Depression in primary care: effectiveness of venlafaxine extended-release in elderly patients; Observational study

The Cardiovascular Effects of Newer Antidepressants in Older Adults and Those With or At High Risk for Cardiovascular Diseases

Depression is common in older adults and those with cardiovascular disease. Although selective serotonin reuptake inhibitors generally have been shown to be safe to treat depression in these patients, it is important to identify additional antidepressants when selective serotonin reuptake inhibitors are not effective. This qualitative narrative review summarizes what is known about the cardiovascular side effects of some of the newer antidepressants. Twelve novel non-selective serotonin reuptake inhibitor antidepressants were identified from the literature: venlafaxine, desvenlafaxine, duloxetine, milnacipran, levomilnacipran, mirtazapine, bupropion, vilazodone, vortioxetine, agomelatine, moclobemide, and ketamine-esketamine. A search restricted to publications written in English was conducted in PubMed and Google Scholar with the following search criteria: the specific antidepressant AND (QT OR QTc OR "heart rate" OR "heart rate variability" OR "hypertension" OR "orthostatic hypotension" OR "cardiovascular outcomes" OR "arrhythmia" OR "myocardial infarction" OR "cardiovascular mortality") AND (geriatric OR "older adults" OR "late life depression" OR "cardiovascular disease" OR "hospitalized" OR "hospitalized"). The recommended use, dosing ranges, cardiovascular effects, and general advantages and disadvantages of each of the drugs are discussed. Levomilnacipran and vilazodone have not received enough study to judge their safety in older patients or in those with, or at high risk for, cardiovascular disease. There is at least some evidence for possible adverse events with each of the other newer antidepressants that could be of concern in these patients. Nevertheless, with careful administration and attention to the potential adverse reactions for each drug, these may provide safe effective alternatives for older adults and patients with cardiovascular disease who do not respond to selective serotonin reuptake inhibitor antidepressants. However, more research on the safety and efficacy of these drugs in these specific patient populations is urgently needed.

Hypertension and orthostatic hypotension with venlafaxine treatment in depressed older adults

BACKGROUND

Venlafaxine, a serotonin-norepinephrine reuptake inhibitor, is often used as first- or second-line therapy for depression in older adults. It can be associated with adverse blood pressure (BP) effects.

METHODS

Adults ⩾60 years of age in a current major depressive episode were treated in a protocolized manner with venlafaxine XR; 429 participants were treated for 8-16 weeks with a daily dose up to 300 mg to achieve remission from depression. Cardiac measures included sitting and standing BP and heart rate.

RESULTS

Of participants who were normotensive at baseline, 6.5% were found to have elevated BP during the study (1.9% <225 mg/day; 9.8% ⩾225 mg/day). There was no significant change in mean BP in the overall sample, or in the subgroup treated with doses ⩾225 mg/day. Additionally, 20.1% of the participants who did not have orthostatic hypotension at baseline were found to have orthostatic hypotension (16.8% <225 mg/day; 22.4% ⩾225 mg/day). Participants with new-onset orthostatic hypotension were significantly more likely to fall than the other participants.

CONCLUSION

A large proportion of older adults treated with venlafaxine experience orthostatic hypotension, putting them at risk for falls. A smaller proportion experience elevated BP. Older patients prescribed venlafaxine, particularly at high doses, should be advised and counseled about these adverse effects.

Venlafaxine and duloxetine: A comparison of efficacy and tolerability for the treatment of depression in elderly patients

The geriatric population has a disproportionally higher rate of depression and related suicide compared to the general population. While selective serotonin reuptake inhibitors are considered first line, serotonin norepinephrine reuptake inhibitors (SNRIs) are commonly used. Online databases including MEDLINE, EMBASE, International Pharmaceutical Abstracts, and CINAHL were searched (up to June 2013) to identify trials using SNRIs in the elderly. Results revealed 15 studies involving venlafaxine (n=10) and duloxetine (n=5) use in the elderly. Overall, venlafaxine and duloxetine appear to be similar in efficacy and tolerability in treating late life depression. However, venlafaxine has been more extensively studied in this particular population, appears to carry fewer drug interactions, and is available in generic forms for regular and extended-release formulations. Doses greater than 225 mg/day for venlafaxine or 60 mg/day for duloxetine appear to lead to greater discontinuation rates.

Comparison of prevalence of symptoms of depression, anxiety, and hostility in elderly patients with heart failure, myocardial infarction, and a coronary artery bypass graft

OBJECTIVE

This study sought to compare the prevalence of anxiety, depression, and hostility among 3 clinically diverse elderly cardiac patient cohorts and a reference group of healthy elders.

METHODS

This was a multicenter, comparative study. A total of 1167 individuals participated: 260 healthy elders, and 907 elderly cardiac patients who were at least 3 months past a hospitalization (478 heart-failure patients, 298 postmyocardial infarction patients, and 131 postcoronary artery bypass graft patients). Symptoms of anxiety, depression, and hostility were measured using the Multiple Affect Adjective Checklist.

RESULTS

The prevalence of anxiety, depression, and hostility was higher in patients in each of the cardiac patient groups than in the group of healthy elders. Almost three quarters of patients with heart failure reported experiencing symptoms of depression, and the heart-failure group manifested the greatest percentage of patients with depressive symptoms.

CONCLUSIONS

The high levels of emotional distress common in cardiac patients are not a function of aging, because healthy elders exhibit low levels of anxiety, depression, and hostility.

A placebo-controlled double-blind randomized study of venlafaxine in the treatment of depression in dementia

BACKGROUND/AIMS

To evaluate the efficacy and safety of venlafaxine in the treatment of major depression in dementia.

