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- Use of ultra-low-dose (≤6 mg) doxepin for treatment of insomnia in older people. [Journal Article, Review]
- Can Pharm J (Ott) 2014 Sep; 147(5):281-9.
Insomnia is one of the most frequent complaints encountered in primary care practice, one that results in significant clinical consequences and cost burden to the public health system. It is more common in elderly adults (≥65 years of age), with frequent complaints regarding sleep maintenance and early morning wakening. Current treatment options have limitations. This review was conducted to evaluate the evidence behind ultra-low-dose doxepin in insomnia and to discuss its potential advantages, its place in therapy and its implications in practice in the treatment of older patients.A systematic literature search was conducted of MEDLINE via Ovid, PubMed and EMBASE using the MeSH and key terms "doxepin," "sleep initiation and maintenance disorders," "insomnia," and "low dose." Only randomized controlled trials comparing 3 mg and/or 6 mg of doxepin to placebo and involving participants diagnosed with primary insomnia were included. Primary outcomes for this review were objective sleep study parameters.Five studies were identified, 3 of which (n = 571) were conducted in older adults. Doxepin 3 mg and 6 mg significantly reduced waking after sleep onset and increased total sleep time. There was no significant difference between the 2 doses of doxepin. Latency to persistent sleep did not differ significantly compared with placebo for any doses of doxepin. The most frequent adverse events reported were somnolence and headache. Adverse events did not appear to be dose-related, and studies reported the incidence of adverse effects to be comparable to placebo.Doxepin 3 mg and 6 mg significantly improved and sustained sleep maintenance and sleep duration into the last third of the night but did not significantly affect sleep onset. Sleep benefits were achieved without next-day residual or discontinuation effects. Doxepin appears to be well suited for managing insomnia in older people.
- [Rapid screening and confirmation of antidepressants in blood using automated solid phase extraction and liquid chromatography-time-of-flight mass spectrometry]. [English Abstract, Journal Article]
- Se Pu 2014 Jul; 32(7):687-92.
A high-throughput method was developed for screening antidepressants in blood by automated solid phase extraction and liquid chromatography with high resolution quadrupole-time-of-flight mass spectrometry (ASPE-LC-Q-TOF/MS). The samples were cleaned up by an HLB solid phase extraction cartridge and analyzed by LC-Q-TOF/MS under electrospray ionization (ESI) mode with scanning range of m/z 50-1 000 Da. The chromatographic separation was performed on an Agilent Eclipse Plus C18 column (50 mm x 2.1 mm, 1.8 microm) with gradient elution using methanol and 5 mmol/L ammonium formate aqueous solution (containing 0.2% formic acid) as mobile phases. Rapid screening and confirmation can be achieved using MS matching scores, deviation of retention time, measured mass, isotopic abundance matching scores, isotope space matching scores and MS/MS matching scores. The quantitative analysis was carried out by correlating the extracting peak area with accurate mass. Good linearities were observed in the range of 1 - 500 microg/L with the correlation coefficients from 0.997 6 to 0.999 7. The limits of detection were 0.01-0.5 microg/L. The spiked recoveries were 79.6%-96.4% with the relative standard deviations of 4.1% - 6.4%. The result screening database was built using Agilent MassHunter PCDL Manager software and then used for the analysis of spiked samples. MS matching scores, isotopic abundance matching scores, isotope space matching scores (all > 95 points) and MS/MS matching scores (> 70 points) were applied to identify the analytes. The results showed that all the spiked antidepressants could be correctly identified with low deviation of retention time (< 0.1 min) and mass (< 1 mDa). The developed method was further applied for the analysis of poisoning cases, and amitriptyline, carbamazepine, doxepin were detected. In brief, the method is rapid, sensitive, simple, reliable, and suitable for the screening and confirmation of antidepressants in forensic and clinical analytical toxicology.
- Drug Treatment of Primary Insomnia: A Meta-Analysis of Polysomnographic Randomized Controlled Trials. [JOURNAL ARTICLE]
- CNS Drugs 2014 Aug 29.
