Paroxetine

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Paroxetine
Systematic (IUPAC) name
(3S,4R)- 3-([benzo[d] [1,3]dioxol-5-yloxy] methyl)- 4-(4-fluorophenyl) piperidine
Identifiers
CAS number 61869-08-7
ATC code N06AB05
PubChem 43815
DrugBank APRD00364
ChemSpider 39888
Chemical data
Formula C19H20FNO3 
Mol. mass 329.3
SMILES eMolecules & PubChem
Pharmacokinetic data
Bioavailability Completely absorbed from GI, but extensive first-pass metabolism in the liver; Tmax 4.9 (with meals) to 6.4 hours (fasting)
Protein binding 93–95%
Metabolism Extensive, hepatic (mostly CYP2D6-mediated)
Half life 24 hours (range 3–65 hours)
Excretion 64% in urine, 36% in bile
Therapeutic considerations
Licence data

US FDA:link
Pregnancy cat.

D(US)
Legal status

℞ Prescription only
Routes Oral

Paroxetine (trade names Seroxat, Paxil) is a selective serotonin reuptake inhibitor (SSRI) antidepressant. It was released in 1992 by the pharmaceutical company GlaxoSmithKline. It is used to treat major depression, obsessive-compulsive, panic and social anxiety disorders in adult outpatients.

In adults, the efficacy of paroxetine for depression is comparable to that of older tricyclic antidepressants with fewer side effects and lower toxicity.[1][2] Differences with newer antidepressants are subtler and mostly confined to side effects. It shares the common side effects and contraindications of other SSRIs, with high rates of nausea, somnolence, and sexual side effects. Unlike two other popular SSRI antidepressants fluoxetine and sertraline, paroxetine is associated with a clinically significant weight gain[3] and statistically significant increase in the risk of suicidality in adults.[4] Pediatric trials of paroxetine for depression did not demonstrate efficacy and showed an increase in the risk of harmful outcomes, including episodes of self-harm and potentially suicidal behavior.[5][6][7] Stopping paroxetine is associated with a high risk of discontinuation or withdrawal syndrome.[8][9] Due to the increased risk of birth defects, pregnant women or women planning to become pregnant are recommended to avoid paroxetine use.

Contents

[edit] Indications

Paroxetine is primarily used to treat the symptoms of major depression, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder, generalized anxiety disorder (GAD),[10] social phobia/social anxiety disorder,[11] and premenstrual dysphoric disorder (PMDD).[12]

It was the first antidepressant formally approved in the United States for the treatment of panic attacks.[13]

According to the prescribing information provided by the manufacturer of Paxil brand of paroxetine GlaxoSmithKline and approved by the FDA,[14] the effectiveness of paroxetine in major depressive disorder has been proven by six placebo-controlled clinical trials. For panic disorder, three 10-12-week studies indicated paroxetine superiority to placebo.[14] Similarly, three 12-week trials for adult outpatients with social anxiety disorder demonstrated better response to paroxetine than to placebo.[14]

[edit] Unapproved/off-label/investigational

Moreover, studies have suggested that paroxetine can in fact be used in the treatment of premature ejaculation. In particular, intravaginal ejaculation latency time (IELT) found to increase with a 6-13-fold, which was somewhat longer than those of a predessor.. the delay achieved by the treatment with other SSRIs (fluvoxamine, fluoxetine, sertraline and citalopram).[15][16][17] However, paroxetine taken acutely ("on demand") 3–10 hours before coitus resulted only in a "clinically irrelevant and sexually unsatisfactory" 1.5-fold delay of ejaculation and was inferior to clomipramine, which induced a fourfold delay.[17]

There is also evidence that paroxetine may be effective in the treatment of compulsive gambling[18] and hot flashes.[19]

In two double-blind studies of bipolar disorder patients, addition of paroxetine to a mood stabilizer had no advantages over addition of placebo.[20][21] Benefits of paroxetine prescription for diabetic neuropathy[22] or chronic tension headache.[23] are uncertain.

