectively controlled ESz in nonresponders to phenobarbital/phenytoin and correlated with significantly improved long-term neurodevelopment.
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Affiliation(s)
- J R Castro Conde
- Neonatology Service, University Hospital of the Canary Islands, Ofra S/N, La Laguna 28230, Spain.
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Almirón RS, Ramírez OA. Participation of dorsal raphe nucleus in the behavioral alteration observed after discontinuation of chronic diazepam administration: Possible neural circuitry involved. Synapse 2005; 56:61-8. [PMID: 15714479 DOI: 10.1002/syn.20118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Previous findings from our laboratory have demonstrated a positive correlation between the development of tolerance to diazepam (DZ) 5 mg/kg/day over 4 days, and increased hippocampal synaptic plasticity. It seems likely that a similar plastic phenomenon may occur on hippocampal formation after chronic (18 days) DZ administration. We postulate hippocampal long-term potentiation (LTP) underlying substrate to the behavioral alteration observed after chronic DZ administration. In the present study, we investigated the involvement of the serotonergic (5-HT) system in the possible neural circuitry recruited during DZ withdrawal and in the increased hippocampal synaptic plasticity associated with the discontinuation of chronic DZ administration. The results of the current research demonstrate an increased neuronal activity in the dorsal raphe nucleus (DRN) during withdrawal. Previous MK-801 administration impairs the development of anxiety signs observed during withdrawal and the concomitant increased electrical activity on 5-HT neurons on DRN. These results are discussed in terms of the participation of 5-HT system in the modulation of hippocampal plasticity developed on DZ withdrawal.
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Affiliation(s)
- Romina Soledad Almirón
- Departamento de Farmacología, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, Argentina
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Pomara N, Willoughby LM, Sidtis JJ, Doraiswamy PM, Wesnes KA, Cooper TB, Greenblatt DJ. Baseline plasma GABA: its relationship to the adverse effects of acute lorazepam administration on cognition in the elderly. Neurochem Res 2005; 29:2311-5. [PMID: 15672555 DOI: 10.1007/s11064-004-7041-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The GABA system is an active target for drugs to treat a variety of disorders and the availability of an indirect measure of central GABA activity would not only enhance psychiatric research, but also permit assessment of the pharmacodynamic effects of drugs designed to act on this system. The relationships between plasma baseline pre-drug GABA concentrations and cognitive impairments induced by an acute oral dose of lorazepam (0.5 and 1.0 mg) were investigated in 22 healthy elderly individuals. Partial correlations controlling for plasma lorazepam concentrations revealed no significant relationship between baseline plasma GABA levels and lorazepam-induced impairments on tests of cognitive functioning. Plasma GABA concentration does not appear to be a useful marker of susceptibility to benzodiazepine-induced cognitive toxicity in the elderly. Other approaches to estimating central GABA activity should be pursued.
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Affiliation(s)
- Nunzio Pomara
- Nathan Kline Institute for Psychiatric Research, Orangeburg, NY 10962, USA.
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Abstract
When benzodiazepines (BZs) supplanted barbiturates as a favored, safer treatment for anxiety and sleep disorders in the 1960s, the abuse liability and dependence potential of these drugs were little understood. Widespread recognition of the difficulty of stopping use of chronically taken BZs emerged through the popular press in the late 1970s, which resulted in reluctance to prescribe these otherwise clinically useful compounds. Evolution of the understanding of the biochemical basis for BZ effects in the 1980s and 1990s, coupled with regulatory emphasis on collection of data used in legal scheduling decisions, made possible a targeted search for drugs that would provide effective treatment for anxiety disorders in the absence of abuse liability or dependence potential. Compounds that have selective efficacy at subtypes of the gamma-aminobutyric acid type A receptor, are active in preclinical anxiolytic screens, but negative in preclinical studies of behavior relevant to evaluation of abuse liability appear to be one promising means for achieving this end.
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Affiliation(s)
- Nancy A Ator
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 5510 Nathan Shock Drive, Hopkins Bayview Campus, Baltimore, MD 21224-6823, USA.
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Rowlett JK, Cook JM, Duke AN, Platt DM. Selective antagonism of GABAA receptor subtypes: an in vivo approach to exploring the therapeutic and side effects of benzodiazepine-type drugs. CNS Spectr 2005; 10:40-8. [PMID: 15618946 DOI: 10.1017/s1092852900009895] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Benzodiazepines (BZs) are clinically used as anxiolytic, hypnotic, anticonvulsant, and antispasmodic drugs. Research using transgenic mouse models has suggested that the effects of BZs involve multiple subtypes of the gamma-aminobutyric acid type A (GABAA) receptor, identified by specific a subunits (alpha1, alpha2, alpha3, alpha5). This review discusses the experimental uses of b-carboline-3-carboxylate-t-butyl ester (betaCCT), a drug that binds preferentially to the GABAA alpha1 subtype but exerts no action (ie, is a pharmacologic antagonist at the GABAA alpha1 subtype receptor). betaCCT blocks the anxiolytic-like effects of BZs, although studies in primates suggests this antagonism may reflect multiple receptor populations. betaCCT antagonized the ataxic but not muscle relaxant effects of BZs, a finding that implicates the GABAA alpha1 subtype receptor in ataxia but not muscle relaxation. The potential clinical utility of betaCCT is discussed, both in terms of treatment (ie, hepatic encephalopathy) and as a diagnostic imaging agent. Altogether, these results indicate that subtype-selective antagonists represent a useful approach to studying receptor mechanisms underlying the behavioral effects of BZ-type drugs.
