A non-inferiority comparison of duloxetine and venlafaxine in the treatment of adult patients with generalized anxiety disorder

Impact of duloxetine on succinylcholine-induced postoperative myalgia after direct microlaryngoscopic surgeries: Randomized controlled double-blind study

BACKGROUND

Succinylcholine is a preferred muscle relaxant for rapid sequence intubation. Postoperative myalgia (POM) is one of its commonest adverse effects with unknown pathogenesis. Various modalities were examined to reduce POM. We hypothesized that duloxetine may reduce the incidence and severity of fasciculation or succinylcholine-induced POM in outpatient surgeries.

METHODS

This randomized double-blinded trial involved controlled 70 adult participants scheduled for elective direct microlaryngoscopic surgeries. Before induction of general anesthesia by 2 h, 35 patients received duloxetine 30 mg orally (group D) and 35 patients received similar oral starch placebo capsules (group C). Fasciculations, POM, sedation score, time to first rescue analgesia, total analgesic consumption 24 h after surgery, patients' satisfaction, and adverse effects were recorded.

RESULTS

Incidence of fasciculation was 77.1% and 94.3% in groups D and C (p value = 0.04), whereas its severity was not significant between groups (p value = 0.09). Incidence and severity of POM were significantly lower in group D (p values = 0.004 and 0.021). Positive correlation was recorded between fasciculations and POM scores (r = 0.732 and p < 0.001). Time required for first analgesia was prolonged in group D (p value < 0.001) with less total analgesic consumption (p value = 0.039). The potassium and creatine kinase levels showed significant differences between both groups after 30 min and 24 h, respectively (p value < 0.05). Sedation scores and patients' satisfaction were better in duloxetine group (p value < 0.05) with no severe complications.

CONCLUSIONS

Preoperative oral duloxetine 30 mg administration decreased incidence and severity of succinylcholine-related muscle POM and fasciculations. It was also effective in reducing postoperative rescue analgesic requirement with better patients' satisfaction and no serious adverse effects.

Duloxetine and cardiovascular adverse events: A systematic review and meta-analysis

Duloxetine has been increasingly administered, but the associated cardiovascular adverse event risk is not clearly understood. Therefore, we identified the association between duloxetine and cardiovascular adverse events through an analysis of heart rate and blood pressure change. We searched PubMed, EMBASE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and psycINFO in June 2019. The title, abstract, and full text were checked in order to obtain articles. A meta-analysis was conducted with random effect model and quality of articles was evaluated using Cochrane Risk of Bias 2.0. The manuscript has been written according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) harm checklist. A total of 4009 studies were screened by the title and abstract. After reviewing 186 full texts, 17 studies were finally selected for the meta-analysis. Nine of the 17 studied duloxetine given for mood disorders and 8 for pain control. The duration of 14 studies was under 13 weeks. Cardiovascular adverse events (hypertension, myocardial infarction, transient ischemic attack, tachycardia atrial fibrillation, and cerebrovascular accident) were reported. The meta-analysis demonstrated that duloxetine increased heart rate by 2.22 beats/min (95% confidence intervals [CIs]: 1.53, 2.91) and diastolic blood pressure by 0.82 mmHg (95% CI: 0.17, 1.47). Our findings may be the signal for the safety of cardiovascular disease for short-term use of duloxetine. Well-designed pharmaco-epidemiological studies evaluating the causal relationship between long-term use of duloxetine and cardiovascular disease is still necessary.

A Systematic Review of Efficacy, Safety, and Tolerability of Duloxetine

Duloxetine is a serotonin-norepinephrine reuptake inhibitor approved for the treatment of patients affected by major depressive disorder (MDD), generalized anxiety disorder (GAD), neuropathic pain (NP), fibromyalgia (FMS), and stress incontinence urinary (SUI). These conditions share parallel pathophysiological pathways, and duloxetine treatment might be an effective and safe alternative. Thus, a systematic review was conducted following the 2009 Preferred Reporting Items (PRISMA) recommendations and Joanna Briggs Institute Critical (JBI) Appraisals guidelines. Eighty-five studies focused on efficacy, safety, and tolerability of duloxetine were included in our systematic review. Studies were subdivided by clinical condition and evaluated individually. Thus, 32 studies of MDD, 11 studies of GAD, 19 studies of NP, 9 studies of FMS, and 14 studies of SUI demonstrated that the measured outcomes indicate the suitability of duloxetine in the treatment of these clinical conditions. This systematic review confirms that the dual mechanism of duloxetine benefits the treatment of comorbid clinical conditions, and supports the efficacy, safety, and tolerability of duloxetine in short- and long-term treatments.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder

Objective:

To provide practical clinical guidance for the treatment of adults with panic disorder, social anxiety disorder and generalised anxiety disorder in Australia and New Zealand.

