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Drug Information Quarterly Whiskey & Taylor Pramipexole in treatment of depression drug information quarterly Psychiatric Bulletin (2004), 28,438^440 EROMONA WHISKEY AND DAVID TAYLOR Pramipexole in unipolar and bipolar depression AIMS AND METHOD RESULTS CLINICAL IMPLICATIONS To review the evidence for this use of There are limited data on the clinical use In view of the fact that the evidence pramipexole in the treatment of of pramipexole in affective disorders. for the use of pramipexole is still unipolar and bipolar depression, a Only two double-blind trials in bipolar limited at the time of writing, its literature search on Embase and depressionandoneinunipolardepression routine clinical use cannot be Medline was conducted in December were retrieved. Most information is in the recommended.The data appear 2003.The search was updated in July form of case reports and open studies. No promising, but further research is 2004.The reference sections of dose-response relationships have been required to determine its role in retrieved papers were searched for established and a wide range of doses has affective disorders. further relevant references. been employed in the reports. The monoamine hypothesis of depression has been the agonists (Maj & Rogoz, 1999; Renard et al,2001).In driving force behind antidepressant drug development for humans, the dopamine agonist bromocriptine has been several decades. The theory holds that lower levels of shown to be as effective as imipramine in the treatment serotonin, noradrenaline and dopamine may be involved of depression (Willner, 1983). For a review of dopamine in in the pathophysiology of depression. The place of sero- depression, see Willner (1995) and Rampello et al (2000). tonin and noradrenaline in the clinical development of Only a limited number of antidepressant drugs have depression is well established. Most currently available potent activity on dopaminergic transmission. Of the anti- antidepressants are thought to act via inhibition of the depressants currently in use in the UK, the tricycle anti- neuronal reuptake of either or both of these neuro- depressants only have a very weak effect on dopamine transmitters. reuptake, while venlafaxine and sertraline have more More recently, an increased interest in the role of substantial, but stilllimited, dopaminergic effects, albeit at dopamine in the aetiology of depression has developed. higher doses. Bupropion, amineptine and nomifensine are This interest derives in part from the dopamine hypoth- dopaminergic antidepressants that act partly via inhibition esis of reward. In simple terms, pleasurable activity is of dopamine reuptake. Bupropion is licensed in the UK only associated with release of dopamine in the brain reward for smoking cessation. Amineptine has been withdrawn system (BRS). Conversely, inactivation of dopamine func- from major markets because of its propensity for addiction, tion can lead to anhedonia, the inability to experience while nomifensine, a selective dopamine reuptake inhibitor, pleasure, which is a core feature of depression. Further- was withdrawn due to the risk of acute haemolytic anaemia more, psychostimulants such as amphetamine and cocaine and intravascular hemolysis.There is no dopamine agonist in low doses enhance dopamine release and cause activa- currently licensed for the treatment of depression. tion and euphoria in normal volunteers. In higher doses or Pramipexole is a recently introduced dopamine when taken repeatedly, they cause grandiosity, dysphoria D2/D3 agonist with preferential binding affinity to D3 and delusions. The withdrawal of these drugs frequently receptors. It was licensed in the UK in 1998 at doses results in depression and anhedonia. ranging from 0.375 to 4.5 mg per day for idiopathic Data from animal studies and from limited human Parkinson’s disease. data indicate that dopamine agonists have antidepressant We conducted a literature search in December 2003 properties. The forced swimming test is one of the on Medline (1966^2003) and Embase (1980^2003) using methods used to screen for antidepressant activity. When the terms ‘pramipexole’,‘dopamine agonists’,‘bipolar rats are forced to swim in a closed space from which they disorder’ and ‘depression’.The search was updated in July cannot escape, they will eventually stop attempting to 2004. The reference section of retrieved papers were escape and become immobile. Time to immobility in the hand-searched for further relevant references. swim test may be prolonged not only by antidepressants, but also by dopamine agonists. Furthermore, the anti- Results immobility effect of antidepressants in the forced swim Table 1, below, shows the details of papers retrieved test may be enhanced by co-administration of dopamine from the literature searches. 