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Affiliation(s)
- James K Rowlett
- Department of Psychiatry and Division of Behavioral Biology, Harvard Medical School, New England Primate Research Center, One Pine Hill Drive, Southborough, MA 01772, USA.
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Abstract
Four different "club drugs" are reviewed: MDMA (methylenedioxymethamphetamine, "Ecstasy"), GHB (gamma-hydroxybutyrate), ketamine, and Rohypnol (flunitrazepam). The neurobiology, clinical pharmacology, and treatment issues for each are discussed.
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Affiliation(s)
- Gena Covell Britt
- Division of Addiction Psychiatry, Virginia Commonwealth University, Richmond, Virginia 23219, USA.
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Isoardi NA, Martijena ID, Carrer HF, Molina VA. Increased fear learning coincides with neuronal dysinhibition and facilitated LTP in the basolateral amygdala following benzodiazepine withdrawal in rats. Neuropsychopharmacology 2004; 29:1852-64. [PMID: 15138438 DOI: 10.1038/sj.npp.1300478] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Animals chronically administered with diazepam (DZM -- 2 mg/kg/day i.p.) or vehicle (VEH) for 21 days were tested in a fear-conditioning paradigm 4 days after the last administration. Increased freezing was observed in DZM withdrawn rats as compared to VEH injected control rats in both associative and nonassociative context and this increase was greatest for the DZM withdrawal group in the paired context. In animals anesthetized with urethane, single pulses in the medial prefrontal cortex evoked a field potential including a population spike (PS) in the basolateral complex of the amygdala (BLA) of control animals, whereas in DZM withdrawn animals multiple PSs were evoked. In brain slices from control rats, stimulation of the external capsule evoked a field potential including a PS in the BLA, whereas in DZM withdrawn rats multiple PSs were evoked. The amplitude of the PS was smaller in slices obtained from DZM withdrawn rats than from control rats, and paired pulse inhibition was significantly less in the former. Perfusion with DZM 2 microM of slices obtained from DZM withdrawn rats eliminated repetitive spiking. GABAergic blockade with 50 microM picrotoxin in control rats resulted in the appearance of multiple secondary PSs. In slices from DZM withdrawn rats high-frequency stimulation induced a highly significant potentiation that lasted at least 2 h (LTP), whereas in control rats the same stimulation did not induce LTP. Neuronal hyperexcitability leading to facilitated LTP observed in BLA of DZM withdrawn rats could be due to depressed GABAergic activity (dysinhibition). The increased synaptic plasticity may be at the root of the increased fear learning observed in withdrawn animals.
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Affiliation(s)
- Nora A Isoardi
- Departamento de Farmacología, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Ciudad Universitaria, Córdoba, Argentina
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Abstract
Anticonvulsants are not a single therapeutic class, but are composed of multiple distinct subclasses with different mechanisms of action, efficacies, and side effects.
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Affiliation(s)
- Stephen M Stahl
- Neuroscience Education Institute, 5857 Owens Street, Suite 102, Carlsbad, CA 92009, USA
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Dåderman AM, Fredriksson B, Nilsson LH, Kristiansson M, Lidberg L. The abuse of a sleeping pill that contains the active substance flunitrazepam (FZ)--for example, Rohypnol--and the effects of FZ intoxication, such as enhanced violence and disturbed memory. J Am Acad Psychiatry Law 2004; 32:467-468. [PMID: 15704634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
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Abstract
RATIONALE Cocaine abuse represents a significant public health problem. Gamma-aminobutyric acid (GABA) agonists may attenuate the behavioral effects of cocaine and may be effective pharmacotherapies for cocaine abuse and dependence. OBJECTIVES The aim of this experiment was to determine the combined effects of oral cocaine (0 and 300 mg) and triazolam (0 and 0.5 mg), a GABA(A) modulator, in 10 individuals with recent histories of cocaine use. METHODS Volunteers received each of the four possible drug combinations in mixed order. Drug effects were assessed using a battery of subject-rated drug-effect questionnaires and physiological indices. RESULTS Cocaine alone produced prototypical stimulant-like subject-rated drug effects (e.g., increased ratings of High, Like Drug, and Willing to Take Drug Again). Triazolam alone produced sedative-like effects (e.g., increased scores on the Pentobarbital, Chlorpromazine, Alcohol Group [PCAG] scale of the Addiction Research Center Inventory [ARCI]). Triazolam pretreatment did not significantly attenuate the subject-rated effects of cocaine. CONCLUSIONS While the results of this study do not support the utility of GABA(A) modulators as pharmacotherapies for cocaine abuse, future research should test other benzodiazepines (e.g., alprazolam) using more sophisticated methods (e.g., dose-response curves for the drugs alone and in combination) and behavioral arrangements (e.g., drug discrimination).