Method:

Relevant systematic reviews and meta-analyses of clinical trials were identified by searching PsycINFO, Medline, Embase and Cochrane databases. Additional relevant studies were identified from reference lists of identified articles, grey literature and literature known to the working group. Evidence-based and consensus-based recommendations were formulated by synthesising the evidence from efficacy studies, considering effectiveness in routine practice, accessibility and availability of treatment options in Australia and New Zealand, fidelity, acceptability to patients, safety and costs. The draft guidelines were reviewed by expert and clinical advisors, key stakeholders, professional bodies, and specialist groups with interest and expertise in anxiety disorders.

Results:

The guidelines recommend a pragmatic approach beginning with psychoeducation and advice on lifestyle factors, followed by initial treatment selected in collaboration with the patient from evidence-based options, taking into account symptom severity, patient preference, accessibility and cost. Recommended initial treatment options for all three anxiety disorders are cognitive–behavioural therapy (face-to-face or delivered by computer, tablet or smartphone application), pharmacotherapy (a selective serotonin reuptake inhibitor or serotonin and noradrenaline reuptake inhibitor together with advice about graded exposure to anxiety triggers), or the combination of cognitive–behavioural therapy and pharmacotherapy.

Conclusion:

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder provide up-to-date guidance and advice on the management of these disorders for use by health professionals in Australia and New Zealand.

Short-term efficacy and tolerability of venlafaxine extended release in adults with generalized anxiety disorder without depression: A meta-analysis

Background

Although efficacy of venlafaxine extended release (XR) for generalized anxiety disorder (GAD) has been reported in previous analyses in 2002 and 2004, the sample size was rather small and estimate of safety or tolerability was not clear. The present analysis had the advantage of large sample size and provided evidence for tolerability.

Methods

Literature databases were searched, including Pubmed, Embase, Cochrane Central Register of Controlled Trials, Web of science and clinical trials. 10 eligible articles were finally selected and data was extracted and logged into the Review Manager 5.3 by two independent authors. The risk of bias was evaluated by the Cochrane Collaboration’s Risk of Bias Tool and the stability of the results was assessed by sensitivity analysis. The publication bias was assessed by funnel plot and Egger’s/Begg’s test using Stata Version 12.0 software.

Results

In the current meta-analysis, 10 articles (14 studies) satisfying the inclusion criteria were analyzed. As efficacy outcomes, our findings indicated venlafaxine XR was significantly more effective than placebo according to mean change of the Hamilton Rating Scale for Anxiety total scores [mean difference = 3.31, 95% confidence interval(CI) 1.44–5.18, P = 0.0005], response [odds ratio(OR) = 1.83, 95%CI 1.58–2.12, P<0.00001], and remission (OR = 2.55, 95%CI 1.36–4.78, P = 0.003). In terms of tolerability, the most frequently reported treatment-emergent adverse events were nausea, dry mouth, dizziness, insomnia, somnolence, and headache. In addition, discontinuation due to all-cause (OR = 1.17, 95%CI 0.92–1.49, P = 0.19) was not significantly different between the two groups, whereas discontinuation due to adverse events was statistically higher in the venlafaxine XR group compared with the placebo treatment (OR = 2.80, 95%CI 2.21–3.54, P<0.00001) and discontinuation due to inefficacy was lower in venlafaxine than placebo treatment (OR = 0.26, 95%CI 0.17–0.40, P<0.00001). There was no significant publication bias and sensitivity analysis showed that our analysis exhibited high stability.

Conclusion

We concluded that venlafaxine XR (75–225 mg/day) is an effective and well-tolerated pharmacological treatment option for adult patients with GAD.

Duloxetine in treating generalized anxiety disorder in adults: A meta-analysis of published randomized, double-blind, placebo-controlled trials

INTRODUCTION

We carried out a meta-analysis of published randomized, double-blind, placebo-controlled trails to assess the efficacy and tolerability of duloxetine in treating generalized anxiety disorder (GAD).

METHODS

A literature search was conducted using PubMed, ISI Web of Science, Medline, Cochrane Central Register of Controlled Trials databases until October 2014. The search terms used were "anxiety or anxious or generalized anxiety disorder" and "duloxetine or Cymbalta." Meta-analysis was conducted using Revman 5.1. A fixed-effects model was carried out on the response rates, remission rates, and symptom improvement. Risk ratio (RR) and mean difference (MD) were calculated. The overall effect size was calculated with 95% confidence intervals (CIs).