[edit] Contraindications

Paroxetine is contraindicated in all patients under 18, in all patients taking any of the drugs listed in the interactions section below, and in adult women who are or may become pregnant. Paroxetine may also be contraindicated in many adult men due to sexual and reproductive side effects described below. In the United States, the FDA requires this drug to carry a black box warning, its "most serious type of warning in prescription drug labeling,"[24] due to increased risk of suicidal ideation and behavior. The warning also applies to other SSRIs, but the concern began with reports of suicidal behavior in paroxetine trials, as well as recommendations from the United Kingdom Medicines and Healthcare products Regulatory Agency urging that paroxetine not be used in individuals younger than 18 years.[25]

[edit] Side effects

Among the common adverse effects associated with paroxetine treatment of depression and listed in the prescribing information, those with the greatest difference from placebo are nausea (26% on paroxetine vs 9% on placebo), somnolence (23% vs. 9% on placebo), ejaculatory disturbance (13% vs. 0% on placebo), other male genital disorders (10% vs. 0% on placebo), asthenia (15% vs. 6% on placebo), sweating (11% vs. 2% on placebo), dizziness (13% vs. 6% on placebo), insomnia (13% vs. 6% on placebo), dry mouth (18% vs. 12% on placebo), constipation (14% vs. 9% on placebo), and tremor (8% vs. 2% on placebo).[14] Other side effects include headache, activation, weight gain, impaired memory and paresthesia.[26]

General side effects are mostly present during the first 1–4 weeks while the body acquires a tolerance to the drug, although once this happens, withdrawal can cause a rebound effect with symptoms re-emerging in an exaggerated form for very long periods of time. Almost all SSRIs are known to cause either one or more of these symptoms. A person receiving paroxetine treatment may experience a few, all, or none of the following side-effects, and most side-effects will disappear or lessen with continued treatment, though some may last throughout the duration. Side effects are also often dose-dependent, with fewer and/or less severe symptoms being reported at lower dosages, and/or more severe symptoms being reported at higher dosages. Increases or changes in dosage may also cause symptoms to reappear or worsen.[14]

On 9 December 2004 the European Medicines Agency's (EMEA) Committee for Medicinal Products for Human Use (CHMP) informed patients, prescribers and parents that paroxetine should not be prescribed to children. CHMP gave a warning to prescribers recommending close monitoring of adult patients at high risk of suicidal behaviour and/or suicidal thoughts. In other words, CHMP does not prohibit use of paroxetine with adults but stresses extreme caution in actual usage. Also withdrawal reactions upon stopping treatment is mentioned and therefore it is recommended to gradually reduce the dose over several weeks or months if decision of withdrawal is made.[27]

A statistical analysis of paroxetine clinical trials in children and adolescents was conducted by the FDA in 2004. It indicated a statistically significant 2.7-fold raise in suicide behavior and ideation as compared to placebo. The trend for increased suicidality was observed in both trials for depression and for anxiety disorders.[5]

Cases of akathisia[28][29] and activation syndrome[30][31] have been observed during paroxetine treatment.

Rarely serotonin syndrome, a severe adverse effect may occur.[32][33]

Paroxetine and other SSRIs have been shown to cause sexual side effects in most patients, both males and females.[34] In males, paroxetine is also linked to sperm DNA fragmentation.[35]

Mania or hypomania may occur as a serious side effect of paroxetine,[36][37][38] affecting up to 8% of psychiatric patients treated. This side effect can occur in individuals with no history of mania but it is more likely to occur in those with bipolar or with a family history of mania.[39]

Schmitt et al. (2001) suggested that paroxetine negatively affects cognition (i.e., IQ). In their study, healthy participants given paroxetine for 14 days (20 mg for days 1–7 and 40 mg days 8–14) showed poorer recall of words on day 14 compared to those receiving a placebo. Schmitt and co-workers, however, did not account for significant differences in verbal recall at baseline between those receiving paroxetine and those receiving a placebo, differences which produced the significant finding. Furthermore, participants receiving paroxetine recalled as many words at baseline as they recalled on day 14. Accordingly, the conclusion that paroxetine affects verbal recall was unwarranted.

