We report a case of a female patient, 48yo, medicated for depressive features with Clomipramine 75mg 1id and Bromazepam 6mg 3id, with the recent addition (8 weeks at admission time) of Aripiprazole 10mg 1id. She started experiencing fatigue, tachycardia, and paleness (symptoms suggestive of anemia) as well as weight loss and dark coloured urine. She presented with macrocytic anemia (Hb 7.7 g/dL, MGV 108.1 fL), leucocytosis (17.160/L), thrombocytosis (612 x109/L) and hyperbilirubinemia (total 1.86mg/dL, direct 0.46mg/dL). This article is protected by copyright. All rights reserved.

People with epilepsy (PWE) frequently suffer from comorbid mood and anxiety disorders. Depression is one of the major psychiatric comorbidities having a negative impact on the quality of life in people with epilepsy. A review of the literature indicates that the majority of antidepressant-related seizures have been associated with either ultra-high doses or overdosing and, generally, the risk of antidepressant-associated seizures is low. Correspondingly, there is some evidence indicating that antidepressants of most widely used groups may additionally lower the risk of triggering seizures. Four antidepressants are not recommended for patients with epilepsy, i.e.: amoxapine, bupropion, clomipramine and maprotiline. Clinicians applying first line of depression treatment in patients with epilepsy should consider use of SSRIs or SNRIs, particularly sertraline, citalopram, mirtazapine, reboxetine, paroxetine, fluoxetine, escitalopram, fluvoxamine, venlafaxine, duloxetine. Implementation of anticonvulsive drugs in depressed patients should include valproate, carbamazepine, lamotrigine, gabapentin, pregabalin. The paper reviews the evidence for the clinical use of antidepressants in PWE.

Various drugs are available for lifelong and acquired premature ejaculation (PE), but only dapoxetine and FortacinTM have been officially registered. On the other hand, all sorts of pharmacologically not-investigated over-the-counter-products (OTCs) are used by men with complaints of PE with normal ejaculation time durations (subjective PE). There is a need to critically review the current state of registered and nonregistered drugs for PE. Areas covered: In this review, the authors use the guideline of the International Society for Sexual Medicine (ISSM) for the treatment of PE and provide evidence-based recommendations for the pharmacotherapy of lifelong and acquired PE. This should always be accompanied by psychoeducation, counseling, and information about common and rare side effects of the various available drugs. Expert opinion: As long as subjective PE is not officially recognized as the third PE subtype, registration authorities will continue to demand drugs for subjective PE to be studied in men with lifelong PE. This is unfortunate as the method and design of studies of drugs for subjective PE differ from those of lifelong PE but also because drugs for subjective PE need to be investigated in men with subjective PE and not in men with lifelong PE.

Limited evidence indicates that use of clomipramine during breastfeeding is acceptable. For women who were taking clomipramine during pregnancy, the amount of drug in breastmilk may be insufficient to prevent neonatal withdrawal symptoms in breastfed infants. For use as an antidepressant, clomipramine may be less desirable than other antidepressants that have been studied more thoroughly.

CASE DESCRIPTION A 2.5-year-old 12-kg (26.4-lb) castrated male Miniature American Shepherd was referred because of a 3-week history of a localized crusted skin lesion on the digital pad of digit 3 of the right hind limb. CLINICAL FINDINGS Skin lesions were noted on the digital pads of the right hind limb. Serum biochemical analyses indicated severe hypercholesterolemia and hypertriglyceridemia. Ultrasonography of the terminal portion of the aorta and other major arterial vessels revealed substantial arteriosclerotic change. TREATMENT AND OUTCOME Medical treatments included administration of atorvastatin calcium, a low-fat diet, and omega-3 fatty acids to reduce serum lipids concentration; clopidogrel to prevent thrombosis; pentoxifylline to improve microcirculatory blood flow; clomipramine hydrochloride and trazodone hydrochloride to help with the behavioral problems; and gabapentin to help with pain management and behavioral problems. Surgical management included amputation of the initial digit involved, then eventually the entire initial limb involved. The response to treatment was poor, and euthanasia was elected. Postmortem findings revealed severe, widespread, and chronic intimal atherosclerosis; mild, widespread, and degenerative changes in the cerebral cortex; and edema and vascular congestion in the meninges. CLINICAL RELEVANCE To the authors' knowledge, this was the first report of skin necrosis secondary to atherosclerosis in a dog. Although the incidence of atherosclerosis has been considered very low in dogs, it should be investigated in dogs with severe hyperlipidemia. Primary hyperlipidemia has not been previously described in Miniature American Shepherd dogs but was the suspected underlying metabolic disorder.