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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2012/10/16 10:51:10」(JST)

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Milnacipran (Ixel, Savella, Dalcipran, Toledomin) is a serotonin–norepinephrine reuptake inhibitor (SNRI) used in the clinical treatment of fibromyalgia. It is not approved for the clinical treatment of major depressive disorder in the USA, but it is in other countries.

History

Milnacipran was first approved for the treatment of major depressive episodes in France in December 1996. It is currently marketed (as Ixel) for this indication in over 45 countries worldwide including several European countries such as Austria, Bulgaria, Finland, France, Portugal, and Russia. It is also available in Japan (as Toledomin) and Mexico (as Dalcipran). Cypress Bioscience bought the exclusive rights for approval and marketing of the drug for any purpose in the United States and Canada in 2003 from the manufacturer Laboratoires Pierre Fabre.

In January 2009 the U.S. Food and Drug Administration (FDA) approved milnacipran (under the brand name Savella) only for the treatment of fibromyalgia, making it the third medication approved for this purpose in the United States.

Pharmacology

Milnacipran inhibits the reuptake of serotonin and norepinephrine in an approximately 1:3 ratio, respectively; in practical use this means a relatively balanced action upon both neurotransmitters. Inhibition of both neurotransmitters simultaneously works synergistically to treat both depression and fibromyalgia. Milnacipran exerts no significant actions on H₁, α₁, D₁, D₂, and mACh receptors, as well as on benzodiazepine and opioid binding sites.^[1]^[2]^[3]

Clinical results in depression

In a pooled analysis of 7 comparative trials with imipramine,^[4] milnacipran and imipramine were shown to have comparable efficacy while milnacipran was significantly better tolerated. A pooled analysis of studies comparing milnacipran and SSRIs ^[5] concluded a superior efficacy for milnacipran with similar tolerability for milnacipran and SSRIs. A more recent meta-analysis of 6 studies involving more than 1,000 patients showed no distinction between milnacipran and SSRIs in efficacy or discontinuation rates, including discontinuation for side effects or lack of efficacy.^[6] A meta-analysis of a total of 16 randomized controlled trials with more than 2200 patients ^[7] concluded that there were no statistically significant differences in efficacy, acceptability and tolerability when comparing milnacipran with other antidepressant agents. However, compared with TCAs, significantly fewer patients taking milnacipran dropped out due to adverse events. As with other antidepressants, 1 to 3 weeks may elapse before significant antidepressant action becomes clinically evident.

Clinical results in fibromyalgia

During its development for ﬁbromyalgia, milnacipran was evaluated utilizing a composite responder approach. To be considered as a responder for the composite ‘treatment of ﬁbromyalgia’ endpoint, each patient had to show concurrent and clinically meaningful improvements in pain, physical function and global impression of disease status. Using these criteria placebo-controlled trials ^[8]^[9] involving a total of over 2000 patients have shown milnacipran, at both 100 and 200 mg/day, to be significantly more effective than placebo in treating both pain and the broader syndrome of ﬁbromyalgia. Response rates with milnacipran were similar in patients with and without co-morbid depression.

Pharmacokinetics

Milnacipran is well absorbed after oral dosing and has a bioavailability of 85%. Meals do not have an influence on the rapidity and extent of absorption. Peak plasma concentrations are reached 2 hours after oral dosing. The elimination half-life of 8 hours is not increased by liver impairment and old age, but by significant renal disease. Milnacipran is conjugated to the inactive glucuronide and excreted in the urine as unchanged drug and conjugate. Only traces of active metabolites are found.

Indications and dosage

Milnacipran is indicated for:

treatment of major depressive disorder (not in USA)
management of fibromyalgia (USA and Russia)

The recommended dose for depression is 100 mg/day (given as 50 mg 2 times daily), with a starting period of 4 days on 25 mg/day. The dose should be decreased in patients with renal disease. The recommended dose for fibromyalgia is 100 mg/day (after an uptitration period ) which may be increased to 200 mg/day based on individual patient response.