RESULTS

Seven studies (n = 2,674) were found eligible for inclusion in analysis. Six studies provided data on response, which showed a significant difference between duloxetine and placebo (n = 1,975, RR = 1.48, 95% CI, 1.34-1.63). Remission rates revealed significant superiority of duloxetine (n = 2,399, RR = 1.60, 95% CI, 1.43-1.80). Change from baseline scores on Hamilton Rating Scale for Anxiety showed a reduction in anxiety symptoms to be significantly efficient for duloxetine (n = 1,135, MD = 3.34, 95% CI, 2.37-4.32). Duloxetine increased statistically Sheehan Disability Scale total score (n = 1,652, MD = 2.84, 95% CI, 2.08-3.60). The discontinuation of the duloxetine was not significantly different from that of the placebo.

CONCLUSION

Duloxetine is moderately effective in treating GAD with improvement in overall function and well tolerability.

The noradrenergic paradox: implications in the management of depression and anxiety

Both major depressive disorder and the anxiety disorders are major causes of disability and markedly contribute to a significant global burden of the disease worldwide. In part because of the significant socioeconomic burden associated with these disorders, theories have been developed to specifically build clinical treatment approaches. One such theory, the monoaminergic hypothesis, has led to the development of several generations of selective and nonselective inhibitors of transporters of serotonin and norepinephrine, with the goal of augmenting monoaminergic transmission. These efforts have led to considerable success in the development of antidepressant therapeutics. However, there is a strong correlation between enhanced noradrenergic activity and fear and anxiety. Consequently, some physicians have expressed concerns that the same enhanced noradrenergic activity that alleviates depression could also promote anxiety. The fact that the serotonergic and noradrenergic reuptake inhibitors are successfully used in the treatment of anxiety and panic disorders seems paradoxical. This review was undertaken to determine if any clinical evidence exists to show that serotonergic and noradrenergic reuptake inhibitors can cause anxiety. The PubMed, EMBASE, and Cochrane Library databases were searched, and the results limited to randomized, double-blind, placebo-controlled studies performed in nongeriatric adults and with clear outcome measures were reported. Based on these criteria, a total of 52 studies were examined. Patients in these studies suffered from depression or anxiety disorders (generalized and social anxiety disorders, panic disorder, and posttraumatic stress disorder). The large majority of these studies employed venlafaxine or duloxetine, and the remainder used tri-cyclic antidepressants, atomoxetine, or reboxetine. All the studies reported clinically significant alleviation of depressive and/or anxious symptoms by these therapeutics. In none of these studies was anxiety a treatment-emergent adverse effect. This review argues against the impression that enhanced generalized noradrenergic activity promotes the emergence of anxiety.

Pharmacological treatment for generalized anxiety disorder in adults: an update

INTRODUCTION

Modest response and remission rates for the selective serotonin reuptake inhibitors and the serotonin-norepinephrine reuptake inhibitors, coupled with mounting evidence that the tolerability of the antidepressants (ADs) may have been overstated in the literature, has contributed to changes in prescribing patterns for generalized anxiety disorder (GAD). New interest in the absence of evidence that supports these standard therapies as superior to benzodiazepines stimulated a review of the literature.

AREAS COVERED

A literature search was conducted in the MedLine database with search terms 'generalized anxiety disorder' and 'treatment' for purposes of including relevant literature related to pharmacologic treatment of GAD. Aside from a review of pivotal literature, the authors also included newer studies that evaluated novel drug treatments. Last, the database was searched for benzodiazepine comparisons to standard therapy secondary to concerns that such literature is sparse. The review of newer modalities and the decision to include related literature was also based on the strength of the evidence and the status of their approval for the treatment of GAD.

EXPERT OPINION

Although ADs remain the most frequently prescribed medications for GAD, alternative and off-label therapies such as pregabalin, the atypical antipsychotics and vortioxetine are garnering interest. Based on the evidence available to us, it is our recommendation that along with the ADs, benzodiazepines be considered a possible first-line therapy in eligible patients based on the discretion and clinical judgment of the treating physician.

