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Levomilnacipran for the Treatment of Major Depressive Disorder

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Levomilnacipran for the Treatment of Major Depressive Disorder Out of the Pipeline Levomilnacipran for the treatment of major depressive disorder Matthew Macaluso, DO, Hala Kazanchi, MD, and Vikram Malhotra, MD An SNRI with n July 2013, the FDA approved levomil- Table 1 once-daily dosing, nacipran for the treatment of major de- Levomilnacipran: Fast facts levomilnacipran pressive disorder (MDD) in adults.1 It is I Brand name: Fetzima decreased core available in a once-daily, extended-release formulation (Table 1).1 The drug is the fifth Class: Serotonin-norepinephrine reuptake symptoms of inhibitor serotonin-norepinephrine reuptake inhibi- MDD and was well Indication: Treatment of major depressive tor (SNRI) to be sold in the United States disorder in adults tolerated in clinical and the fourth to receive FDA approval for FDA approval date: July 26, 2013 trials treating MDD. Availability date: Fourth quarter of 2013 Levomilnacipran is believed to be the Manufacturer: Forest Pharmaceuticals more active enantiomer of milnacipran, Dosage forms: Extended–release capsules in which has been available in Europe for 20 mg, 40 mg, 80 mg, and 120 mg strengths years and was approved by the FDA in Recommended dosage: 40 mg to 120 mg 2009 for treating fibromyalgia. Efficacy of capsule once daily with or without food levomilnacipran for treating patients with Source: Reference 1 MDD was established in three 8-week ran- domized controlled trials (RCTs).1 cial and occupational functioning in addi- Clinical implications tion to improvement in the core symptoms Levomilnacipran is indicated for treating of depression.5 MDD in adults and is unique compared Levomilnacipran is the more active en- with other SNRIs because it is relatively antiomer of milnacipran, an SNRI that is more selective for norepinephrine reuptake approved for treating fibromyalgia in the inhibition (NRI) compared with serotonin United States and approved for treating reuptake inhibition (SRI).1 In vitro stud- depression in many other countries.6 In ies demonstrate that the drug has >10-fold general, enantiomeric formulations are greater selectivity for norepinephrine reup- believed to have advantages over racemic take inhibition than it does for serotonin formulations because they are less com- reuptake inhibition, compared with dulox- etine or venlafaxine.2 Dr. Macaluso is Assistant Professor, Director of Research and Associate This difference in selectivity could Director of Residency Training, and Drs. Kazanchi and Malhotra are Senior Residents, University of Kansas School of Medicine-Wichita, lend itself to treating symptoms of MDD Wichita, Kansas. that might be related to norepinephrine Disclosures deficiency; these include decreased con- Dr. Macaluso has been the principal investigator in clinical trials for AbbVie, Eisai, Envivo, Janssen, Naurex, and Pfizer. All clinical trial centration, lassitude, mental and physical and study contracts and payments were made through the Kansas slowing, and decreased self-care.3,4 Some University Medical Center Research Institute. Drs. Kazanchi and Malhotra report no financial relationship with any company whose authors claim that individual patients Current Psychiatry products are mentioned in this article or with manufacturers of 50 December 2013 could experience improvement in their so- competing products. Out of the Pipeline plex and have a more selective pharmaco- it susceptible to DDIs with drugs that in- dynamic profile, better therapeutic index, hibit or induce this enzyme. For example, lower liability for drug-drug interactions a person taking levomilnacipran with a (DDIs), and a less complicated relation- potent CYP3A4 inhibitor, such as keto- ship between plasma concentration and conazole, may require a dosage adjust- pharmacodynamic effect.6 In addition, ment. No dosage adjustment is needed regulatory guidelines in the United States when given with a CYP3A4 inducer or recommend development of enantiomers substrate. Drinking alcohol with levomil- over racemates where appropriate.7 nacipran may cause more rapid release of the drug into the blood stream.1 How it works Levomilnacipran’s exact mechanism of ac- Efficacy tion is unknown. Similar to other SNRIs, Levomilnacipran decreased core symp- it binds with high affinity to the serotonin toms of MDD and showed a statistically Clinical Point (5-HT) and norepinephrine (NE) trans- significant separation from placebo in 2 Levomilnacipran is porters and potently inhibits 5-HT and NE phase III RCTs (Table 2, page 54).3,5 The first reuptake. Levomilnacipran lacks signifi- study was a 10-week flexible dose (75 or suitable for once-daily cant affinity for any other receptors, ion 100 mg) trial in 563 outpatients age 18 to dosing; maximum channels, or transporters tested in vitro.2 70 who met DSM-IV-TR criteria of MDD plasma concentration It differs from other SNRIs such as ven- for >1 month and had a 17-item Hamilton is 6 to 8 hours, and lafaxine and duloxetine in having