After successful treatment of the acute depressive episode, patients should be maintained on milnacipran for several months (normally 9 months) in order to prevent relapse of depression.

Side effects

The most frequently occurring adverse reactions (≥ 5% and greater than placebo) were nausea, headache, constipation, dizziness, insomnia, hot flush, hyperhidrosis, vomiting, palpitations, heart rate increase, dry mouth, and hypertension [FDA Savella prescribing information]. Milnacipran can have a significant impact on sexual functions, including both a decrease in sexual desire and ability. Milnacipran can cause pain and swelling of the testicles in men as well as blood in the urine and stools. The incidence of cardiovascular and anticholinergic side effects was significantly lower compared to TCAs as a controlled study with over 3,300 patients revealed. Elevation of liver enzymes without signs of symptomatic liver disease has been infrequent. Mood swing to mania has also been seen and dictates termination of treatment. In psychotic patients emergence of delirium has been noticed. Milnacipran has a low incidence of sedation but improves sleep (both duration and quality) in depressed patients. In agitated patients or those with suicidal thoughts additive sedative/anxiolytic treatment is usually indicated.

Interactions

MAOIs - hyperserotonergia (serotonin syndrome), potentially lethal hypertensive crisis
5-HT1 receptor agonists - coronary vasoconstriction with risk of angina pectoris and myocardial infarction
Epinephrine, Norepinephrine (also in local anesthesia) - hypertensive crisis and/or possible cardiac arrhythmia
Clonidine - antihypertensive action of clonidine may be antagonized
Digitalis - hemodynamic actions increased
Alcohol - no interactions known; however, because milnacipran can cause mild elevation of liver enzymes, caution is recommended

Contraindications

Administration of milnacipran should be avoided in individuals with the following:

Known hypersensitivity to milnacipran (absolute contraindication)
Patients under 15 years of age (no sufficient clinical data)
Concomitant treatment with irreversible MAO inhibitors (e.g. tranylcypromine (Parnate), phenelzine (Nardil), >10 mg L-deprenyl (Selegiline)), digitalis glycosides or 5-HT_1D-agonists (e.g. triptan migraine drugs) is an absolute contraindication.

Administration of milnacipran should be done with caution in individuals with the following:

Concomitant treatment with parenteral epinephrine, norepinephrine, with clonidine and reversible MAO-A Inhibitors (moclobemide, toloxatone).
Advanced renal disease (decreased dosage required)
Hypertrophy of the prostate gland (possibly urination hesitancy induced), with hypertension and heart disease (tachycardia may be a problem) as well as with open angle glaucoma

Milnacipran should not be used during pregnancy because it may cross the placenta barrier and no clinical data exists on harmful effects in humans and animal studies. Milnacipran is contraindicated during lactation because it is excreted in the milk, and it is not known if it is harmful to the newborn.