Role of quetiapine beyond its clinical efficacy in bipolar disorder: From neuroprotection to the treatment of psychiatric disorders (Review)

The aim of the present review was to discuss the following aspects of treatment with quetiapine in psychiatric disorders: i) Neurocognition and functional recovery in bipolar disorder (BD); ii) neuroprotective profile in different models; and iii) potential off-label indications. A PubMed search was conducted of articles published in English between 2000 and 2012 on quetiapine, cross-referenced with the terms ‘anxiety’, ‘attention deficit disorder’, ‘borderline personality disorder’, ‘dementia’, ‘insomnia’, ‘major depressive disorder’ (MDD), ‘obsessive-compulsive disorder’, ‘post-traumatic stress disorder’, ‘remission’, ‘cognition’, ‘neurobiology’, ‘neuroprotection’, ‘efficacy’ and ‘effectiveness’. Articles were selected from meta-analyses, randomized clinical trials and open trials, and the results were summarized. Quetiapine, when studied in off-label conditions, has shown efficacy as a monotherapy in MDD and general anxiety disorder. Quetiapine also appears to exhibit a small beneficial effect in dementia. The review of other conditions was affected by methodological limitations that precluded any definitive conclusions on the efficacy or safety of quetiapine. Overall, the present review shows evidence supporting a potential role for quetiapine in improving cognition, functional recovery and negative symptoms in a cost-effective manner in BD. These benefits of quetiapine are potentially associated with its well-described neuroprotective effects; however, further studies are clearly warranted.

From guideline to patient: a review of recent recommendations for pharmacotherapy of painful diabetic neuropathy

Painful diabetic peripheral neuropathy (DPN) is a common complication of diabetes mellitus, affecting, by some estimates, up to one quarter of diabetic patients. Since 2010, no fewer than 5 major international treatment guidelines for painful DPN have been issued, and there are meaningful differences among them. Duloxetine, pregabalin, gabapentin, and tricyclic antidepressants are the mainstays of treatment, but the choice of which class or agent to use in any given patient should be informed by patient characteristics. This review seeks to describe the differences among the recently issued guidelines, to assess the evidence on which they are based, and to offer insight into the most appropriate treatment choices based on patient characteristics.

Efficacy and safety of duloxetine in the treatment of older adult patients with generalized anxiety disorder: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

This was a flexible-dosed study to evaluate the efficacy and safety of duloxetine 30-120 mg once daily in the treatment of generalized anxiety disorder (GAD) in older adult patients.

METHODS

Patients with GAD, who were at least 65 years of age, were randomly assigned to double-blind treatment with either duloxetine (N = 151) or placebo (N = 140). The primary efficacy measure was the Hamilton Anxiety Rating Scale (HAM-A) total score, and the primary endpoint was at week 10. Global functioning was assessed by the Sheehan Disability Scale (SDS). Safety and tolerability was assessed by the occurrence of treatment-emergent adverse events, serious adverse events, laboratory analyses, and vital signs. Analyses were conducted on an intent-to-treat basis.

RESULTS

The overall baseline mean HAM-A total score was 24, and SDS global score was 14. Completion rates were 75% for placebo and 76% for duloxetine. At week 10, duloxetine was superior to placebo on mean changes from baseline in HAM-A total scores (-15.9 vs. -11.7, p < 0.001) and in SDS global scores (-8.6 vs. -5.4, p < 0.001). Treatment-emergent adverse events occurred in ≥5% of duloxetine-treated patients and twice the rate than with placebo including constipation (9% vs. 4%, p = 0.06), dry mouth (7% vs. 1%, p = 0.02), and somnolence (6% vs. 2%, p = 0.14).

CONCLUSION

Duloxetine treatment was efficacious in the improvement of anxiety and functioning in older adult patients with GAD, and the safety profile was consistent with previous GAD studies.

A review of the suitability of duloxetine and venlafaxine for use in patients with depression in primary care with a focus on cardiovascular safety, suicide and mortality due to antidepressant overdose

Depression and anxiety disorders are among the most common disorders treated by general practitioners (GPs) in the UK. Since both disorders are associated with a significantly increased risk of suicide, including with antidepressant overdose, the safety of antidepressants in overdose is of paramount importance. Numerous updates relating to antidepressant safety have been issued by regulators in the UK which may have eroded GP confidence in antidepressants. Venlafaxine, a serotonin nor adrenaline reuptake inhibitor (SNRI) had primary care prescribing restrictions placed on it in 2004 due to concerns about cardiotoxicity and mortality in overdose. Although a review of the evidence led to a reversal of the majority of restrictions in 2006, evidence suggests GPs may still be cautious in their prescribing of venlafaxine and possibly other SNRI antidepressants for patients with depression and anxiety disorders. This paper reviews the evidence pertaining to the safety of SNRI antidepressants from a perspective of cardiovascular safety and overdose. The currently available evidence suggests a marginally higher toxicity of venlafaxine in overdose compared with another SNRI duloxetine and the selective serotonin reuptake inhibitors (SSRIs), although this may be related to differential patterns of prescribing in high-risk patients. Based on this review SNRIs have a positive risk benefit profile in the treatment of depression and generalized anxiety disorder in primary care, especially as second-line agents to SSRIs.