higher Depression Rating Scale (HDRS-17) score the drug has a half-life selectivity for norepinephrine vs serotonin >22 and a Sheehan Disability Scale (SDS) reuptake inhibition. In vitro studies dem- score >10.3 The primary efficacy mea- of 12 hours onstrated a 2-fold preference for NE over sure was change in Montgomery-Åsberg 5-HT reuptake inhibition.2 Depression Rating Scale (MADRS) score from baseline to week 10. Secondary ef- Pharmacokinetics ficacy measures included the HDRS-17, Levomilnacipran reaches maximum plas- SDS, and Clinical Global Impressions- ma concentration within 6 to 8 hours of improvement scale. Efficacy analyses in- oral administration and has a half-life of cluded 276 subjects treated with levomil- approximately 12 hours, which makes it nacipran and 277 treated with placebo.3 suitable for once-daily dosing. The concen- Levomilnacipran was significant- tration of levomilnacipran at steady state ly superior to placebo on the MADRS is proportional to the dosage of the drug and HDRS-17 from baseline to week when administered within the range of 25 10. Response and remission rates were to 300 mg once daily.1 significantly greater for the levomil- The drug’s mean apparent total clear- nacipran group compared with pla- ance is 21 to 29 liters/hour and its bioavail- cebo. Response exceeded the 10% aver- ability is not significantly affected when age advantage for drug vs placebo and taken with food. The drug is widely dis- 46% of levomilnacipran-treated patients tributed in the body and is converted pri- achieved remission.3 marily to 2 metabolites: desethyl levomil- The number needed to treat (NNT), nacipran and p-hydroxy-levomilnacipran. based on the MADRS scores for the levo- Discuss this article at Both metabolites are inactive and undergo milnacipran group compared with the pla- www.facebook.com/ CurrentPsychiatry further conjugation with glucuronide. cebo group, was 6 for response and 5 for The drug is eliminated primarily via renal remission.3 By comparison, most studies of excretion.1 venlafaxine demonstrate a NNT of 8.3 The major enzyme that catalyzes me- Levomilnacipran generally was report- tabolism of levomilnacipram is cyto- ed to be safe and well tolerated. The most Current Psychiatry chrome P 450 (CYP) 3A4, which makes common adverse events leading to discon- Vol. 12, No. 12 51 Out of the Pipeline tinuation in the levomilnacipran group the number of patients reporting adverse were nausea, vomiting, change in systolic events and who discontinued participa- and diastolic blood pressure, and increase tion because of adverse events was higher in heart rate. The favorable tolerability in the 80-mg group than in the 40-mg and profile of levomilnacipran may relate to 120-mg groups.5 the 2-fold greater potency for NE reuptake inhibition compared with 5-HT reuptake Tolerability inhibition.3 Overall, levomilnacipran was well toler- The second study was an 11-week, ated in clinical trials, during which 2,673 fixed-dose trial of levomilnacipran using subjects were exposed to the drug— 40, 80, or 120 mg. A total of 724 outpatients translating to 942 patient-years of expo- age 18 to 65 who met DSM-IV-TR criteria sure. These patients ranged in age from for MDD and who had an ongoing episode 18 to 78; 825 of these subjects were enrolled Clinical Point of depression lasting >8 weeks were ran- in long-term studies for 1 year. Dosing of Levomilnacipran domly assigned to receive placebo (n = 179) levomilnacipran during these studies or levomilnacipran at 40 mg (n = 181), ranged from 40 to 120 mg once daily, with- was well tolerated 80 mg (n = 181), or 120 mg (n = 183) once out regard to food.1 in clinical trials; 9% daily for 8 weeks of double-blind treat- Nine percent of patients who received of patients who ment followed by a 2-week, double-blind levomilnacipran in short-term studies dis- received the drug taper of the drug.5 The primary efficacy continued because of adverse events, com- parameter was change from baseline on pared with 3% of patients who received discontinued because the MADRS and the secondary efficacy placebo. The most common adverse event of adverse events parameter was change from baseline in reported was nausea; other common ad- SDS total score. HDRS-17, CGI-I, and verse events reported included constipa- CGI-S were included as secondary out- tion, hyperhidrosis, elevated heart rate, come measures.5 erectile dysfunction, tachycardia, palpita- Significant difference in MADRS total tions, and vomiting. Of these events, only score were seen in the levomilnacipran erectile dysfunction and urinary hesita- group compared with the placebo group tion were dose-related.1 Among levo- (least mean squared difference: 40 mg/d, milnacipran-treated female patients, <2% −3.23; 80 mg/d, −3.99; and 120 mg/d, reported adverse events related to sexual −4.86). Higher dosages produced a numer- dysfunction. ically greater change and significant sepa- All SNRIs have well established associa- ration from placebo occurred sooner in the tions with elevation in blood pressure and 80-mg and 120-mg groups compared with heart rate.
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