![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 14 of 14. This is the beginning of the thread.
Posted by SalArmy4me on August 29, 2001, at 18:15:45
Comparable to Paroxetine:
Dose Escalation vs. Continued Doses of Paroxetine and Maprotiline: A Prospective Study in Depressed Out-patients With Inadequate Treatment Response
Dose Escalation vs. Continued Doses of Paroxetine and Maprotiline: A Prospective Study in Depressed Out-patients With Inadequate Treatment ResponseBenkert O, Szegedi A, Wetzel H, et al (Univ of Mainz, Germany; Smith Kline Beecham Pharma GmbH, Munich); Acta Psychiatr Scand 95:288-296, 1997
Abstract 8-14
Introduction.-The therapeutic response to some antidepressant agents improves as the dosage is increased within certain limits, whereas dosage escalation offers no advantage with other antidepressants. A study of 544 outpatients with various degrees of depression compared the possible benefits of dosage escalation of paroxetine and maprotiline.
Methods.-The multicenter study was conducted in a randomized, double-blind manner. Eligible patients were aged 18 to 71 and had major or minor depression and a total score of 13 or greater on the 17-item Hamilton Depression Rating Scale. Paroxetine was started at 20 mg daily, given in a single oral dose in the morning; the other patients received maprotiline (100 mg) divided into 3 doses per day. Patients who failed to have sufficient clinical improvement after 3 weeks had the dosage increased or continued with the previous dosage for an additional 3 weeks.
Results.-Response rates were 40% mg at week 3 in the paroxetine 20 mg and maprotiline 100 mg group. At 6 weeks, approximately 75% to 80% of all groups (those increased and those maintained at the initial dose) had responded. Thirty-six nonresponders to paroxetine were randomized to continue the previous dosage and 50 to receive an increase to 40 mg daily; 48 nonresponders continued to receive 100 mg of maprotiline and 40 were given the increased dosage (150 mg). Dose escalation did not significantly increase therapeutic response with either antidepressant. Response was defined as a reduction of 50% or greater in the Hamilton Depression Rating Scale. Results were unchanged after patients were stratified according to baseline severity of depression. The incidence of adverse events was not increased by the larger dosage.
Conclusion.-This prospective study using explicit criteria for dosage escalation found no significant benefit when the dosages of paroxetine and maprotiline were increased for nonresponders (from 20 mg to 40 mg and from 100 mg to 150 mg daily, respectively). For most patients with acute depression, a dosage of 20 mg of paroxetine a day is optimal.
[r tri, filled] This article provides an example of a good idea that was limited by an inadequate experimental design. The authors are clearly aware of the limitations of this study of dosage escalation vs. continuation of the same dosage of either paroxetine or maprotiline in nonresponsive patients with major or minor depression. This is a particularly important problem which clinicians often face, and this study had a chance to provide some useful information. Unfortunately, the authors included a broad spectrum of patients and used only a 3-week observation period for assessing initial response, followed by a second 3-week period for assessing the effects of the second manipulation (dosage escalation vs. no change). Although it could be argued that the robust endpoint response rates in this group of patients should address my concern about the short initial treatment period, there was not adequate observation time for the patients who are randomized to an increased dosage vs. no dosage change. There may have been more resistant patients, and these patients may have required a longer period to become responders.
Of course, the lack of a placebo control, which the authors note, is another limitation of this study. The diagnostic categorization of these patients was not clear. They were assessed through "modified research diagnostic criteria," and for many patients all procedures were apparently carried out by experienced research assistants. This leaves open the question of both diagnostic and assessment capabilities, and since these individuals were not more thoroughly characterized in the article, the reader is left wondering whether this was another problematic aspect in the methodology. I selected this article because if 1 were to read quickly through it, one could easily walk away with the impression that in clinical practice it is not worthwhile to increase the dosage of an antidepressant if patients haven't responded after 3 weeks; this does not correlate with my clinical experience. This was clearly a study which involved a great deal of effort, and one which could have been made much better with closer attention to methodology.
R.B. Lydiard, Ph.D., M.D.
Posted by Cam W. on August 29, 2001, at 18:46:55
In reply to Think About Maprotiline- the forgotten multicylcic, posted by SalArmy4me on August 29, 2001, at 18:15:45
Sal - Did you even read the rebuttal by Dr.Lydiard? Why did you post this abstact? The study was poorly designed, so no real information can be gleaned from it. It tells us nothing about maprotiline's effectiveness. - Cam
Posted by SalArmy4me on August 29, 2001, at 20:03:52
In reply to Re: Think About Maprotiline- the forgotten multicylcic » SalArmy4me, posted by Cam W. on August 29, 2001, at 18:46:55
I assure you that I could post all day about maprotiline's (Ludiomil) effectiveness. It is as effective as any SSRI, tricylcic, or MAOI:
http://biopsychiatry.com/maprotvparox.htm
http://biopsychiatry.com/mianvmaprot.htm
http://amineptine.com/amivmaprot.html
http://biopsychiatry.com/maprotvamitrip.htm
http://biopsychiatry.com/maprotvfluvox.htmAnd as far as I'm concerned, it has a good side-effect profile among the NE-inhibiting tricyclics.
Posted by Cam W. on August 29, 2001, at 20:21:18
In reply to Re: Think About Maprotiline- the forgotten multicylcic » Cam W., posted by SalArmy4me on August 29, 2001, at 20:03:52
Sal - There is a reason that it is not prescribed too often, it doesn't work very well, in most people with depression. Also, it does have anticholinergic side effects (in vivo) which can cause confusion and cognitive problems.
Please sort your data as to clinical evidence and scientific evidences (which also should be split into animal trials and human trials).