The best next drug in the course of generalized anxiety disorders: the "PN-GAD-algorithm"

OBJECTIVE

Today, there are many pharmacotherapeutic options for generalized anxiety disorder (GAD). The question is, which is the best medication for a particular patient at a particular moment? This is especially challenging because GAD is by definition a chronic disorder and new interventions should learn from earlier experiences. An algorithm which can help to use pretreatment information for drug selection is the "Pretreatment - Next Treatment (PN) - Algorithm". This article introduces an PN-algorithm for GAD.

METHODS AND RESULTS

For the development of a GAD-specific PN-algorithm, all possible pharmacological options for GAD are reviewed and brought into a rank order on the basis of scientific evidence regarding efficacy, tolerability, or price: (1) pregabalin, (2) venlafaxine XR, (3) selective serotonin reuptake inhibitors, (4) tricyclic antidepressants, (5) buspirone, (6) antipsychotics, (7) benzodiazepines, and (8) hydroxyzine. Based on this hierarchy and patient-specific information, a decision algorithm is derived, which allows to assess and evaluate pretreatment and to select the drug with no contraindications, limited negative or convincing positive effects, or the option which has not been used so far but which is the next compound in the hierarchy.

CONCLUSIONS

The "PN-GAD-algorithm" can be easily translated into a checklist to support clinical decision-making. It can also help to increase patient empowerment and cooperation in long-term treatment.

Comprehensive review of generalized anxiety disorder in primary care in Europe

OBJECTIVE

This review aims to summarize meta-analyses and other relevant data relating to the efficacy and safety of the various treatment options for generalized anxiety disorder (GAD) in Europe. In addition, it will provide an overview of the prevalence, burden, and recognition of the disorder, with a view to raise awareness of GAD and inform primary care practitioners.

RESEARCH DESIGN AND METHODS

Relevant research or review articles on psychological or pharmacological treatments for GAD published in the English language between March 2006 and March 2012 were identified via a literature search in PubMed and ISI Web of Knowledge and from the Cochrane Library. Other relevant references/clinical guidelines were individually selected by the authors.

RESULTS

Prevalence rates of GAD vary across Europe but its economic and social burden is increasing. A large proportion of patients with GAD present with symptoms in primary care. However, due to the disorder's complexity and the incidence of comorbid diseases, some primary care physicians may lack the knowledge or confidence to effectively recognize, manage, and/or treat the disorder. This is despite psychological and pharmacological treatments being available for the effective management of GAD.

CONCLUSIONS

GAD remains a difficult disorder to detect and comorbid complications add to its economic and social burden. Early detection and intervention reduces the societal burden and improves GAD patients' quality of life and functional ability. Primary care practitioners play a key role in identifying and treating patients with GAD.

The diagnosis and treatment of generalized anxiety disorder

BACKGROUND

Generalized anxiety disorder (GAD) is a common and serious disease with a lifetime prevalence of 4.3% to 5.9%. It is underdiagnosed in primary care.

METHODS

Recommendations on the treatment of GAD are given on the basis of all available findings from pertinent randomized trials, retrieved by a selective search of the literature.

RESULTS

Among psychotherapeutic techniques, various kinds of cognitive behavioral therapy (CBT) have been found useful in controlled trials. The drugs of first choice include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephine reuptake inhibitors (SNRIs), and the calcium-channel modulator pregabalin. Tricyclic antidepressants are also effective but have more adverse effects than SSRIs. Although benzodiazepines are effective anxiolytic agents for short-term use, they should not be given over the long term because of the danger of addiction. Buspirone, an azapirone, was found to be effective in a small number of trials, but the findings across trials are inconsistent. The response rate of GAD to CBT in published studies lies between 47% and 75%, while its response rate to drug treatment lies between 44% and 81%.

CONCLUSION

The treatment of GAD with CBT and drugs is evidence-based and has a good chance of improving the manifestations of the disorder.

Predictors of Treatment with Duloxetine or Venlafaxine XR among Adult Patients Treated for Depression in Primary Care Practices in the United Kingdom

Background. Knowledge about real-world use of duloxetine and venlafaxine XR to treat depression in the UK is limited. Aims. To identify predictors of duloxetine or venlafaxine XR initiation. Method. Adult depressed patients who initiated duloxetine or venlafaxine XR between January 1, 2006 and September 30, 2007 were identified in the UK's General Practice Research Database. Demographic and clinical predictors of treatment initiation with duloxetine and venlafaxine XR were identified using logistic regression. Results. Patients initiating duloxetine (n = 909) were 4 years older than venlafaxine XR recipients (n = 1286). Older age, preexisting unexplained pain, respiratory disease, and pre-period use of anticonvulsants, opioids, and antihyperlipidemics were associated with increased odds of initiating duloxetine compared to venlafaxine XR. Pre-period anxiety disorder was associated with decreased odds of receiving duloxetine. Conclusion. Initial treatment choice with duloxetine versus venlafaxine XR was primarily driven by patient-specific mental and medical health characteristics. General practitioners in the UK favor duloxetine over venlafaxine XR when pain conditions coexist with depression.

