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Duloxetine and Escitalopram for Hot Flushes: Efficacy and Compliance in Breast Cancer Survivors

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Duloxetine and Escitalopram for Hot Flushes: Efficacy and Compliance in Breast Cancer Survivors Original Article Duloxetine and escitalopram for hot flushes: efficacy and compliance in breast cancer survivors N. BIGLIA, MD, PHD, Gynaecology and Obstetrics Unit, Umberto I Hospital, Department of Surgical Sciences, University of Turin, Turin, V.E. BOUNOUS, MD, Gynaecology and Obstetrics Unit, Umberto I Hospital, Department of Surgical Sciences, University of Turin, Turin, T. SUSINI, MD, PHD, Breast Unit Department of Health Science, OB & GYN Section, AOU Careggi, School of Medicine, University of Florence, Florence, S. PECCHIO, MD, Gynaecology and Obstetrics Unit, Umberto I Hospital, Department of Surgical Sciences, University of Turin, Turin, L.G. SGRO, MD, PHD, Gynaecology and Obstetrics Unit, Umberto I Hospital, Department of Surgical Sciences, University of Turin, Turin, V. TUNINETTI, Gynaecology and Obstetrics Unit, Umberto I Hospital, Department of Surgical Sciences, University of Turin, Turin, & R. TORTA, MD, PHD, Psycho-Oncology Unit, Department of Neurosciences, University of Turin, Turin, Italy BIGLIA N., BOUNOUS V.E., SUSINI T., PECCHIO S., SGRO L.G., TUNINETTI V. & TORTA R. (2016) Euro- pean Journal of Cancer Care Duloxetine and escitalopram for hot flushes: efficacy and compliance in breast cancer survivors Selective serotonin reuptake inhibitors (SSRI) and serotonin–norepinephrine reuptake inhibitors (SNRI) might be an effective treatment for hot flushes (HFs) in breast cancer survivors (BCSs). This study aims to compare the efficacy and tolerability of duloxetine (SNRI) versus escitalopram (SSRI) in reducing frequency and severity of HFs in BCSs and to assess the effect on depression. Thirty-four symptomatic BCSs with emotional impairment received randomly duloxetine 60 mg daily or escitalopram 20 mg daily for 12 weeks. Patients were asked to record in a diary HF frequency and severity at baseline and after 4 and 12 weeks of treatment. Depression was evaluated through validated questionnaires (Beck Depression Inventory and Montgomery Asberg Depression Rating Scale) at baseline and after 4 and 12 weeks of treatment. Both drugs showed a significant reduction of HF frequency and severity after 12 weeks of treatment with no significant difference between the two groups. A significant improvement in depression symptoms was observed at the end of the study period within both the groups, without difference between the two drugs. In conclusion, escitalopram and duloxetine are both effective treatment for the relief of HFs in BCSs, with similar beneficial effect. A significant improvement of depression was obtained with no major side effects. Keywords: breast cancer, hot flushes, duloxetine, escitalopram, serotonin–norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors. ment in treatment. Every year, an increasing number of INTRODUCTION new cancers are diagnosed among women in reproduc- The number of breast cancer survivors (BCSs) is increas- tive age. The young women may experience premature ing over time, due to early detection and to improve- menopause, due to adjuvant chemotherapy and/or to ovarian suppression and menopausal symptoms are typi- cally more severe in young patients, due to the abrupt Correspondence address: Nicoletta Biglia, Department of Surgical Sciences, Gynaecology and Obstetrics Unit, “Umberto I” Hospital, Largo depletion of oestrogens (Knobf 2006). Despite the well- Turati 62, 10128 Turin, Italy (e-mail: [email protected]). established efficacy of adjuvant treatments, up to 20% Accepted 9 February 2016 of breast cancer patients consider stopping or actually DOI: 10.1111/ecc.12484 cease endocrine therapy because of menopausal symp- European Journal of Cancer Care, 2016 toms (Hickey et al. 2008). © 2016 John Wiley & Sons Ltd BIGLIA ET AL. Hot flushes (HFs) are the most frequently reported women. In healthy women, escitalopram has been shown menopausal symptom, affecting around 65% of BCSs to be superior to other SSRIs in terms of efficacy for HFs (Biglia et al. 2003; Antoine et al. 2008). Vasomotor symp- (Shams et al. 2014). toms (HFs and night sweats) are related to estradiol deple- Among SNRIs, previous studies on venlafaxine tion both in the serum and in the hypothalamic (Loprinzi et al. 2000; Biglia et al. 2005; Evans et al. 2005; temperature regulating centre. Furthermore, the alteration Carpenter et al. 2007; Boekhout et al. 2011) and its active of serotonergic and noradrenergic activity due to oestrogen metabolite O-desmethylvenlafaxine (Speroff et al. 2008; deprivation determines mood swings, depression or Archer et al. 2009; Pinkerton et al. 2013) demonstrated somatic complaints (Freedman 2001). HFs, as well as night their efficacy in reducing the number and intensity of sweats, may disrupt sleep, leading to loss of energy and HFs. Data from the few studies performed on duloxetine performance, contributing to mood depression and with a showed a benefit in reducing number and severity of HFs consequent negative impact on quality of life (Conde et al. (Joffe et al. 2007; Henry et al. 2011; Freeman et al. 2013). 