[edit] Discontinuation syndrome (withdrawal)

See also: SSRI discontinuation syndrome

Many psychoactive medications can cause withdrawal symptoms upon discontinuation from administration. Evidence has shown that paroxetine has among the highest incidence rates and severity of withdrawal syndrome of any medication of its class.[40][41] Common withdrawal symptoms for paroxetine include nausea, dizziness, lightheadedness and vertigo; insomnia, nightmares and vivid dreams; feelings of electricity in the body, as well as crying and anxiety.[42][43] Liquid formulation of paroxetine is available and allows a very gradual decrease of the dose, which may prevent discontinuation syndrome. Another recommendation is to temporarily switch to fluoxetine, which has a longer half-life and thus decreases the severity of discontinuation syndrome.[8][44][45]

In addition, The Lancet published an analysis of World Health Organization data showing SSRIs taken during pregnancy may cause withdrawal symptoms, including convulsions, in newborn children: among "93 suspected cases of SSRI-induced neonatal withdrawal syndrome...64 were associated with paroxetine, 14 with fluoxetine, nine with sertraline, and seven with citalopram."[46]

[edit] Paroxetine and pregnancy

The American College of Obstetricians and Gynecologists recommends that pregnant women and women planning to become pregnant should avoid using paroxetine.[47] According to the prescribing information[14] "epidemiological studies have shown that infants born to women who had first trimester paroxetine exposure had an increased risk of cardiovascular malformations, primarily ventricular and atrial septal defects (VSDs and ASDs). In general, septal defects range from those that are symptomatic and may require surgery to those that are asymptomatic and may resolve spontaneously. If a patient becomes pregnant while taking paroxetine, she should be advised of the potential harm to the fetus. Unless the benefits of paroxetine to the mother justify continuing treatment, consideration should be given to either discontinuing paroxetine therapy or switching to another antidepressant. For women who intend to become pregnant or are in their first trimester of pregnancy, paroxetine should only be initiated after consideration of the other available treatment options." These conclusions are supported by multiple systematic reviews and meta-analyses that found that, on average, the use of paroxetine during pregnancy is associated with about 1.5-1.7-fold increase in congenital birth defects, in particular, heart defects.[48][49][50][51][52] A recent non-systematic review in the Journal of Clinical Psychiatry, with the lead author, Salvatore Gentile, reporting to have received material or financial support from GSK, came to a different conclusion: "the teratogenic potential of paroxetine that has been reported in some studies remains unproven." Gentile called for large, epidemiologic, prospective, controlled studies on "mothers who accept taking paroxetine during pregnancy".[53] Other reviews vary on whether the teratogenic risks outweigh the risk of disease relapse if the drug is discontinued: some advocate discontinuation,[48] while others suggest caution;[50] even where the overview of antidepressants generally is favorable, paroxetine is singled out for specific risks.[51]

Abrupt discontinuation of psychotropic drugs during pregnancy can also lead to serious adverse effects.[54]

Counseling is effective in reassuring women to adhere to therapy,[55] but neonatal paroxetine withdrawal symptoms described above have been documented from mothers taking Paxil during pregnancy.[56]

[edit] Paroxetine interactions with other drugs

GlaxoSmithkline cautions that drug interactions may create or increase specific risks, including Serotonin Syndrome or Neuroleptic Malignant Syndrome (NMS)-like Reactions:

The development of a potentially life-threatening serotonin syndrome or Neuroleptic Malignant Syndrome (NMS)-like reactions have been reported with SNRIs and SSRIs alone, including treatment with PAXIL, but particularly with concomitant use of serotonergic drugs (including triptans) with drugs which impair metabolism of serotonin (including MAOIs), or with antipsychotics or other dopamine antagonists.

The prescribing information states that paroxetine should "not be used in combination with an MAOI (including linezolid, an antibiotic which is a reversible non-selective MAOI), or within 14 days of discontinuing treatment with an MAOI," and should not be used in combination with pimozide, thioridazine, tryptophan, or warfarin.[57]

[edit] Pharmacology

Paroxetine is the most potent and one of the most specific selective serotonin (5-hydroxytryptamine, 5-HT) reuptake inhibitors (SSRI).[58] This activity of the drug on brain neurons is thought to be responsible for its antidepressant effects.

Paroxetine is a phenylpiperidine derivative which is chemically unrelated to the tricyclic or tetracyclic antidepressants. In receptor binding studies, paroxetine did not exhibit significant affinity for the adrenergic (α1, α2, β), dopaminergic, serotonergic (5HT1, 5HT2), or histamine receptors of rat brain membrane. A weak affinity for the muscarinic acetylcholine and noradrenaline receptors was evident. The predominant metabolites of paroxetine are essentially inactive as 5-HT reuptake inhibitors.