Pharmacological treatment of generalized anxiety disorder

INTRODUCTION

Generalized anxiety disorder (GAD) is a chronic, relapsing, debilitating disorder, associated with markedly impaired social and occupational functioning. Pharmacological treatment is considered standard care and several drug classes are now FDA approved for the treatment of GAD. While there are clear data for the efficacy of short-term acute treatment, long-term treatment and treatment-resistant GAD remain challenging.

AREAS COVERED

This article describes current pharmacological treatment options for GAD, with focus on benzodiazepines, azapirones, antidepressants and anticonvulsant and antipsychotic drugs. Recent findings from placebo-controlled clinical trials are reviewed and evidence-based clinical implications are discussed. A PubMed search was completed using the terms: 'generalized anxiety disorder AND treatment' and 'generalized anxiety disorder AND therapy'. Additional pivotal trials were included for a historical perspective (older landmark trials that established efficacy and safety for older drug classes in the treatment of GAD).

EXPERT OPINION

Efficacy for treatment of GAD has been established for several different drug classes. At present, based on clear efficacy and good tolerability, first-line treatment with either a selective serotonin reuptake inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor (SNRI) is indicated. If an initial, at least moderate, clinical response is achieved under antidepressant therapy, treatment should be at least continued for 12 months.

An open, non-randomised comparison of escitalopram and duloxetine for the treatment of subjects with Generalized Anxiety Disorder

OBJECTIVES

This study compares the effectiveness of a 6-months treatment with escitalopram (ESC), a selective serotonin reuptake inhibitor, or duloxetine (DUL), a balanced serotonin and nor-adrenaline reuptake inhibitor, in 43 subjects with Generalized Anxiety Disorder (GAD).

METHODS

Assessment was made with the Hamilton Anxiety and Depression scales (HAM-A; HAM-D), with the CGI, and with the GAF at T0 (intake), T1, T3, T6 (1, 3, and 6 months later). The comparison among the two treatment groups (ESC=20; DUL=23) at the four endpoints was made through a GLM-ANOVA for repeated measures. Rates of remission (HAM-A<7), response (HAM-A reduction of 50% or above) and dropout were evaluated.

RESULTS

At 1, 3, and 6 months after treatment inception both treatment groups showed a significant improvement in the scores of CGI, HAMA, HAM-D, and GAF, and an equivalent rate of dropout. The DUL group registered a greater amount of remission and response rates at T1 against the ESC group in all the scales except in the HAM-D scale. Duloxetine was more effective than escitalopram after the first month of treatment only in the somatic subscale of HAM-A. The presence of a cluster C personality disorder was associated in both groups to greater difficulties in attaining remission and to dropout.

CONCLUSIONS

Implications for clinical practice are discussed.

Noradrenergic function in generalized anxiety disorder: impact of treatment with venlafaxine on the physiological and psychological responses to clonidine challenge

Serotonin and noradrenaline reuptake inhibitor (SNRI) antidepressants have evidence of efficacy in the treatment of generalized anxiety disorder (GAD); however, it is not clear whether there is an advantage over selective serotonin reuptake inhibitor (SSRI) medicines and there is limited evidence for noradrenergic dysfunction in GAD. We tested whether a dysfunctional alpha-2 adrenoceptor system is present in patients with GAD and the effects of SNRI treatment on this system. The method used was an infusion of clonidine (a selective alpha-2 adrenergic receptor agonist) on psychological and physiological outcomes in three subject groups: 10 untreated GAD patients, five SNRI-treated GAD patients and seven normal controls. The clonidine challenge elicited sedation, a rise in growth hormone, decrease in blood pressure, decline in saccadic eye movement (SEM) variables, and improvement in verbal fluency as anticipated in the 22 subjects examined. Lower cortisol levels were found in controls and higher blood pressure readings in GAD-treated subjects, as well as evidence that GAD-treated subjects had SEMs that were intermediate between control and GAD subjects' scores and have less clonidine-induced sedation. The implications of these findings with reference to the study hypothesis in this small study are discussed.