References

^ Moret C, Charveron M, Finberg JP, Couzinier JP, Briley M (1985). "Biochemical profile of midalcipran (F 2207), 1-phenyl-1-diethyl-aminocarbonyl-2-aminomethyl-cyclopropane (Z) hydrochloride, a potential fourth generation antidepressant drug". Neuropharmacology 24 (12): 1211–9. doi:10.1016/0028-3908(85)90157-1. PMID 3005901.
^ Briley M, Prost JF, Moret C (1996). "Preclinical pharmacology of milnacipran". International clinical psychopharmacology 11 Suppl 4: 9–14. PMID 8923122.
^ Puozzo C, Panconi E, Deprez D (2002). "Pharmacology and pharmacokinetics of milnacipran". International clinical psychopharmacology 17 Suppl 1: S25–35. PMID 12369608.
^ Kasper S, Pletan Y, Solles A, Tournoux A (1996). "Comparative studies with milnacipran and tricyclic antidepressants in the treatment of patients with major depression: a summary of clinical trial results". International Clinical Psychopharmacolgy 11 (Suppl 4): 35–39. doi:10.1097/00004850-199609004-00005. PMID 8923125.
^ Lopez-Ibor J, Guelfi JD, Pletan Y, Tournoux A, Prost JF (1996). "Milnacipran and selective serotonin reuptake inhibitors in major depression". International Clinical Psychopharmacology 11 (Suppl 4): 41–46. doi:10.1097/00004850-199609004-00006. PMID 8923126.
^ Papakostas GI, Fava M (2007). "A meta-analysis of clinical trials comparing milnacipran, a serotonin--norepinephrine reuptake inhibitor, with a selective serotonin reuptake inhibitor for the treatment of major depressive disorder". European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology 17 (1): 32–6. doi:10.1016/j.euroneuro.2006.05.001. PMID 16762534.
^ Nakagawa A, Watanabe N, Omori IM, Barbui C, Cipriani A, McGuire H, Churchill R, Furukawa TA (2009). Nakagawa, Atsuo. ed. "Milnacipran versus other antidepressive agents for depression". Cochrane Database of Systematic Reviews 8 (3): CD006529. doi:10.1002/14651858.CD006529.pub2. PMID 19588396.
^ Clauw DJ, Mease P, Palmer RH, Gendreau RM, Wang Y (2008). "Milnacipran for the treatment of fibromyalgia in adults: a 15-week, multicenter, randomized, double-blind, placebo-controlled, multiple-dose clinical trial". Clinical Therapeutics 30 (11): 1988–2004. doi:10.1016/j.clinthera.2008.11.009. PMID 19108787.
^ Mease PJ, Clauw DJ, Gendreau RM, Rao SG, Kranzler J, Chen W, Palmer RH (2009). "The efficacy and safety of milnacipran for treatment of fibromyalgia. a randomized, double-blind, placebo-controlled trial". Journal Rheumatology 36 (2): 398–409. doi:10.3899/jrheum.080734. PMID 19132781.

External links

Savella official site
Scientific Information on Ixel (German)

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

1. セロトニン - ノルエピネフリン再取り込み阻害剤（SNRIs）：薬理学、投与、および副作用 serotonin norepinephrine reuptake inhibitors snris pharmacology administration and side effects
2. 成人における線維筋痛症の初期治療 initial treatment of fibromyalgia in adults
3. 小児への授乳による抗うつ薬およびベンゾジアゼピン曝露の安全性 safety of infant exposure to antidepressants and benzodiazepines through breastfeeding
4. 成人における初期治療の効果がない線維筋痛症の治療 treatment of fibromyalgia in adults not responsive to initial therapies
5. 小児および思春期における線維筋痛症：治療および予後 fibromyalgia in children and adolescents treatment and prognosis

English Journal

A systematic review of the efficacy of venlafaxine for the treatment of fibromyalgia.

VanderWeide LA1, Smith SM, Trinkley KE.
Journal of clinical pharmacy and therapeutics.J Clin Pharm Ther.2015 Feb;40(1):1-6. doi: 10.1111/jcpt.12216. Epub 2014 Oct 8.
WHAT IS KNOWN AND OBJECTIVE: Fibromyalgia is a painful disease affecting 1-2% of the United States population. Serotonin and norepinephrine reuptake inhibitors (SNRIs), such as duloxetine and milnacipran, are well studied and frequently used for treating this disorder. However, efficacy data are lim
PMID 25294655

The many different faces of major depression: It is time for personalized medicine.

Korte SM1, Prins J1, Krajnc AM1, Hendriksen H1, Oosting RS1, Westphal KG1, Korte-Bouws GA1, Olivier B1.
European journal of pharmacology.Eur J Pharmacol.2015 Jan 12. pii: S0014-2999(15)00016-3. doi: 10.1016/j.ejphar.2014.11.045. [Epub ahead of print]
First line antidepressants are the so-called SSRIs (selective serotonin reuptake inhibitors), e.g. fluvoxamine, fluoxetine, sertraline, paroxetine and escitalopram. Unfortunately, these drugs mostly do not provide full symptom relief and have a slow onset of action. Therefore other antidepressants a
PMID 25592320

Prediction of in vivo plasma concentration-time profile from in vitro release data of designed formulations of milnacipran using numerical convolution method.