[edit] Formulations

Paroxetine CR (controlled release) was shown to be associated with a lower rate of nausea during the first week of treatment than paroxetine immediate release. However, the rate of treatment discontinuation due to nausea was not significantly different.[59]

[edit] Controversy

For 10 years, GlaxoSmithKline's marketing of the drug stated falsely that it was not habit forming.[41][60] In 2001, the BBC reported the World Health Organization had found paroxetine to have the hardest withdrawal problems of any antidepressant.[61] In 2002, the U.S. Food and Drug Administration published a new product warning about the drug, and the International Federation of Pharmaceutical Manufacturers Associations found GSK guilty of misleading the public about paroxetine and breaching two of the Federation's codes of practice.[40][62] The British Medical Journal quoted Charles Medawar, head of Social Audit: "This drug has been promoted for years as safe and easy to discontinue.... The fact that it can cause intolerable withdrawal symptoms of the kind that could lead to dependence is enormously important to patients, doctors, investors, and the company. GlaxoSmithKline has evaded the issue since it was granted a license for paroxetine over 10 years ago, and the drug has become a blockbuster for them, generating about a tenth of their entire revenue. The company has been promoting paroxetine directly to consumers as 'non-habit forming' for far too long."[40] Paroxetine prescribing information posted at GlaxoSmithKline now acknowledges the occurrence of a discontinuation syndrome, including serious discontinuation symptoms.[63]

A British Government parliamentary inquiry into a number of prescription and over the counter drugs noted problems with SSRI antidepressants including withdrawal, suicidal thoughts and other adverse effects. The inquiry found that paroxetine (Paxil, Seroxat) has, more commonly than other SSRI antidepressants, a very devastating impact on some users' lives.[64] Since the FDA approved paroxetine in 1992, approximately 5,000 U.S. citizens have sued GSK. Most of these people feel they were not sufficiently warned in advance of the drug's side effects—particularly the withdrawal syndrome discussed above, after GSK had specifically advertised the drug as non-habit forming[60]

In the UK since 2001 lawsuits have been filed representing people who have been prescribed Seroxat. They allege that the drug has serious side effects, which GlaxoSmithKline downplayed in patient information.[65][66]

In early 2004, GSK agreed to settle charges of consumer fraud for $2.5 million (a tiny fraction of the over $2.7 billion in yearly Paxil sales at that time).[67] The legal discovery process also uncovered evidence of deliberate, systematic suppression of unfavorable Paxil research results. One of GSK's internal documents had said, "It would be commercially unacceptable to include a statement that efficacy [in children] had not been demonstrated, as this would undermine the profile of paroxetine"[68].

On January 29 2007, the BBC broadcast a fourth documentary in its Panorama series about the drug Seroxat.[69] This programme, entitled Secrets of the Drug Trials, focused on three GSK paediatric clinical trials on depressed children and adolescents. Data from the trials show that Seroxat could not be proven to work for teenagers. Also, one clinical trial indicated that adolescents were six times more likely to become suicidal after taking it.

The court documents released as a result of one of the lawsuits in October 2008 indicated that GSK "and/or researchers may have suppressed or obscured suicide risk data during clinical trials" of paroxetine. One of the investigators, "Charles Nemeroff, former Chairman of the Department of Psychiatry at Emory University, was the first big name 'outed' ...In early October, Nemeroff resigned from Emory amid revelations that he had received over $960,000 from GSK in 2006, yet reported less than $35,000 to the school. Subsequent investigations revealed payments totaling more than $2.5 million from drug companies between 2000 and 2006, yet only a fraction was disclosed."[70]

The suppression of unfavorable research findings on Paxil by GSK — and the legal discovery process that uncovered it — is the subject of Alison Bass's 2008 book Side Effects: A Prosecutor, a Whistleblower, and a Bestselling Antidepressant on Trial[71].

[edit] Sales

In 2006, paroxetine was the fifth-most prescribed antidepressant in the United States retail market, with more than 19.7 million prescriptions.[72] In 2007, sales had dropped slightly to 18.1 million but paroxetine remained the fifth-most prescribed antidepressant in the U.S.[73]

[edit] Footnotes

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