Duloxetine: a review of its use in the treatment of generalized anxiety disorder

Duloxetine (Cymbalta(R)) is a potent serotonin and noradrenaline (norepinephrine) reuptake inhibitor (SNRI) in the CNS. It is indicated for the treatment of generalized anxiety disorder (GAD) as well as other indications. In patients with GAD of at least moderate severity, oral duloxetine 60-120 mg once daily was effective with regard to improvement from baseline in assessments of anxiety and functional impairment, and numerous other clinical endpoints. Longer-term duloxetine 60-120 mg once daily also demonstrated efficacy in preventing or delaying relapse in responders among patients with GAD. In addition, duloxetine was generally well tolerated, with most adverse events being of mild to moderate severity in patients with GAD in short- and longer-term trials. Additional comparative and pharmacoeconomic studies are required to position duloxetine among other selective serotonin reuptake inhibitors and SNRIs. However, available clinical data, and current treatment guidelines, indicate that duloxetine is an effective first-line treatment option for the management of GAD. Duloxetine is a potent and selective inhibitor of serotonin and noradrenaline transporters, and a weak inhibitor of dopamine transporters. It has a low affinity for neuronal receptors, such as alpha(1)- and alpha(2)-adrenergic, dopamine D(2), histamine H(1), muscarinic, opioid and serotonin receptors, as well as ion channel binding sites and other neurotransmitter transporters, such as choline and GABA transporters. It does not inhibit monoamine oxidase types A or B. The pharmacokinetics of duloxetine in healthy volunteers were dose proportional over the range of 40-120 mg once daily. Steady state was typically reached by day 3 of administration. Duloxetine may be administered without regard to food or time of day. Duloxetine is highly protein bound and is widely distributed throughout tissues. It is rapidly and extensively metabolized in the liver by cytochrome P450 (CYP) 1A2 and 2D6, and its numerous metabolites, which are inactive, are mainly excreted in the urine. The mean elimination half-life of duloxetine is approximately 12 hours. Duloxetine is a substrate for CYP1A2 and CYP2D6 and a moderate inhibitor of CYP2D6. Concomitant use of duloxetine and potent CYP1A2 inhibitors should be avoided and duloxetine should be used with caution in patients receiving drugs that are extensively metabolized by CYP2D6, particularly those with a narrow therapeutic index. Duloxetine was effective in the short-term treatment of patients with primary GAD of at least moderate severity. In four randomized, double-blind, placebo-controlled, multicentre, phase III trials, duloxetine 60-120 mg once daily for 9 or 10 weeks was significantly more effective than placebo with regard to the primary endpoint of mean change in Hamilton Anxiety Rating Scale (HAM-A) total score from baseline to study endpoint. In addition, all other endpoints were generally improved from baseline to a greater extent with duloxetine 60-120 mg once daily than with placebo. Duloxetine also improved patient role functioning (assessed using Sheehan Disability Scale global impairment functioning scores), health-related quality of life and patient well-being compared with placebo. Duloxetine was effective in patients with GAD who were aged >/=65 years. Pooled results of data from the two short-term efficacy trials that also included an active comparator arm showed that the mean change in HAM-A scores with duloxetine relative to placebo were of the same magnitude as those with venlafaxine extended release versus placebo. Duloxetine 60-120 mg once daily was also more effective than placebo in preventing or delaying relapse in responders to duloxetine in a longer-term study. In this study, patients with GAD received duloxetine during a 26-week, open-label, acute treatment phase and responders were then randomized to continue on duloxetine or receive placebo during a 26-week, double-blind, continuation phase. Time to relapse was significantly longer in duloxetine recipients than in placebo recipients. In addition, significantly fewer duloxetine recipients than placebo recipients relapsed during the double-blind phase of the trial and more duloxetine recipients achieved remission. Short- (9-10 weeks) and longer-term (52 weeks) treatment with duloxetine 60-120 mg once daily was generally well tolerated in patients with GAD, with the majority of adverse events being of mild to moderate severity. Nausea, dry mouth, headache, constipation, dizziness and fatigue were among the most common treatment-emergent adverse events. The adverse event profile of duloxetine did not differ with dose or treatment duration. Significantly more patients receiving short-term duloxetine than placebo discontinued treatment because of an adverse event, with nausea being the only event that resulted in significantly more treatment discontinuations in duloxetine recipients than in placebo recipients. Serious adverse events were uncommon with both short- and longer-term duloxetine treatment. Two episodes of attempted suicide and one episode of completed suicide occurred in duloxetine recipients during the 24-week open-label phase of a longer-term trial. No deaths or suicides were reported in any of the short-term trials. Discontinuation-emergent adverse events, most commonly nausea and dizziness, occurred in up to one-third of duloxetine recipients in the short-term trials.