Thanks - Cam
Posted by SalArmy4me on August 30, 2001, at 1:34:53
In reply to Re: Think About Maprotiline- the forgotten multicylcic » SalArmy4me, posted by Cam W. on August 29, 2001, at 20:21:18
"Confusion" is listed as rare and "cognitive side-effects" does not even appear on the drug monograph for Maprotiline: http://www.mentalhealth.com/drug/p30-l04.html
Posted by Cam W. on August 30, 2001, at 1:53:01
In reply to Re:Think About Maprotiline- forgotten multicyclic » Cam W., posted by SalArmy4me on August 30, 2001, at 1:34:53
Sal - Read the latest on anticholinergic use in schizophrenia and the neuropsychological testing of same. If you browse topics on cognition at Neuroscion, you will find a plethora on the cognitve dulling due to cholinergic blockade.
Monographs are lawyers documents, written by lawyers, for lawyers. The PDR and CPS are fairly useless for psychopharmacologists.
You have to be able to understand what the side effects are saying Sal, it is not enough to take them at face value.
I'll bite Sal, why then isn't Ludiomil one of the first line drugs for the treatment of depression? If it was so good, wouldn't it have a large market share?
You are at the point in your home-study where you need to start reading for understanding, and not believe every study you read. This year and last year BMJ had article on how to read journal articles. You may want to review these.
- Cam
Posted by SalArmy4me on August 30, 2001, at 1:57:17
In reply to Re:Think About Maprotiline- forgotten multicyclic » SalArmy4me, posted by Cam W. on August 30, 2001, at 1:53:01
Maprotiline is not a first-line agent because:
1) overdoses with cyclic drugs are sometimes fatal
2) It came out and was overshadowed by the concurrent marketing of Prozac.
3) It can cause heart problems in those with serious pre-existing conditions....NOT because it is ineffective.
Posted by Cam W. on August 30, 2001, at 2:05:23
In reply to Re:Think About Maprotiline- forgotten multicyclic » Cam W., posted by SalArmy4me on August 30, 2001, at 1:57:17
Sure, whatever you say, dude.
> Maprotiline is not a first-line agent because:
> 1) overdoses with cyclic drugs are sometimes fatal
> 2) It came out and was overshadowed by the concurrent marketing of Prozac.
> 3) It can cause heart problems in those with serious pre-existing conditions....
>
> NOT because it is ineffective.
Posted by Ed on August 30, 2001, at 7:14:38
In reply to Re:Think About Maprotiline- forgotten multicyclic » SalArmy4me, posted by Cam W. on August 30, 2001, at 2:05:23
Robust thread!
Posted by Jane D on August 30, 2001, at 11:18:02
In reply to Re:Think About Maprotiline- forgotten multicyclic » SalArmy4me, posted by Cam W. on August 30, 2001, at 1:53:01
> You are at the point in your home-study where you need to start reading for understanding, and not believe every study you read. This year and last year BMJ had article on how to read journal articles. You may want to review these.
Cam,
I read at least one article on just that. Possibly from BMJ. What would you think of doing a mini course on how to learn this stuff? We could do how to look stuff up on the internet at the same time and stick it on tips.Jane, who can always think of work for other people to do.
Posted by SLS on August 31, 2001, at 6:33:26
In reply to Re:Think About Maprotiline- forgotten multicyclic » Cam W., posted by Jane D on August 30, 2001, at 11:18:02
> > You are at the point in your home-study where you need to start reading for understanding, and not believe every study you read. This year and last year BMJ had article on how to read journal articles. You may want to review these.
> Cam,> What would you think of doing a mini course on how to learn this stuff? We could do how to look stuff up on the internet at the same time and stick it on tips.
MEEEE 2!
Regarding pharmacodynamics, I have found that even manufacturer's labels and package inserts can be wrong, especially early in a drug's life. Modafinil (Provigil) is a good expample. After being marketed in the US for awhile, they updated their package label from claiming it was a NE alpha-1 agonist to stating that they didn't know what the hell the drug did. Of course, they used nicer words.
Cam, is there is anything on the Internet that I could read?
Thanks.
- Scott
Posted by SLS on August 31, 2001, at 6:37:17
In reply to Re:Think About Maprotiline- forgotten multicyclic, posted by SLS on August 31, 2001, at 6:33:26
I would just like to add that I am grateful that Ludiomil (maprotiline) is still available. It is one more tool to add to our arsenal. It is one more unknown that I can call hope.
- Scott
Posted by Cam W. on August 31, 2001, at 6:56:39
In reply to Re:Think About Maprotiline- forgotten multicyclic, posted by SLS on August 31, 2001, at 6:33:26
Jane & Scott - I have a whole file of articles on how to properly read and write journal articles (most I would have accessed from the internet). The problem is, is that they are in one of 12 boxes of files in my garage. My files were not handled with the care and time I would have liked to have taken when I was removed from my office. I do plan on organizing and sorting my files in the near future, but right now I need to find a job first. I have written this on my to do list, so I won't forget. It may be a month or so, though.
- Cam
Posted by Elizabeth on August 31, 2001, at 15:17:51
In reply to Re:Think About Maprotiline- forgotten multicyclic » SalArmy4me, posted by Cam W. on August 30, 2001, at 1:53:01
> I'll bite Sal, why then isn't Ludiomil one of the first line drugs for the treatment of depression? If it was so good, wouldn't it have a large market share?
There are obviously patent issues here (did anyone ever bother making generic maprotiline? I don't know). But Ludiomil isn't even a first- (or second-) choice TCA: nortriptyline and desipramine (and several others) are preferable in just about any situation. Maprotiline's main distinction is the increased risk of seizures.
-elizabeth
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.