METHODS

Thirty-one outpatients who had dementia and major depression participated in this randomized, double-blind, placebo-controlled, 6-week, flexible dose clinical trial. The screening measures were Cornell Scale for depression in dementia, DSM-IV for depression and dementia and Mini-Mental State Examination. The outcome measures were response rate, Montgomery-Asberg Depression Rating scale and Clinical Global Impressions.

RESULTS

The percentage of patients defined as Montgomery-Asberg Depression Rating scale responders was approximately the same in the placebo and in the venlafaxine groups. Clinical Global Impressions showed no significant difference between the groups. The reasons for dropouts show borderline significance between the two groups. There was no statistically significant difference in the incidence of adverse events between the venlafaxine and placebo-treated groups.

CONCLUSIONS

Our data do not support the hypothesis that venlafaxine improves mood in elderly demented patients.

Effectiveness and safety of venlafaxine extended release in elderly depressed patients

The main objectives of this multicenter, naturalistic, open-label study is to evaluate the effectiveness, tolerability and safety of venlafaxine extended release (VXR) in a sample of 59 patients older than 60 years of age diagnosed of depressive disorders in the primary care setting. VXR was administered for 24 weeks at daily doses ranging from 75 mg to 225 mg. Effectiveness measurements included the 17 items Hamilton Depression Rating Scale (HAM-D(17)), the Clinical Global Impression Scales for Severity (CGI-S) and Improvement (CGI-I), the Visual Analogical Scale for Pain (P-VAS), and the Mini-Mental State Examination (MMSE) scale. At the endpoint, VXR achieved response and remission rates of 81.6% and 59.2%, respectively. Treatment was associated with a significant improvement of the patient's condition (89.8% of patients were rated by physicians as "much/very much improved"). Painful physical symptoms (p<0.0001) and cognitive state (p=0.0017) scores decreased along the study. A total of 83% of patients completed the study. Seven adverse events were recorded for four patients (6.8% overall). Data of this study suggest that VXR could be an effective and safe therapeutic option in the treatment of geriatric depression, reducing also the associated painful physical symptoms.

Venlafaxine extended-release in patients older than 80 years with depressive syndrome

OBJECTIVES

The aim of this evaluation was to assess the efficacy and safety of venlafaxine extended-release (ER) in very old primary care out-patients with depressive syndrome and associated anxiety symptoms.

METHODS

This was an observational, naturalistic, multicenter, prospective, open-label study in an outpatient population with a diagnosis of depressive syndrome with anxiety symptoms. Minimum scores of 17 and 10 on the Hamilton Rating Scale for Depression (HAM-D(17)) and Anxiety (HAM-A), respectively, were required. Daily doses of 75 mg to 225 mg of venlafaxine extended release (ER) were administered for 24 weeks. Effectiveness for depressive-anxious symptomatology was assessed using the HAM-D(17) and HAM-A scales.

PATIENTS

The 97 patients discussed in this report are a subgroup comprising all elderly patients, aged >or= 80 years, who were part of the larger observational, naturalistic, multicenter, prospective, open-label study and who had received venlafaxine ER for a maximum duration of 24 weeks.

RESULTS

At endpoint, remission rates were 57.1% (HAM-D(17) <or=7), 66.2% (HAM-A <or= 7), and 52% (HAM-D(17) <or=7 and HAM-A <or= 7). Twenty patients (20.6%) dropped out or were withdrawn. Adverse events were reported by seven (7.2%) patients, none were reported as serious.

CONCLUSIONS

Venlafaxine ER was shown to be an effective and safe drug for the treatment of very elderly primary care patients with depressive syndrome and associated anxiety symptoms.

Duloxetine and venlafaxine-XR in the treatment of major depressive disorder: a meta-analysis of randomized clinical trials

BACKGROUND

Duloxetine has joined venlafaxine on the antidepressant market as a second serotonin-norepinephrine reuptake inhibitor. No previous studies have directly compared these drugs.

OBJECTIVE

To compare indirectly the efficacy and safety of extended-release (XR) venlafaxine and duloxetine, the 2 currently available serotonin-norepinephrine reuptake inhibitors (SNRIs) in treating major depressive disorder.

METHODS

Outcomes from published, randomized, placebo-controlled trials reporting on moderately to severely depressed patients (Hamilton Rating Scale for Depression [HAM-D] > or =15 or Montgomery-Asberg Depression Rating Scale [MADRS] > or =18). A systematic literature search of Cochrane, EMBASE, and MEDLINE (1996-January 2005) was performed. Two independent reviewers judged the trials for acceptance, and last observation carried forward data were extracted. Differences in remission (8-week HAM-D score < or =7 or MADRS < or =10), response (50% decrease on either scale), and dropout rates from lack of efficacy and adverse events were meta-analyzed using a random effects model. Each rate was contrasted with placebo. Sensitivity analyses were performed to examine the robustness of the results.

RESULTS

Data were obtained from 8 trials evaluating 1754 patients for efficacy and 1791 patients for discontinuation/safety. Venlafaxine-XR rates were 17.8% (95% CI 9.0 to 26.5) and 24.4% (95% CI 15.0 to 37.7) greater than those with placebo for remission and response compared with 14.2% (95% CI 8.9 to 26.5) and 18.6% (95% CI 13.0 to 24.2) for duloxetine. Although numerically higher for venlafaxine-XR, no statistically significant differences were found between the drugs; however, both demonstrated overall remission and response rates significantly higher than the rates achieved with placebo (p < 0.001). Reported adverse events were comparable between drugs.

CONCLUSIONS

Venlafaxine-XR tends to have a favorable trend in remission and response rates compared with duloxetine. However, dropout rates and adverse events did not differ. A direct comparison is warranted to confirm this tendency.