438 Table 1. Papers retrieved in the literature search Duration of No PPX Assessment Study N Study design Patient characteristics Dose of PPX treatment completers Main adverse effects of efficacy Comments Goldberg et Tot al 22 Double-blind, Refractory bipolar 1to2.5mg 6 weeks 10/12 Nausea, sedation, PPX-67% Only 2 patients on PPX experienced al,2004 PPX 12 Placebo-controlled depression target dose headache, 1 case of PLA-20% remission in 6 weeks. Patients allo- PLA 10 Adjunctive PPX or (up to 5 mg hypomania (550% cated to PPX and PLA may be PLA to mood stabilisers if needed) # in HAMD) dissimilar Zarate et al, Tot al 21 Double-blind, Placebo- Depression in 1-3mg/day 6 weeks 9/10 Insomnia, nausea, PPX-60% Flaws in the design and 2004 PPX 10 controlled. Adjunctive PPX Bipolar II target dose vomiting, tremor, PLA-9% methodology PLA 11 or PLA to lithium or (up to agitation, somnolence (550% # in MADRS) valproate 4.5 mg max) Rektorova¤et Tot al 41 Prospective, Patients with mild to 1.5 to 8 months 19/22 Sleep disturbance, PPX-44% No evaluation of acute antidepres- al,2003 PPX 22 randomised trial moderate depression 4.5 mg/day dyskinesias, nausea, PRG-18.7% sant effect. Patients in the PPX group PRG 19 comparing PPX and PRG. and advanced PD ortostatic hypo- (550% # in MADRS) had higher baseline MADRS scores Adjunctive DA tension and to L-dopa hallucinations Ostow, 2002 22 patients Open series. PPX alone Mixed group of 0.5 to 51 month N/A Nausea, sedation, 13 patients with Letter in Am J Psych. Tolerance to or as adjunct to anti- patients including, 4.5 mg/day to alertness marked improve- therapeutic effects noted, requiring depressants or mood depressed, bipolar 46 months ments. No objective dose increase stabilisers and borderline measures 439 personality disorder Lattanz et al, 37 patients Naturalistic, open label Refractory depres- 0.375 to 16 weeks 19/37 Dysphoria, psycho- 68% response (21/31 High drop out rate. Alterations in 2002 series. Adjunctive PPX to sion. 21 bipolar and 1mg/day motor agitation, pts with 450% drug treatment and ECT during study. antidepressants and mood 16 unipolar patients hypotension and # in MADRS) No difference between bipolar and stabilisers tremor unipolar Perugi et al, 18 pa- Open study, chart Refractory bipolar II 0.75 mg to 4-34 weeks 17/18 GI disturbance, Overall response rate 5/18 (27.8%) patients had transient 2001 tients, PPX review of adjunctive PPX depression 1.5 mg/day (mean 17.6 agitation, irritability, 44.4%. PPX (4/10), response 10 or RPN (mean weeks) headache. 1 case of RPN (4/8) 50% RPN 8 1.23 mg) hypomania Sporr et al, 32 patients Retrospective chart Refractory depres- 0.125 to 24.4 weeks 20/32 Tremor, sedation, 44% overall. 50% Retrospective uncontrolled 2000 review. Adjunctive PPX sion. 12 patients 2mg/day irritability. 1 case of (6/12) bipolar, 40% treatment with bipolar and 20 (mean hypomania (8/20) unipolar unipolar depression 0.7 mg) (Scale CGI-1) Corrigan et Tot al 174 Placebo run in, double- Depression excluding 0.375 mg, 8 weeks 65/104 Headache, nausea, % response on ITT PPX 1mg significantly superior to al,2000 PPX 104 blind, placebo controlled bipolar and refractory 1mg, and somnolence, dizziness analysis. PPX: placebo at 8 weeks. Industry- FLU 35, study, comparing 3 fixed depression 5mg/day and insomnia 0.375 mg 741.7 %; sponsored study. Many missing PLA 35 doses of PPX and fluoxe- 1mg 737.1%; 5 mg data. Difficult to draw any firm tine with placebo 733.3%. Pla-25.7% conclusions. Flu-48.6% Whiskey & Taylor Golberg et 3 patients Case reports. Adjunctive 1 case of refractory 0.75 mg to 6weeksto N/A Nausea 3/3. Much improved Improved sleep and restless legs in 1 al,1999; PPX depression, 2 cases of 1.5 mg/day 6 months patient DeBattista et refractory bipolar al,2000 depression Szegedi et 26 patients Open label, monotherapy Unipolar depression 1.75 mg to 28 days 21/26 Agitation, nausea CGI global-50% (13/ Only 23% achieved 50% reduction in al,1997 6.25 mg/day insomnia, postural 26); HAMD (6/26) HAMD Pramipexole in treatment of depression hypotension PPX - Pramipexole; PRG - Pergolide; RPN - Ropinizole; FLU - Fluoxetine, PLA - Placebo; PD - Parkinson’s disease, CGI - Clinical Global Impression, HAMD - Hamilton’s Depression Rating Scale; MADRS - Montgomery^Asberg Depression Rating Scale. information quarterly drug Whiskey & Taylor Pramipexole in treatment of depression Discussion depressive illness. At least four cases of hypomania have been reported with pramipexole (Sporr et al, 2000; Perugi drug The majority of the data relating to the use of pramipexole et al, 2001; Goldberg et al,2004;Zarateet al,2004). information in affective illness are in the form of chart reviews, natura- quarterly listic, open studies or case reports (Table 1). Only one double-blind controlled trial has been published in patients Conclusion with unipolar depression (Corrigan et al,2000).Thistrial Data on the efficacy of pramipexole are still very limited. compared three fixed doses of pramipexole with fluoxetine There is possibly a subgroup of patients who may respond and placebo. Both pramipexole 1mg and fluoxetine 20 mg preferentially to dopaminergic agents.
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