Although insomnia is a frequent health complaint that is often treated with drugs, little is known about differences in treatment efficacy of various drug classes on objective versus subjective outcome measures.Our aim was to compare treatment efficacy of classical benzodiazepines, benzodiazepine receptor agonists (zopiclone, zolpidem and zaleplon), antidepressants (including low-dose doxepin), neuropeptides, progesterone receptor antagonists, hormones, melatonin receptor agonists, antihistamines, antiepileptics, and narcotics addressing primary insomnia.We conducted a comprehensive literature search (up to 5 April 2013) using PubMed, Cochrane Clinical Trials, PQDT OPEN, OpenGREY, ISI Web of Knowledge, PsycINFO, PSYNDEX, and the WHO International Clinical Trials Registry Platform.Only polysomnographic, parallel-group, randomized controlled drug trials were included; eligibility was determined by two independent authors.We used a random effects model, based on 31 studies reporting 80 treatment conditions, covering 3,820 participants.Effect size estimates for the total sample of pooled drug classes suggest that there is a small-to-moderate, significant, and robust effect for objective outcomes (sleep onset latency g = -0.36, total sleep time g = 0.27) and subjective outcomes (sleep onset latency g = -0.24, total sleep time g = 0.21). Results indicate higher effect sizes for benzodiazepine receptor agonists and classical benzodiazepines compared with antidepressants (including low-dose doxepin) and for classical benzodiazepines compared with benzodiazepine receptor agonists. Benzodiazepine receptor agonists demonstrated higher effect sizes for objective outcomes.Data on drug safety were not analyzed.Future studies should use objective and subjective assessment. Focusing on efficacy, clinicians should favor benzodiazepine receptor agonists and classical benzodiazepines over antidepressants (including low-dose doxepin) for primary insomnia treatment, but the additional consideration of different side effect profiles can lead to alternative treatment decisions.
- Doxepin for insomnia: A systematic review of randomized placebo-controlled trials. [REVIEW]
- Sleep Med Rev 2014 Jun 19.
Doxepin, a sedating tricyclic drug, at 3 mg and 6 mg doses was recently approved by the U.S. food and drug administration (FDA) for the treatment of insomnia. The objective of this systematic review was to obtain a precise summary of the efficacy and safety of doxepin as a hypnotic. We searched key databases and trial registers up to March 2014 and contacted pharmaceutical companies and the FDA for unpublished data. A total of nine randomized placebo-controlled trials were analyzed. Six studies were on doxepin 1-6 mg/d, two on doxepin 25-300 mg/d, and one on ramelteon 8 mg and doxepin 3 mg combined. All low-dose studies were industry-sponsored. We found that low-dose doxepin had a small to medium effect size against placebo for sleep maintenance and sleep duration but not for sleep initiation at both immediate and short-term posttreatment. There was no significant next-day residual effect with low-dose doxepin. Headache and somnolence were the most common side effects. We concluded that low-dose doxepin for 1-2 nights appeared to be safe and effective in improving sleep. However, a clear conclusion on its short-term benefits and risks as well as withdrawal effects was not possible due to the small number of studies.
- Topical treatments of skin pain: a general review with a focus on hidradenitis suppurativa with topical agents. [JOURNAL ARTICLE]
- Dermatol Online J 2014; 20(7)
Hidradenitis Supprurativa (HS) is a painful chronic follicular disease. Few papers have addressed pain control for this debilitating condition. Possible topical agents include tricyclic antidepressants, opioids, anticonvulsants, NSAIDs, NMDA receptor antagonists, local anesthetics and other agents. The first line agents for the topical treatment of the cutaneous pain of HS are diclonefac gel 1% and liposomal xylocaine 4% and 5% cream or 5% ointment. The chief advantage of topical xylocaine is that is quick acting i.e. immediate however with a limited duration of effect 1-2 hours. The use of topical ketamine, which blocks n-methyl-D-aspartate receptors in a non-competitive fashion, might be a useful tool for the treatment of HS pain. Topical doxepin, which available in a 5% commercially preparation (Zonalon®) , makes patients drowsy and is not useful for controlling the pain of HS . Doxepin is available in a 3% or 3.3% concentration (which causes less drowsiness) from compounding pharmacies and can be used in compounded analgesic preparations with positive effect. Topical doxepin is preferred over use of topical amitriptyline because topical doxepin is more effective. Nevertheless, topical amitriptyline increase of the tactile and mechanical nociceptive thresholds and can be used for topical pain control in compound mixture of analgesics . Gabapentin and pregablin can also be used compounded with other agents in topical analgesic preparations with positive topical anesthetic effect. Capsaicin is not useful for topical treatment of the pain of HS. Sometimes compounded of anesthetics medications such as ketamine 10%, bupivacaine 1%, diclofenac 3%, doxepin 3% or 3.3%, and gabapentin 6% can extend the duration of effect so that medication only needs to be used 2 or 3 times a day. Still in my experience the easiest to get and most patient requested agent is topical diclonefac 1% gel.
