Desvenlafaxine

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Desvenlafaxine
Desvenlafaxine.svg
Desvenlafaxine3Dan2.gif
Systematic (IUPAC) name
4-[2-dimethylamino-1-(1-hydroxycyclohexyl)
ethyl]phenol
Clinical data
Trade names Pristiq
AHFS/Drugs.com monograph
MedlinePlus a608022
Licence data US FDA:link
Pregnancy cat. B2 (AU) C (US)
Legal status Prescription Only (S4) (AU) -only (CA) -only (US)
Routes Oral
Pharmacokinetic data
Bioavailability 80%
Protein binding Low (30%)
Metabolism CYP3A4, (CYP2D6 is not involved)
Half-life 11 h
Excretion 45% excreted unchanged in urine
Identifiers
CAS number 93413-62-8 YesY
ATC code N06AX23
PubChem CID 125017
DrugBank DB06700
ChemSpider 111300 YesY
UNII NG99554ANW YesY
KEGG D07793 YesY
ChEMBL CHEMBL1118 YesY
Chemical data
Formula C16H25NO2 
Mol. mass 263.38 g/mol
 YesY (what is this?)  (verify)

Desvenlafaxine (brand name: Pristiq), also known as O-desmethylvenlafaxine, is an antidepressant of the serotonin-norepinephrine reuptake inhibitor class developed and marketed by Wyeth (now part of Pfizer). Desvenlafaxine is a synthetic form of the major active metabolite of venlafaxine (sold under the brand names Effexor and Efexor). It is being targeted as the first non-hormonal based treatment for menopause.[1]

Medical uses[edit]

Desvenlafaxine's primary use in medicine is in the treatment of major depressive disorder.[2]

Adverse effects[edit]

Adverse effect incidence[2][3][4]

Very common (>10% incidence) adverse effects include:

  • Nausea
  • Headache
  • Dizziness
  • Dry mouth
  • Hyperhidrosis
  • Diarrhea
  • Insomnia
  • Constipation
  • Fatigue

Common (1-10% incidence) adverse effects include:

  • Tremor
  • Blurred vision
  • Mydriasis
  • Decreased appetite
  • Sexual dysfunction
  • Insomnia
  • Anxiety
  • Elevated cholesterol and triglycerides
  • Proteinuria
  • Vertigo
  • Feeling jittery
  • Asthenia
  • Nervousness
  • Hot flush
  • Irritability
  • Abnormal dreams
  • Urinary hesitation
  • Yawning
  • Rash

Uncommon (0.1-1% incidence) adverse effects include:

Rare (<0.1% incidence) adverse effects include:

Unknown frequency adverse effects include:

Pharmacology[edit]

Desvenlafaxine is a synthetic form of the isolated major active metabolite of venlafaxine, and is categorized as a serotonin-norepinephrine reuptake inhibitor (SNRI). When most normal metabolizers take venlafaxine, approximately 70% of the dose is metabolized into desvenlafaxine, so the effects of the two drugs are expected to be very similar.[5] It works by blocking the "reuptake" transporters for key neurotransmitters affecting mood, thereby leaving more active neurotransmitters in the synapse. The neurotransmitters affected are serotonin (5-hydroxytryptamine) and norepinephrine (noradrenaline). It is approximately 10 times more potent at inhibiting serotonin uptake than norepinephrine uptake.[6]

Transporter Ki[nM][7]
SERT 61.4
NET 2953

Approval status[edit]

United States[edit]

Wyeth announced on 23 January 2007 that it received an "approvable" letter from the Food and Drug Administration for desvenlafaxine. Final approval to sell the drug was contingent on a number of things, including:

  • a satisfactory FDA inspection of Wyeth's Guayama, Puerto Rico facility, where the drug is to be manufactured;
  • several postmarketing surveillance commitments, and follow-up studies on low-dose use, relapse, and use in children;
  • clarity by Wyeth around the company's product education plan for physicians and patients;
  • approval of desvenlafaxine's proprietary name, Pristiq.[8]

The FDA approved the drug for antidepressant use in February 2008, and was to be available in US pharmacies in May 2008.[9]

Canada[edit]

On February 4, 2009, Health Canada approved use of desvenlafaxine for treatment of depression in Canada.[10] Pristiq is now available in Canadian pharmacies.