Singhvi G1, Shah A, Yadav N, Saha RN.
Drug development and industrial pharmacy.Drug Dev Ind Pharm.2015 Jan;41(1):105-8. doi: 10.3109/03639045.2013.850706. Epub 2013 Oct 28.
Abstract The aim of this study was to predict the in vivo plasma drug level of milnacipran (MIL) from in vitro dissolution data of immediate release (IR 50 mg and IR 100 mg) and matrix based controlled release (CR 100 mg) formulations. Plasma drug concentrations of these formulations were pred
PMID 24164467

Japanese Journal

症例ミルナシプラン増量によってセロトニン症候群を生じた1例

萩野谷真人,大曽根彰,下田和孝
精神科 19(5), 526-530, 2011-11
NAID 40019079411

症例ミルナシプランの早期高用量投与が奏効したうつ病症例

張替直基
精神科 18(2), 244-248, 2011-02
NAID 40018703253

Related Pictures

★リンクテーブル★

リンク元	「抗うつ薬」「セロトニン」「ミルナシプラン」「セロトニン・ノルアドレナリン再取り込み阻害薬」
拡張検索	「milnacipran hydrochloride」

「抗うつ薬」

Milnacipran
Systematic (IUPAC) name
	(1R,2S)-2-(aminomethyl)-N,N-diethyl-1-phenylcyclopropanecarboxamide
Clinical data
AHFS/Drugs.com	Consumer Drug Information
MedlinePlus	a609016
Pregnancy cat.	X (US)
Legal status	℞-only (US)
Routes	Oral
Pharmacokinetic data
Bioavailability	85%
Protein binding	13%
Metabolism	Hepatic
Half-life	8 hours
Excretion	Renal
Identifiers
CAS number	92623-85-3
ATC code	N06AX17
PubChem	CID 65833
DrugBank	DB04896
ChemSpider	59245
UNII	G56VK1HF36
KEGG	D08222
ChEMBL	CHEMBL252923
Chemical data
Formula	C15H22N2O
Mol. mass	246.348 g/mol
	SMILES O=C(N(CC)CC)[C@@]2(c1ccccc1)[C@@H](CN)C2;
	InChI InChI=1S/C15H22N2O/c1-3-17(4-2)14(18)15(10-13(15)11-16)12-8-6-5-7-9-12/h5-9,13H,3-4,10-11,16H2,1-2H3/t13-,15+/m1/s1 ; Key:GJJFMKBJSRMPLA-HIFRSBDPSA-N ;
(what is this?) (verify);

　　[★]

英: antidepressant, antidepressants
関: 薬理学、そううつ病、精神疾患

作用機序

三環系抗うつ薬 tricyclic antidepressant

２つの説がある。

1. (急性作用)シナプス前膜におけるノルアドレナリン、セロトニンの再取り込み↓→シナプス間隙における薬剤濃度↑
2. (慢性作用)(2週間後)シナプス後膜における受容体の数↓

