Vortioxetine/Trintellix

I was privileged to attend an educational session at Black and Blue Restaurant hosted by Lundbeck the company that brings us Trintellix.  The Black and Blue Restaurant was an excellent setting for a small group meeting with superb food and service.  At the end of an often 12 hour day full of surprises and emergencies the last thing I want to do is get more education, given I’m already educated beyond my intelligence.
Yet, I was impressed with this latest of antidepressants and glad that it plugged a true gap in the much needed armentarium that doctors bring to fight disease.  Patients often complain of neurocognitive effects of depression. Many have had excellent mood relief and sleep benefits and reduced anxiety but still complained that they didn’t ‘think’ as ‘clearly’ as before. Often the effect  of their depression on concentration, memory, especially focus is an early symptom of depression but not as recognized as the low mood, thoughts of worthlessness and even suicidal ideation and the panic.  Yet when those symptoms are relieved there is really too often this lingering sense most noted subjectively that they’re not in the game, that their brain is sluggish or they’re not as ‘bright’ as they were.
Along comes Trintellix.  The students in my practice loved it.  Afraid of taking anything that would effect their studies I was able to offer this newest of antidepressants and hear the positive reports that yes it worked for depression and anxiety but most importantly it helped them get back the edge on their studies.
So when I’ve tried a medication clinically and seen it work I’m glad to have dinner bought for me to find out more about the medication and how others are finding it.
That’s how clinically medications are used.  I’ve learned of Truvada a medication that prevents people from getting HIV having unprotected sex with people who have HIV.  I’ve not had the opportunity to prescribe it as the medication after millions of research dollars is only available at approximately $50 a pill. Yet I would prescribe it first chance because there is a need and the cost benefit is most positive.  However after I started using it I ‘d be glad to learn what others were finding clinically.  As a researcher clinician I study the journals and studies mostly put out by university departments and those put out by the industry before using a medication.
Pharmaceutical companies, like car companies like Ford  or Toyota and any other big manufacturing company, keep good stats and monitor the experience of the medications., their product.   Because people were finding the 10 mg tablet of Trintellix was triggering GI symptoms even when it was taken with the largest meal at dinner, the 5 mg tablet was released which didn’t cause the GI symptoms.  After 2 weeks I’ve increased my patients to 10 mg even though 5 mg is actually an effective dose, while most of my patients are on 10 to 20 mg.
I’ve given samples which I received very thankfully as well as prescriptions. The samples are a god send for patients starting a new medication. They’re like a ‘test drive’.  They don’t really tell if a medication is going to work because you usually need to be on the medication for a couple of weeks and the samples are usually only for a week. However 90% of all side effects with medications especially the worst allergic reactions happen right away. This allows a patient to save spending $100 or so on a month supply of medication if there is a problem as well as saving them the cost of the first weeks of treatment.
I liked that there were maybe 10 clinical psychiatrists there that night. Several had academic appointments and most were affiliated with a hospital but several like me were solely in private clinical practice doing the work of actually seeing patients.  I knew a couple personally and several by their excellent reputation so it was pleasant to be there. A couple of the young guys impressed me too.  Women and men and a half dozen ethnic backgrounds so typical of Vancouver were present.  Almost all were parents too, so were giving up time with families to learn, which is so typical of the healing profession still.
These are the notes I took.It really was a great presentation by Dr. Dianne Macintosh, a self proclaimed ‘soccer mom’.  I really appreciated learning of it’s safety in the elderly.
Trintellix 

vortioxetine

Lunbeck

Eileen Sutchuck

Dr. Dianne McIntosh

Multi-dimensional disorder

1 in 5 mental illness

51billion cost of mental illness

Ssri

Snri

Multimodal -5ht1a

5ht3

5ht7

Sert

Montgomery - Asberg Depression Rating Scale

- proven efficacy

Hamilton Anxiety and depression

Broad efficacy 

Nausea side effect best start 5 mg or 5 mg eod

No difference in weight gain from placebo so very much appreciated

Sexual side effects not much similar copra led

Tests of cognitive function

Sheehan Disability Scale (SDS)

Digit Symbol Substitution Test (DSST)

PDQ-D6

RAVLT acquisition - 

RAVLT delayed recall

Memory tests

Vortioxetine well replicated

Objective performance data improved

Katona et al - elderly study

Lundbeck provided some of these cognitive assessment tests that were specifically made for brief clinical use in a busy office. I’d not used them though I started using clinical tests in my practice way before the mainstream trend.  Hamilton and Beck Depression scales have been around for a long time but I only just started using the PDQ’s a few years back. I’d not used the SDS so really was thankful to be given a copy. One worries about copyright so it’s great when there’s freeware that can enhance one’s practice.  

All round a very good evening and worthwhile. My patients will benefit from the practical insights I gained and the discussions I had with colleagues.    I really prefer eating take out at home on the couch with the dog in front of the tv after a long day of work after what now is looking like a life time of  clinical service.  The Black and Blue, Eileen and Dianne made the whole experience enjoyable.

I really am thankful to Lundbeck for their work in providing a new medication which really fills a need. I think the speed of society and the increased need for neurocognitive function with computers and cell phones, increased time pressures and more complex intellectual problem solving in the workplace brought the need for Trintellix to the forefront.  In the old days people were just glad to no longer be wanting to kill themselves and not having panic attacks where they thought they were going to die.  Now they and their bosses want people back at work with the capacity to think sharp and focus so Trintellix was needed.  Now it’s here.  