European Union[edit]

In the European Union desvenlafaxine succinate has not been approved for any indication. In 2008, Wyeth withdrew its application for Ellefore, the product under review for treatment of major depressive disorder. The reasons given by Wyeth, and comments regarding the findings of the reviewing agency are provided in a "question and answer" format document.[11] The European Medicines Agency explained that

the [Committee for Medicinal Products for Human Use] had some concerns and was of the provisional opinion that Ellefore could not have been approved for the treatment of major depressive disorder [and] overall, the effectiveness of Ellefore had not been shown convincingly. In relation to its parent substance, venlafaxine, desvenlafaxine seemed to be less effective with no advantages in terms of safety and tolerability. Id.

The Withdrawal Assessment Report,[11] which summarizes the data submitted by the applicant and the opinion of the reviewing agency further noted, at page 19, that

It is curious that the results of all flexible dose studies show a small and non-significant difference from placebo. One would expect the flexible dose studies to produce more positive results, because doses are suited to individual needs rather than being forced, as they are, in the fixed dose studies. Furthermore, flexible dose study mirror to a greater extent the clinical situation. The applicant attributes the failure of the flexible dose studies to the high proportion of failed studies that is usually seen in depression studies but does not address the systematic nature of the difference in study results between the fixed and the flexible dose studies.Id.

The Benefit Risk Assessment section of the Withdrawal Assessment Report begins at p. 26 by noting that

"Desvenlafaxine is the main metabolite of venlafaxine. As venlafaxine is already approved for the treatment of [Major Depressive Disorder] and as venlafaxine is almost entirely transformed into desvenlafaxine, it would be expected that efficacy and safety of desvenlafaxine in the treatment of MDD would be very similar to that of venlafaxine. Id."

Furthermore,

"Efficacy of desvenlafaxine would be expected based on the fact that venlafaxine is an antidepressant with established efficacy and the fact that desvenlafaxine is the active metabolite of venlafaxine. However the efficacy results are far from impressive. The evidence with respect to long-term efficacy is considered lacking. The dose used in the randomised withdrawal study does not support long-term efficacy in the doses that are indicated in the SPC (50 mg). In addition, the definition of relapse that was used in the long-term study allows for relapses that might be due to deteriorations that are not related to depression. Therefore, the data of the long-term study need to be re-analysed with an acceptable definition of relapse."Id.

Similarly, a parallel application for approval of another desvenalfaxine succinate product as a treatment for vasomotor symptoms associated with menopause ("hot flashes") was withdrawn by Wyeth under similar circumstances in 2008. The proposed product contained the same active compound at the same dose as "Ellefore" but this application was for "Pristiq".

The Committee for Medicinal Products for Human Use found,[12]that

"meaningful benefit of Pristiqs had not been demonstrated, when considered alongside the safety of the medicine in postmenopausal women, including side effects after stopping treatment."

Complete reporting from the European Medicines Agency regarding the withdrawal of Wyeth's application for Ellefore, including multiple language versions of the Q and A document, is freely available for public review.[13]

Complete reporting from the European Medicines Agency regarding the withdrawal of Wyeth's application for Pristiqs, including the Withdrawal Assessment Report as well as multiple language versions of the Q and A document, is also freely available for public review.[14]

Clinical efficacy[edit]

Pristiq 50 mg tablets (US)

In published phase 3 trials, desvenlafaxine was compared only to placebo. In these trials, primary endpoints were powered to measure a reduction in depression (HAM-D17) scores[15][16][17] and not the standard response measure of ≥50% reduction in depression scores.[18]

Response scores were secondary measures which the studies may or may not have been powered to address. These trials showed dose-erratic reductions in HAM-D17 scores, reductions which undermined the results. Response rates varied from 43-60%, lower than most current antidepressants, which have a 60-70% response rate.[18] Remission rates of 23-37% for desvenlafaxine are also lower than those of other antidepressants, which have rates of 30-40%. Of course, generalizations of this nature cannot be made without careful statistical testing, and such testing was beyond the scope of this project.

Treatment duration for the three reviewed trials seemed inadequate, given the staging of Major Depressive Disorder (MDD). MDD acute phase lasts 12 weeks, while all three reviewed studies treated patients for only 8 weeks.[18][19] Although it may not be practical or required to conduct a study of continuing therapy for an entire year, without the data that would result it is difficult to determine whether or not desvenlafaxine is an appropriate therapy.