- Eosinophilic folliculitis occurring after stem cell transplant for acute lymphoblastic leukemia: a case report and review. [JOURNAL ARTICLE]
- Int J Dermatol 2014 Jul 11.
Eosinophilic folliculitis (EF) comprises classic eosinophilic pustular folliculitis (EPF), human immunodeficiency virus (HIV)-related EF, and infantile EPF subtypes. A fourth proposed subtype describes EF associated with hematologic malignancy. Recently, EF has occurred after bone marrow or stem cell transplantation (SCT).We report a unique case of EF after haploidentical allogeneic SCT for acute lymphoblastic leukemia (ALL) and review the literature for similar cases.A 56-year-old, HIV-negative ALL patient presented with an intensely pruritic papulopustular eruption. He had undergone haploidentical allogeneic SCT 65 days earlier, which he had tolerated well. Histopathology revealed a moderately dense perifollicular and perivascular lymphocytic infiltrate with many eosinophils extending from the superficial dermis to the subcutaneous fat. Fungal stains were negative. These findings were highly consistent with EF.Therapy with a class II topical corticosteroid ointment, oral doxepin, and emollients achieved near-resolution of the lesions within eight weeks. Transition to topical tacrolimus 0.1% ointment applied twice daily to residual lesions yielded complete clearance by 12 weeks with mild post-inflammatory hyperpigmentation. The patient's ALL remains in remission.A fourth proposed subtype of EF is associated with HIV-negative hematologic disease. This subtype is distinguished by a predictable timeframe to presentation and a relatively rapid response to therapy. Although EF is an important consideration in all patients with hematologic malignancy, clinically heightened suspicion is warranted during the 2-3 months after transplant.
- Formulation and evaluation of thermosensitive biogels for nose to brain delivery of doxepin. [Journal Article]
- Biomed Res Int 2014.:847547.
Thermoreversible biogels can serve as effective systems for delivery of drugs through nose with increased nasal residence time. The objective of this study was to use chitosan and glycerophosphate based thermoreversible systems for delivery of doxepin to brain through intranasal administration. Formulations were prepared by admixture of suitable dilutions of chitosan and glycerophosphate with or without polyethylene glycol, followed by addition of the antidepressant doxepin hydrochloride. Both systems were evaluated for gelling characteristics, rheology, mucoadhesion, in vitro release, and ex vivo permeation through sheep nasal mucosa. In vivo efficacy was evaluated in Swiss albino mice through the forced swim test. Nasal tissues of mice subjected to repeated exposure to formulation were evaluated histopathologically. Both formulations gelled rapidly at 37°C, returned to sol state on cooling, and exhibited thixotropy. Addition of polyethylene glycol decreased the glycerophosphate content required for gelation and rendered the formulation isotonic. Both gels showed good mucoadhesion, enhanced drug permeation, and provided prolonged in vitro release at 37°C. Efficacy of the formulation in treated groups was inferred from the measured pharmacodynamic parameter and histopathological reports of formulation treated groups showed no significant local toxicity. The biogels could be potential systems for effective drug delivery to brain via nose.
- Efficacy and safety of low-dose doxepin in depressed patients suffering from insomnia: a retrospective, naturalistic case series analysis. [Journal Article]
- Prim Care Companion CNS Disord 2014; 16(1)
Objective:Low-dose doxepin has produced favorable results in healthy adults and elderly persons with chronic or transient insomnia, while exhibiting an amenable adverse event profile. The aim of this article is to investigate the efficacy and safety of low-dose doxepin for insomnia in depressed patients. Method: In this retrospective case series analysis, the files of 17 inpatients diagnosed with major depressive disorder (MDD) and comorbid insomnia between January 1, 2011, and October 1, 2012 who had received a course of off-label doxepin (< 25 mg/d) were analyzed with regard to dose, efficacy, and safety for up to 4 weeks of treatment. Hamilton Depression Rating Scale (HDRS) sleep item scores were used to estimate efficacy.
