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Q) What can you tell me about the newest antidepressant that recently became available in Canada?
A) The drug Fetzima (fet-ZEE-muh) entered the Canadian marketplace a few months ago.
Its active ingredient, levomilnacipran, is a modified version of a drug previously released years ago throughout Europe (for major depressive disorder and fibromyalgia) and the United States (where it only underwent the testing to get approval for treating fibromyalgia) called milnacipran.
Both drugs work by binding to serotonin and norepinephrine transporters thereby inhibiting their reuptake. This leaves both essential neurotransmitters available in greater quantities for the brain which we believe aids in the relief of many of the symptoms found in depression, fibromyalgia and quite possibly peripheral neuropathy although it has not been approved for this use as of yet.
Its mechanism of action makes it a SNRI (serotonin norepinephrine reuptake inhibitor) similar to previously released drugs such as Effexor (venlafaxine), Pristiq (desvenlafaxine) and Cymbalta (duloxetine).
These pre-existing drugs are amongst the world’s most heavily prescribed drugs and form the cornerstone of contemporary treatment of depression along with the class of drugs known as the selective serotonin reuptake inhibitors (SSRI’s such as Prozac and Paxil).
Where Fetzima may have an advantage (which is not to say that it does as it has not been studied head to head versus any of our commonly prescribed current treatments) is that it appears to be the drug that increases the amount of brain available norepinephrine to a far greater degree than the increase it induces in the amount of serotonin relative to any of the other available options.
What this actually means in clinical practice is unclear as we still do not fully understand just what roles these neurotransmitters actually play both in reversing the effects of depression and in causing some of the side effects that prove troublesome for the patients who rely on these medications to restore themselves.
All that being said, perhaps time will prove that there is a niche group of patients who are poorly served by their current treatments that may well respond favourably to the somewhat unique properties of Fetzima.
The drug is usually initiated at 20mg once a day for a couple of days and is then increased to 40mg daily which is a dose more likely to actually help. As is often the case with many drugs, this tapering up of the dose in two steps is done to minimize potential side effects such as nausea.
Most patients who do find that Fetzima benefits them will respond to the 40mg dose however for those who fail to find much help from it, the dose can be increased all the way up to 120mg (still taken just once a day).
For patients with some degree of kidney impairment, the maximum safe dose may be less than this. Like other antidepressants, the effects often take a few weeks to “kick in” so most practitioners will reassess its effectiveness and the need to possibly increase the dose at the 4 to 6 week mark.
The principal side effects seen during clinical trials include nausea, sweating, constipation, dizziness, nose bleeds and possible negative effects on male sexual function. About 1-3% of patients will experience a significant increase in blood pressure and 6% will report a significant increase in their pulse (heart rate).
Based on the results of three major studies, it appears to work about as well as most of its competitors however it may well work in some patients who have thus far failed to respond to similar drug treatments. As for its current place in treatment, it should probably be left as a back-up treatment option as its price at 40mg/ day is about $115 per month (compared to generic venlafaxine at $10/month, duloxetine at $30/month and Pristiq at $90/month) and we have a greater comfort level and experience with the pre-existing options.
While I don’t see Fetzima as anything close to a game changer in the treatment of depression, it is my firm hope that it will be a major difference maker in the lives of a couple of my patients who have yet to be lifted from the depths of suffering they continue to go through.
For more information about this or any other health related subjects, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination in Port Elgin and Kincardine.
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Thursday, September 01, 2016