References[edit]

  1. ^ "Wyeth Receives Approvable Letter From FDA for PRISTIQ for the Treatment of Vasomotor Symptoms Associated With Menopause" (Press release). Wyeth. 2007-07-24. Retrieved 2007-07-31. 
  2. ^ a b "PRODUCT INFORMATION PRISTIQ® desvenlafaxine (as succinate)" (PDF). TGA eBusiness Services. Pfizer Australia Pty Ltd. 10 December 2012. Retrieved 8 November 2013. 
  3. ^ "DESVENLAFAXINE tablet, extended release [Ranbaxy Pharmaceuticals Inc.]". DailyMed. Ranbaxy Pharmaceuticals Inc. March 2013. Retrieved 9 November 2013. 
  4. ^ "desvenlafaxine (Rx) - Pristiq, Khedezla". Medscape Reference. WebMD. Retrieved 9 November 2013. 
  5. ^ Lemke, Thomas L.; Williams, David A. (2012). Foye's Principles of Medicinal Chemistry. Lippincott Williams & Wilkins. p. 609. ISBN 978-1-60913-345-0. 
  6. ^ Deecher, DC; Beyer, CE; Johnston, G; Bray, J; Shah, S; Abou-Gharbia, M; Andree, TH (August 2006). "Desvenlafaxine succinate: A new serotonin and norepinephrine reuptake inhibitor" (PDF). The Journal of Pharmacology and Experimental Therapeutics 318 (2): 657–665. doi:10.1124/jpet.106.103382. PMID 16675639. 
  7. ^ Roth, BL; Driscol, J (12 January 2011). "PDSP Ki Database". Psychoactive Drug Screening Program (PDSP). University of North Carolina at Chapel Hill and the United States National Institute of Mental Health. Retrieved 9 November 2013. 
  8. ^ "Wyeth Receives Approvable Letter From FDA For Pristiq (Desvenlafaxine Succinate) For The Treatment Of Major Depressive Disorder" (Press release). 2007-01-23. Retrieved 2007-04-04. 
  9. ^ "FDA Approves Pristiq" (Press release). Wyeth. 2008-02-29. Retrieved 2008-02-29. 
  10. ^ Health Canada Notice of Compliance - Pristiq. February 4, 2009, retrieved on March 9, 2009.
  11. ^ a b http://www.ema.europa.eu/humandocs/PDFs/EPAR/ellefore/H-932-WQ&A-en.pdf
  12. ^ http://www.ema.europa.eu/humandocs/PDFs/EPAR/pristiqs/12542108en.pdf
  13. ^ http://www.ema.europa.eu/humandocs/Humans/EPAR/ellefore/elleforeW.htm
  14. ^ http://www.ema.europa.eu/humandocs/Humans/EPAR/pristiqs/pristiqsW.htm
  15. ^ DeMartinis, NA; Yeung, PP; Entsuah, R; Manley, AL (2007). "A double-blind, placebo-controlled study of the efficacy and safety of desvenlafaxine succinate in the treatment of major depressive disorder". J Clin Psychiatry 68 (5): 677–88. doi:10.4088/JCP.v68n0504. PMID 17503976. 
  16. ^ Liebowitz, MR; Yeung, PP; Entsuah, R. "A randomized, double-blind, placebo-controlled trial of desvenlafaxine succinate in adult outpatients with major depressive disorder". J Clin Psychiatry 68 (11): 1663–72. doi:10.4088/JCP.v68n1105. PMID 18052559. 
  17. ^ Septien-Velez, L; Pitrosky, B; Padmanabhan, SK; Germain, JM; Tourian, KA (2007). "A randomized, double-blind, placebo-controlled trial of desvenlafaxine succinate in the treatment of major depressive disorder". Int Clin Psychopharmacol 22 (6): 338–47. doi:10.1097/YIC.0b013e3281e2c84b. PMID 17917552. 
  18. ^ a b c Koda-Kimble, Mary Anne; Young, Lloyd Lee; Kradjan Wayne A, Guglielmo, B. Joseph; Alldredge, Brian K. (June 2004). Applied Therapeutics: The Clinical Use of Drugs. Lippincott Williams & Wilkins. ISBN 978-0-7817-4845-2. 
  19. ^ Karasu, TB; Gelenberg, A; Meriam, A; Wang, P. "Practice Guideline for the Treatment of Patients With Major Depressive Disorder Second Edition". Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Second Edition. American Psychiatric Association. doi:10.1176/appi.books.9780890423363.48690. ISBN 0-89042-336-9. Retrieved 2008-04-22. 

External links[edit]