Results:Our results showed no improvement in sleep onset and sleep maintenance insomnia in patients with MDD during the 4 weeks of treatment. We found a significant improvement in insomnia between baseline and week 3 when considering all 3 HDRS sleep items (P = .058).
Conclusion:Contrasting previous results in healthy subjects, low-dose doxepin does not seem to improve sleep onset or maintenance in patients with MDD. Further research, preferably placebo-controlled, double-blind sleep laboratory trials, is necessary to determine whether low-dose doxepin may be beneficial in this important patient subgroup.
- Analgesic effects of antidepressants alone and after their local co-administration with morphine in a rat model of neuropathic pain. [JOURNAL ARTICLE]
- Pharmacol Rep 2014 Jun; 66(3):459-465.
The therapy of neuropathic pain may include the use of co-analgesics, such as antidepressants, however, their desired analgesic effect is associated with significant side effects. An alternative approach to this is their local administration which has been proposed, but there is little data regarding their local co-administration with morphine and the nature of the interaction between morphine and either doxepin or venlafaxine, two antidepressant drugs that have been recently used in neuropathic pain therapies.This study was performed on rats after chronic constriction injury (CCI) to the sciatic nerve. The von Frey and Hargreaves' tests were used to assess mechanical allodynia and thermal hyperalgesia, respectively, after intraplantar (ipl) or subcutaneous (sc) administration of amitriptyline, doxepin, or venlafaxine, or their ipl co-administration with morphine on day 12-16 after injury.The ipl administration of amitriptyline (3, 15mg), doxepin (1, 5, 10, 15mg), or venlafaxine (2, 7mg) was effective in antagonizing CCI-induced allodynia. Their sc injection at a site distal to the injured side, did not induce alterations in pain thresholds, which supports the local mode of action. Of the three antidepressants used in this study, only ipl co-administration of amitriptyline with morphine significantly enhanced its effect in contrast to doxepin and venlafaxine, both of which weakened the analgesic effect of morphine.In summary, the results suggest that when amitriptyline (but not doxepin or venlafaxine) is locally co-administered with morphine the effectiveness under neuropathic pain is enhanced, although additional studies are necessary to explain differential mechanisms of interaction of antidepressant drugs with morphine after local administration.
- Bilastine vs. Hydroxyzine: Occupation of Brain Histamine H1 Receptors Evaluated by Positron Emission Tomography in Healthy Volunteers. [JOURNAL ARTICLE]
- Br J Clin Pharmacol 2014 May 15.
A close correlation exists between positron emission tomography (PET)-determined histamine H1 -receptor occupancy (H1 RO) and the incidence of sedation. Antihistamines with H1 RO <20% are classified as nonsedating. The objective was to measure H1 RO of bilastine, a new second-generation antihistamine, compared with that of hydroxyzine.This randomized, double-blind, crossover study used PET imaging with [11C]doxepin to evaluate 12 healthy males (mean age 26.2 years), after single oral administration of bilastine (20 mg), hydroxyzine (25 mg) or placebo. Binding potentials (BP) and H1 ROs were calculated in five cerebral cortex regions of interest: frontal, occipital, parietal, temporal, insula. Plasma bilastine concentrations, subjective sedation (visual analogue scale), objective psychomotor performance (digital symbol substitution test), physiological variables and safety (adverse events, AEs), were also evaluated.The mean BP of all five regions of interest [TOTAL BP] was significantly greater with bilastine than hydroxyzine (mean value 0.26 vs. 0.13, p< 0.01, mean difference and 95% CI: -0.130 [-0.155,-0.105]), with no significant difference between bilastine and placebo. Overall H1 RO by bilastine was significantly lower than that by hydroxyzine (mean value -3.92% vs. 53.95%, p< 0.01, mean difference and 95% CI: 57.870% [42.664%, 73.075%]). There was no significant linear relationship between individual bilastine plasma concentrations and TOTAL BP values. No significant between-treatment group differences were observed regarding sedation and psychomotor performance. Twenty-six non-serious AEs were reported. Sleepiness or sedation was not reported with bilastine or hydroxyzine.A single oral dose of bilastine 20 mg had minimal H1 RO, was not linked with subjective sedation or objective impairment of psychomotor performance, and was devoid of treatment-related sedative AEs, thus satisfying relevant subjective, objective, and PET criteria as a nonsedating antihistamine.