慢性作用はシナプス間隙のノルアドレナリン、セロトニン濃度が上昇した結果、シナプス後膜の受容体が減少したために出現すると考えられる。

抗うつ薬

三環系

四環系

選択的セロトニン再取り込み阻害薬 selective serotonin reuptake inhibitor SSRI

セロトニン・ノルアドレナリン再取り込み阻害薬 serotonin noradrenaline reuptake inhibitor SNRI

ミルナシプラン milnacipran

非定型抗うつ薬 atypical agent

トラゾドン trazodone

副作用

Adams and s Principles of Neurology, Ninth Edition Allan Ropper p.1474

		不眠、焦燥	鎮静	低血圧	抗コリン作用	消化管症状(嘔吐等)	性機能低下	体重増加
三環系	アミトリプチリン	±	2+	2+	3+	±	＋	2+
三環系	ドスレピン	±	2+	2+	2+	±	＋	2+
三環系	イミプラミン	2+	＋	2+	2+	±	＋	2+
SSRI	フルオキセチン	2+	±	±	＋	2+	2+	＋
SSRI	パロキセチン	2+	±	±	±	2+	2+	＋
SSRI	セルトラリン	2+	±	±	±	2+	2+	＋
SSRI	フルボキサミン	2+	＋	±	±	2+	2+	＋
SSRI	シタロプラム	2+	±	±	±	2+	2+	＋
SSRI	エスシタロプラム	2+	±	±	±	2+	2+	＋
SNRI	デシプラミン	＋	±	2+	＋	±	＋	＋
SNRI	ノルトリプチリン	＋	＋	＋	＋	±	＋	＋
SNRI	マプロチリン	＋	±	＋	＋	±	＋	2+
SNRI	ベンラファキシン	2+	±	±	±	2+	2+	±
SNRI	デュロキセチン	±	＋	±	＋	＋	±	±
NDRI	ブプロピオン	2+	±	±	＋	＋	±	±
MAOI	フェネルジン	2+	＋	2+	＋	＋	2+	＋
MAOI	トラニルシプロミン	2+	＋	2+	＋	＋	2+	＋
MAOI	イソカルボキサジド	2+	±	2+	＋	＋	2+	2+
MAOI	セレギリン	＋	±	＋	＋	＋	＋	＋
NaSSA	ミルタザピン	±	3+	＋	±	±	±	3+
非定型	ネファゾドン	±	2+	＋	＋	＋	±	＋
非定型	トラゾドン	±	3+	＋	±	＋	2+	＋

「セロトニン」

　　[★]

英: serotonin, 5-HT, 5-hydroxytryptamine
関: 神経伝達物質、セロトニン受容体、セロトニン作動性ニューロン、5-ヒドロキシインドール酢酸 5-HIAA

トリプトファンから生合成される。
生合成：(1)トリプトファンの5位にヒドロキシ基付加　→　(2)脱炭酸
酵素は、芳香族アミノ酸デカルボキシラーゼ(補酵素はピリドキサル5'-リン酸(PLP))
脳や神経で起こる。

生合成
　トリプトファン　　 　　　　　　 →　　　　　　5-ヒドロキシトリプトファン
　　　　　　　　　トリプトファン5-モノオキシゲナーゼ

　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　   　　　OH
　　　　　　　　           ／＼　　　   　　　　　　　       　 ／＼／
　-OOC-CH(NH3+)-CH2----|○｜　→　-OOC-CH(NH3+)-CH2----| ○|
　　　　　　　      ||    |  |　　     　　　　　　   ||    |　 ｜
　　 　　　　 　      ＼ ／ ＼／　　　   　　　　　　     ＼ ／ ＼／
　　　 　　 　          NH　　　　　　          　　　　　　NH
　　　　　　　　　　+                              +
　　　　テトラヒドロビオプテリン　　　　　ジヒドロビオプテリン
　　　　　　　　　　+
　　　　　　　　　　O2

　5-ヒドロキシトリプトファン　　 →　　　　　　セロトニン
　　　　　　　　　芳香族アミノ酸デカルボキシラーゼ

　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　OH
　　　　　　　　           ／＼　　　   　　　　      　 ／＼／
　-OOC-CH(NH3+)-CH2----|○ |　→　H2N-CH2-CH2----| ○|
　　　　　　　      ||    |  ｜ 　    　　　   ||    |   |
　　 　　　　 　      ＼ ／ ＼／　　　   　　　     ＼ ／＼／
　　　 　　 　          NH　　　　　　        　　　　NH