2005; Gupta et al. 2006; Nappi & Kokot-Kierepa 2010). In a pilot study, duloxetine was effective in decreasing Furthermore, in BCSs, the awareness of having had cancer musculoskeletal symptoms in breast cancer patients trea- can determine emotional impairment. ted with aromatase inhibitors as well (Henry et al. 2011). Systemic oestrogen supplementation is the most effec- Although evidence supports SSRIs and SNRIs efficacy in tive strategy in reducing menopausal symptoms in reducing HFs (Carroll & Kelley 2009; Handley & Williams healthy women but unfortunately it is contraindicated in 2015), only paroxetine has been recently approved by the BCSs (International Menopause Society 2013; The North Food and Drug Administration (FDA) for the treatment of American Menopause Society (NAMS), 2012). The safety moderate-to-severe vasomotor symptoms associated with of systemic oestrogens in BCSs has been studied and dee- menopause (Orleans et al. 2014). ply debated. The Stockholm trial (Von Schoultz & Rutq- The majority of the studies evaluating the role of SSRIs vist 2005) was prematurely stopped in 2003 when the and SNRIs on vasomotor symptoms were performed on parallel HABITS trial (Holmberg & Anderson 2004) healthy women and only few of them were performed on a reported a higher recurrence rate in breast cancer patients population of BCSs (Loprinzi et al. 2000; Biglia et al. who received systemic oestrogens compared to women 2005; Carpenter et al. 2007; Boekhout et al. 2011; Henry treated with placebo. At 4 years of follow-up, the HABITS et al. 2011). study still found an increased risk of recurrence (Holmberg Furthermore, to the best of our knowledge, so far no et al. 2008), whereas a recent updated analysis of the data study was carried out comparing SSRIs and a SNRIs effi- from the Stockholm trial at 10.8 years of follow-up did not cacy on HF treatment, neither in the general population show any excess of recurrence risk (Fahlen et al. 2013). nor in women with breast cancer. In this study we com- An alternative compound to conventional oestrogen/ pared, as primary outcome, the efficacy of two antidepres- progestogen treatment, tibolone was tested versus placebo sant drugs, a SSRI (escitalopram) versus a SNRI in the LIBERATE trial, showing a significant superiority (duloxetine), in reducing the frequency and severity of to placebo in reducing vasomotor symptoms and improv- vasomotor symptoms in post-menopausal BCSs s with ing sleep quality, sexual behaviour, mood and attraction depressive mood and as secondary outcome we evaluated (Sismondi et al. 2011), but unfortunately also a significant the effect of these antidepressants on mood depression. increase in the recurrence rate (Kenemans et al. 2009). Open and controlled trials demonstrated that selective MATERIALS AND METHODS serotonin reuptake inhibitors (SSRIs), as well as selective serotonin–norepinephrine reuptake inhibitors (SNRIs) are Fifty-eight breast cancer patients with troublesome HFs effective non-hormonal alternatives for the treatment of (>20/week), emotional impairment and with no evidence vasomotor symptoms (Sassarini & Lumsden 2013; ACOG of disease attending the outpatient clinic for menopause 2014). symptoms entered the study. They were randomly allo- Among SSRIs, paroxetine (Stearns et al. 2003, 2005; cated to receive either duloxetine oral tablets (30 mg/day Soares et al. 2008; Simon et al. 2013), sertraline (Gordon in the morning during the first week and then 60 mg/day) et al. 2006), fluoxetine (Loprinzi et al. 2002), citalopram or escitalopram (10 mg/day in the morning for the first (Kalay et al. 2007; Barton et al. 2010) and escitalopram week and then 20 mg/day) for 12 weeks. (Soares et al. 2006; Defronzo Dobkin et al. 2009; Freeman The study design had been approved by the local ethic et al. 2011) have been studied, showing benefit in reduc- committee (approval number 0047015) and all patients ing the number and intensity of HFs in menopausal gave their written informed consent before participating. 2 © 2016 John Wiley & Sons Ltd Hot flushes in breast cancer survivors Patients were provided with a diary and asked to record ried out in order to compare the emotional assessments HF frequency and severity, at baseline (T0) (the first week (T0–T1–T2) (evaluated through MADRS and BDI score). without treatment), after 4 (T1) and 12 weeks (T2) of treat- Since data from literature show that placebo can deter- ment. In the HF diary, the patient recorded daily HF num- mine a reduction in HF frequency and score up to 40%, we ber and severity (mild, moderate, severe and very severe considered as effective a further reduction given by any of HFs). The HF score was calculated by scoring each individ- the two drugs on study. ual HF (one point for a mild HF, two points for a moderate Statistical significance was determined by using an HF, three points for a severe HF, and four points for a very alpha level of 0.05 and two-sided tests. severe HF). This type of questionnaire was already used and validated in previous trials enquiring about HFs (Sloan RESULTS et al. 2001). Furthermore, in the HF diary the patient had to record treatment related side effects.
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