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Affiliation(s)
- Jamie L Haga
- Department of Behavioral Science, University of Kentucky, Lexington, KY 40536-0086, USA
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Buysse DJ. Opening up new avenues for insomnia treatment research. Sleep 2003; 26:786-7. [PMID: 14655907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023] Open
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Hackett D, Haudiquet V, Salinas E. A method for controlling for a high placebo response rate in a comparison of venlafaxine XR and diazepam in the short-term treatment of patients with generalised anxiety disorder. Eur Psychiatry 2003; 18:182-7. [PMID: 12814852 DOI: 10.1016/s0924-9338(03)00046-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
This randomised, double-blind, placebo-controlled study compared the efficacy of venlafaxine XR (75 or 150 mg/d) with diazepam (15 mg/d) over an 8-week treatment period in 540 non-depressed outpatients with generalised anxiety disorder (GAD). At week 8, significant improvements from baseline were observed in the venlafaxine XR, diazepam and placebo groups. Although these improvements were higher in the first two groups than in the placebo group for each of the primary efficacy variables (Hamilton Rating Scale for Anxiety (HAM-A) total, HAM-A psychic anxiety factor, Hospital Anxiety and Depression Scale (HAD) anxiety sub-scale and Clinical Global Impression (CGI) improvement), there were no statistically significant differences between groups. These non-positive results were thought to be due to the very high placebo response observed in some centres. To understand the variability of the study, a secondary preplanned analysis was performed. This involved sub-dividing the study centres according to their ability to detect a two-point mean difference between diazepam and placebo at week 8 on the HAM-A total score. Centres able to show such a difference were termed verum-sensitive. Improvements from baseline to week 8 in venlafaxine XR-treated patients from verum-sensitive centres were significantly greater than in placebo on each of the primary efficacy measures (P </= 0.05). This suggests that those centres able to detect an anxiolytic effect of diazepam were also able to detect an anxiolytic effect of venlafaxine XR. Significant differences in baseline demographics, rates of adverse event reporting and rates of patient discontinuations were noted between patients enrolled at verum-sensitive and verum-insensitive sites. These results reflect the importance of study centre selection in accurately determining efficacy in placebo-controlled trials.
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Affiliation(s)
- David Hackett
- Wyeth Research, 80 avenue du Général-de-Gaulle, Paris La Défense, France.
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Falissard B. Statistical considerations about the question of a selection of discriminating centres in the analysis of clinical trial. In response to the paper: "A method for controlling for a high response rate in a comparison of venlafaxine XR and diazepan in the short-term treatment of patients with generalised anxiety disorder". Eur Psychiatry 2003; 18:188-9. [PMID: 12814853 DOI: 10.1016/s0924-9338(03)00049-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Abstract
Flumazenil, an imidazobenzodiazepine, is the first benzodiazepine antagonist and is being used to reverse the adverse pharmacological effects of benzodiazepine. There have been a few reports on the central nevous system side effects with its use. We report a patient with generalized ballism following administration of flumazenil. The mechanism through which flumazenil induced this symptom is unknown. It is conceivable that flumazenil may antagonize the GABA-benzodiazepine receptor complex and induce dopamine hypersensitivity, thus induce dyskinesic symptoms.
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Affiliation(s)
- Joong-Seok Kim
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Abstract
OBJECTIVE To determine which is the most effective and safe treatment for controlling seizures in children out-of-hospital: diazepam or midazolam. METHODS A retrospective review of the medical records of children presenting to the Emergency Department of the Children's Hospital at Westmead (CHW-ED) with seizures requiring treatment in the field by paramedics was carried out over a 4-year period (April 1996 to March 2000). In New South Wales, children with seizures in the prehospital setting received 0.5 mg/kg per rectum (p.r.) or 0.1 mg/kg i.v. diazepam until March 1998 and from March 1997 onwards they received 0.15 mg/kg i.m. or 0.1 mg/kg i.v. midazolam. The main outcome measured was cessation of seizure in the prehospital setting. Secondary outcomes were time taken to initiate treatment and the frequency of cardiorespiratory compromise. RESULTS Over the 4-year period, 2566 children presented to CHW-ED with a seizure; 107 children were eligible for entry into the present study. Of these 107 patients, 62 received diazepam and 45 received midazolam. Thirty-one (50.0%) in the diazepam group and 15 (33.3%) in the midazolam group were febrile seizures. Both groups were similar in terms of demographics and seizure type. A comparison of diazepam with midazolam showed that both drugs were effective in stopping seizures within 5 min of drug administration (37.1% cf. 51.1%). Fewer patients in the midazolam group suffered apnoea (20.0% cf. 29.0%; P < 0.05). CONCLUSION Midazolam controls seizures as effectively as diazepam in the prehospital setting. Furthermore, midazolam potentially reduces respiratory depression and time to treatment.
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Affiliation(s)
- J Rainbow
- Department of Emergency Medicine, Royal Alexandra Hospital for Children, Westmead, New South Wales, Australia
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