Cipralex - Escitalopram

I've been prescribing Lundbeck Pharmaceutical's, Cipralex, (Escitalopram) since it first became available in the last few years.  Finally it's covered by our provincial formulary.
Prozac or fluoxetine, the first of the SSRI, Serotonin Specific Reuptake Inhibitors,  was truly a break through in pharmaceutical therapeutics. Prior to it's introduction the tricyclics, such as Amitriptylline,  were all that was available. I remember the horrors of seeing acutely suicidal patients and beginning them on one of the tricyclics knowing that the medications had unpleasant side effects. They would have to be titrated upwards slowly because of toxicity and would take at least 6 weeks to become psychoactive. The tricyclics further had a narrow window of benefit versus danger. A small amount of medication, usually less than a week or twos supply was all that was necessary to cause cardiac arrest if taken as an overdose. If the patient didn't die they had to be admitted to an intensive care units for days to protect against lethal arrythmias.
Having faced all of those risks as a clinician I was thankful for the SSRI"s.  The first generation brought rapid onset of action, with patients experiencing benefits in as little as 2 weeks though the full benefits of the medication could still take 1-2 months.  The side effects were far less and each generation has resulted in a medication with fewer and fewer side effects.  Finally the risk of suicide by overdose is very little and much less with later generations of SSRI.
Cipralex is the latest of the SSRI generations. It's advantage over the previous SSRI"s is it's short action. Prozac could accumulated in the system because of it's long half life, half life being the length of time it took to remove half of a compound from the system.  Cipralex clears out of the system in a day or two. This is important in case there are any reactions to the medication by itself or in combination with others. In comparison consider that alcohol clears in less time and marijuana is psychoactive for 6 weeks or sometimes more.
The second generation of SSRI"s included two I found very useful and beneficial.  Zoloft or sertraline was specifically used for PTSD whereas Paxil or Paroxetine was an amazing anti anxiety medication for generalized anxiety disorders and panic attacks.  Zoloft continues to be used extensive as does Prozac.  The difficulty with paxil was that it was most likely to cause sexual side effects, delayed ejaculation, decreased desire and erectile failure in as many as 40 per cent of patients at higher dosages. This could be counteracted first with ginkgo biloba and secondly with viagra or cialis.
Trazadone anothe second generation SSRI still tends to be used more for an interesting side effect. It's extremely good for keeping people asleep so that it can be combined with most of the other antidepressants in those people who have difficulty with insomnia, a common sympton in depression.
Celexa , or citalopram, a third generation SSRI, was extremely useful in the elderly and in treatment of patients who had other medical conditions especially a history of myocardial infarction or cardiac concerns in general.  It was a surprisingly safe medication with a very 'clean' profile in its being least likely to interact negatively with medications used in other specialities. It commonly was beneficial for patients with major medical illness and post surgical depressions without having any signficant down side. Celexa is essentially the closest precurser of Cipralex.
Cipralex in contrast to Celexa, while retaining it's benefits, had specific superiority in the treatment of anxious depression, anxiety disorders with panic attacks and interestingly Obsessive Compulsive Disorder.
Clomipramine the tricyclic antidepressant was shown before Prozac to be almost essential to the treatment of OCD.  High dosage of medication was commonly needed too. Whereas a person with depression or general anxiety might benefit from 10 mg of prozac , the ocd patient would often need more than 60 mg to get the full benefit.  Cipralex appears almost equally beneficial for OCD but again at higher dosage that presently recommended.
Both Celexa and Cipralex have another interesting clinical significance. Of all the antidepressants I've used treating head injured patients, patient with traumatic brain injury it's been these two and wellbutrin or buproprion that my patients have literally sworn by.  I think it's interesting that these cipralex has benefit in brain injured patients and OCD because these are considered more 'biological' than what can be described as the more psychological depressions that tend to respond to a wide variety of therapies.  That the patients and their families see the benefit so significantly is what is most exciting.
Cipralex is a good antidepressant and really shines as a long term anti anxiety medication.  It's beneficial in TBI and in OCD. It's also beneficial in patients who have mood disorder but the diagnosis is Bipolar.  Because of the safety and cleaness of it's pharmaceutical proflie and relatively short half life it's also one of the safest medication that can be used with patients who use drugs or alcohol but may well not be open about this with the doctor. It's been well tried in a street clinic I work at with much benefit and no serious side effects of concern.  Safety is appreciated and the pharmaceutical companies are most concerned that their medications are safe simply because they pay the costs when things go wrong.
Prozac is the only antidepressant that is said to be acceptable for the treatment of childhood depression in Canada.  The research on patients whose mother was on an SSRI when they were intrauterine is now in 30 year follow up with one of the safest profiles in the history of pharmaceutical treatment.
Depression is a life threatening disease. Anxiety is a horror to live with. It's not just something that goes away. OCD is wholly disabling for some patients.  Suicide is a major cause of death and medications like Cipralex are truly beneficial adjuncts to the armentarium of ways we successfully and effectively treat cases mild to severe to save patients from hospitalization.
I thank Dr. Tsung, a colleague for 'picking my brain' and causing me to think of the thousands of prescriptions I've written over the years for SSRI and how I chose which medications. I do choose the latest medication which usually is the best in the way that the newest of cars incorporates the latest science and technology in those who have not responded or only had a partial response to previously available treatments. Further I will use the latest medication in those who are well off and can afford it and have moderate to severe symptons.  I was very thankful when cipralex became part of the formulary, which means it was available to all patients on disability or pensions or even welfare.  It's a recognition by the decision makers of the benefit of the medication and a testimony to the pharmaceutical company to bring in a new and very beneficial product at a price where most people can afford it and governments can see the benefit of providing coverage. It makes it that much easier for clinicians.