Postgraduate corner: Continuing medical education: Psychopharmacology

Byline: Chittaranjan. Andrade CME Questions A) Fibromyalgia is a poorly understod syndrome that is characterized by chronic, widespread musculoskeletal and joint pain. There are often multiple tender nodules present in specific anatomical loci, such as over the shoulders and back. Common accompanying symptoms include stiffness, fatigue, mood disturbance, and insomnia. Affected patients suffer from pain-related disability and impaired functioning in everyday life. With this background, mark True or False against each of the following statements: *Escitalopram is an approved treatment for fibromyalgia. *Duloxetine 120mg/day is more effective than duloxetine 60mg/day in the treatment of fibromyalgia. *An adequate trial of duloxetine for fibromyalgia should last at least 4-6 months. *In addition to attenuating measures of pain, duloxetine improves functional outcomes in fibromyalgia. *Fibromyalgia treatments have demonstrated efficacy in long-term as well as short-term management. B) Tamoxifen is prescribed for various indications to women with estrogen receptor-positive breast cancer. These women may require antidepressant medication for concurrent depression; or for the treatment of hot flushes and other symptoms of artificial menopause. With this background, mark True or False against each of the following statements: *Tamoxifen is metabolized by CYP3A4. *Mirtazapine should be preferred to duloxetine over depressed women who are receiving tamoxifen. C) Benzodiazepines have anxiolytic and anticonvulsant properties and are cross-tolerant with alcohol. They are therefore prescribed during alcohol withdrawal to reduce the severity of the withdrawal syndrome and to reduce the risk of withdrawal seizures. Diazepam and chlordiazepoxide are traditionally preferred for this indication because both have long half-lives of approximately 1-2 days, each; their levels in blood therefore tend to remain uniform across the course of the day, and drug withdrawal difficulties are fewer. However, they are metabolized by demethylation and hydroxylation and have active metabolites; as a result of these pharmacokinetic properties, they may accumulate, and mask or even precipitate hepatic encephalopathy in patients with alcoholic liver disease. With this background, mark True or False against each of the following statements: *For important theoretical reasons, if alcoholic liver disease is present or suspected, lorazepam should be avoided in patients who are being withdrawn from alcohol. *Clinical data exist to suggest that lorazepam may be effective in the management of uncomplicated alcohol withdrawal. View Answer CME Answers A) Fibromyalgia Answers: 1. False; 2. False; 3. False. 4. True; 5. True. *Citalopram appears ineffective in patients with fibromyalgia[sup] [1],[2] and, to judge from a PubMed search conducted on June 14, 2009, escitalopram has not been studied for this indication. Pregabalin,[sup] [3],[4] duloxetine[sup] [5],[6] and milnacipran[sup] [7],[8] are USA Food and Drug Administration-approved treatments for fibromyalgia. However, as serotonergic and noradrenergic mechanisms have both been described to mediate pain relief,[sup] [9] it is likely that most antidepressants, especially dual-acting drugs such as the tricyclic antidepressants, could be effective treatments for fibromyalgia. In other words, antidepressant efficacy against fibromyalgia could be a class action. *Short-term, randomized, double-blind, placebo-controlled clinical trials of duloxetine (60 or 120mg/day) in patients with fibromyalgia found that the 120mg/day dose was not better than the 60mg/day dose. [sup] [10],[11] A 1-year randomized controlled study also found no advantage with the higher dose. [sup] [12] For the majority of patients, therefore, 60mg/day is likely an adequate dose; whereas some patients may indeed require a higher dose, it should be kept in mind that the higher dose could increase the adverse effect burden. …