Efficacy of pregabalin and venlafaxine-XR in generalized anxiety disorder: results of a double-blind, placebo-controlled 8-week trial

The objective of this study was to evaluate the anxiolytic efficacy, and speed of onset of efficacy, of pregabalin (PGB) and venlafaxine-XR (VXR) in patients with generalized anxiety disorder (GAD). In this double-blind trial, outpatients, ages 18-65 years, who met Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for GAD were randomized to 8 weeks of flexible-dose treatment with PGB (300-600 mg/day), VXR (75-225 mg/day), or placebo (PBO). The intent-to-treat sample consisted of 121 patients on PGB [least square (LS) mean ± SE baseline Hamilton Anxiety Rating Scale (HAM-A), 27.6 ± 0.4], 125 patients on VXR (baseline HAM-A, 27.4 ± 0.4), and 128 patients on PBO (baseline HAM-A, 26.8 ± 0.4). Treatment with PGB was associated with a significantly greater LS mean change in the HAM-A total score at last observation carried forward endpoint versus PBO (-14.5 ± 0.9 vs. -11.7 ± 0.9; P = 0.028). Treatment with VXR was not significant versus PBO at endpoint (-12.0 ± 0.9; -11.7 ± 0.9; P =0.968). Treatment with PGB showed an early onset of improvement, with significantly greater LS mean change in the HAM-A by day 4 versus both PBO (-5.3 ± 0.5 vs. -3.4± 0.5; P = 0.008) and VXR (-2.9 ± 0.5; P = 0.0012). The proportion of patients reporting a severe adverse event was similar for PGB (9.1%) and PBO (7.8%), but higher for VXR (20.0%; P < 0.05). In conclusion, PGB was a safe and effective treatment of GAD, with a significantly earlier onset of anxiolytic activity than VXR.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision

In this report, which is an update of a guideline published in 2002 (Bandelow et al. 2002, World J Biol Psychiatry 3:171), recommendations for the pharmacological treatment of anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are presented. Since the publication of the first version of this guideline, a substantial number of new randomized controlled studies of anxiolytics have been published. In particular, more relapse prevention studies are now available that show sustained efficacy of anxiolytic drugs. The recommendations, developed by the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-traumatic Stress Disorders, a consensus panel of 30 international experts, are now based on 510 published randomized, placebo- or comparator-controlled clinical studies (RCTs) and 130 open studies and case reports. First-line treatments for these disorders are selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and the calcium channel modulator pregabalin. Tricyclic antidepressants (TCAs) are equally effective for some disorders, but many are less well tolerated than the SSRIs/SNRIs. In treatment-resistant cases, benzodiazepines may be used when the patient does not have a history of substance abuse disorders. Potential treatment options for patients unresponsive to standard treatments are described in this overview. Although these guidelines focus on medications, non-pharmacological were also considered. Cognitive behavioural therapy (CBT) and other variants of behaviour therapy have been sufficiently investigated in controlled studies in patients with anxiety disorders, OCD, and PTSD to support them being recommended either alone or in combination with the above medicines.

Duloxetine in the treatment of generalized anxiety disorder

Duloxetine, a medication with effects on both serotonin and noradrenaline transporter molecules, has recently been approved for the treatment of generalized anxiety disorder. The evidence for its efficacy lies in a limited number of double blind, placebo controlled comparisons. Statistically significant improvements in the Hamilton Anxiety Rating Scale from baseline were demonstrated in all studies at doses of 60 to 120 mg per day. The significance of such changes in terms of clinical improvements compared to placebo is less certain, particularly when the effect size of the change is calculated. In comparative trials with venlafaxine, duloxetine was as effective in providing relief of anxiety symptoms. In addition to improvements in clinical symptoms duloxetine has also been associated with restitution of role function as measured by disability scales. Duloxetine use is associated with nausea, dizziness, dry mouth, constipation, insomnia, somnolence, hyperhidrosis, decreased libido and vomiting. These treatment emergent side effects were generally of mild to moderate severity and were tolerated over time. Using a tapered withdrawal schedule over two weeks in the clinical trials, duloxetine was associated with only a mild withdrawal syndrome in up to about 30% of patients compared to about 17% in placebo treated patients. Duloxetine in doses of up to 200 mg twice daily did not prolong the QTc interval in healthy volunteers. Like other agents with dual neurotransmitter actions duloxetine reduces the symptoms of generalized anxiety disorder in short term treatments. Further evidence for its efficacy and safety in long term treatment is required.