Paroxetine

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Paroxetine
Paroxetine2DACS.svg
Paroxetine3DACS2.gif
Systematic (IUPAC) name
(3S,4R)-3-[(2H-1,3-benzodioxol-5-yloxy)methyl]-4-(4-fluorophenyl)piperidine
Clinical data
Trade names Paxil, Pexeva, Brisdelle, Rexetin
AHFS/Drugs.com monograph
MedlinePlus a698032
Licence data US FDA:link
Pregnancy cat. D (AU) D (US)
Legal status Prescription Only (S4) (AU) -only (CA) POM (UK) -only (US)
Routes Oral
Pharmacokinetic data
Bioavailability Extensively absorbed from the GI tract, but extensive first-pass metabolism in the liver[1][2][3][4]
Protein binding 93–95%[1][2][3]
Metabolism Extensive, hepatic (mostly CYP2D6-mediated)[1][2][3]
Half-life 21 hours[1][2][3]
Excretion Renal (64%; 2% unchanged and 62% as metabolites), Faecal (36%; <1% unchanged)[1][2][3]
Identifiers
CAS number 61869-08-7 YesY
ATC code N06AB05
PubChem CID 43815
DrugBank DB00715
ChemSpider 39888 YesY
UNII 41VRH5220H YesY
KEGG D02362 YesY
ChEBI CHEBI:7936 N
ChEMBL CHEMBL490 YesY
Chemical data
Formula C19H20FNO3 
Mol. mass 329.3
 N (what is this?)  (verify)

Paroxetine (also known by the trade name Paxil among others) is an antidepressant drug of the SSRI type. Paroxetine is used to treat major depression, obsessive-compulsive disorder, panic disorder, social anxiety, posttraumatic stress disorder, generalized anxiety disorder and vasomotor symptoms (e.g. hot flashes and night sweats) associated with menopause[5][6] in adult outpatients.

Marketing of the drug began in 1992 by the pharmaceutical company SmithKline Beecham, now GlaxoSmithKline. Generic formulations have been available since 2003 when the patent expired.[7] As with all antidepressants there may be an increased risk of suicidality in patients receiving paroxetine, although the only solid evidence regarding this is with regard to children and young adults under the age of 25.[2]

Differences between newer antidepressants are usually fairly subtle and mostly confined to side effects. It shares the common side effects and contraindications of other SSRIs, with high rates of nausea, sleepiness, and sexual side effects. Paroxetine is associated with weight gain.[8] Discontinuing paroxetine is associated with a high risk of withdrawal syndrome.[9][10] Paroxetine is the only SSRI proven to be associated with an increased risk of birth defects.[11]

Medical uses[edit]

Paroxetine is primarily used to treat major depression, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder, generalized anxiety disorder (GAD),[12] social phobia/social anxiety disorder,[13] premenstrual dysphoric disorder (PMDD)[14] and menopausal hot flashes.

Paroxetine was the first antidepressant formally approved in the United States for the treatment of panic attacks.[15]

Depression[edit]

When both published and unpublished trials are looked at, paroxetine does not appear to be any better than placebo in adults with moderate or severe depression.[16] The quality of the evidence for new antidepressants in children of which paroxetine is one is poor.[17] Overall the available evidence does not support the efficacy of paroxetine in children.[18][19][20][21] The efficacy of paroxetine is inferior to sertraline, escitalopram, mirtazapine and venlafaxine.[22]

Menopausal hot flashes[edit]

On June 28, 2013 U.S. FDA approved low dose paroxetine – for the treatment of moderate-to-severe vasomotor symptoms (e.g. hot flashes and night sweats) associated with menopause.[23] Side effect such as nausea and weakness are however relatively common.[24]

Pregnancy[edit]

The American College of Obstetricians and Gynecologists recommends that for pregnant women and women planning to become pregnant, "treatment with all SSRIs or selective norepinephrine reuptake inhibitors or both during pregnancy be individualized and paroxetine use among pregnant women or women planning to become pregnant be avoided, if possible."[11] According to the prescribing information[25] "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.[26][27][28][29][30] A recent non-systematic review, reporting to have received support from GSK, came to a different conclusion: "the teratogenic potential of paroxetine that has been reported in some studies remains unproven".[31] Other reviews vary on whether the teratogenic risks outweigh the risk of disease relapse if the drug is discontinued: some advocate discontinuation,[26] while others suggest caution;[28] even where the overview of antidepressants generally is favorable, paroxetine is singled out for specific risks.[29] Paroxetine use during pregnancy increases the risk of spontaneous abortion.[32][33]

A large 2010 study — using the Swedish Medical Birth Register (MBR) from 1 July 1995 up to 2007 identified women who reported the use of antidepressants in early pregnancy or were prescribed antidepressants during pregnancy by antenatal care — found a specific association between Paxil use and infant cardiovascular defects.[34] A strong association between Paxil and hypospadias was also concluded in this study, though the researchers concluded that it is not clear if these effects were due to drug use or underlying pathology.[34]

Abrupt discontinuation of psychotropic drugs during pregnancy can also lead to serious adverse effects.[35]

Counseling is effective in reassuring women to adhere to therapy,[35] but neonatal paroxetine withdrawal symptoms described above have been documented from mothers taking Paxil during pregnancy.[36]

Contraindications[edit]

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 Food and Drug Administration requires this drug to carry a boxed warning, its "most serious type of warning in prescription drug labeling",[37] 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.[38]

Adverse effects[edit]

Paroxetine shares many of the common adverse effects of SSRIs, including: nausea (15–24%), diarrhoea (10–15%), constipation (10–15%), dry mouth (15–20%), somnolence (20–25%), insomnia (11–24%), headache (17%), hypomania (a dangerously elated/irritable mood; 0.3–2.2%), blurred vision (5–10%), loss of appetite (5–10%), nervousness (2–5%), paraesthesia (2–5%), dizziness (10–15%), asthenia (weakness; 10–15% incidence), inappropriate hugging and touching (1-5%), tremor (10–15%), change in personality (5-10%), aggression (1-3%), anxiety (5–10%), sweating (10–15%) and sexual dysfunction (≥10% incidence).[4] Most of these adverse effects are transient and go away with continued treatment. Excess 5-HT2 receptor stimulation in the brain results in the increased anxiety, insomnia, reduced libido and irritability.[39] Excess 5-HT2receptor stimulation in the spinal cord results in the physical (as opposed to psychological, namely reductions in libido) aspects of sexual dysfunction such as erectile dysfunction, ejaculatory delay and anorgasmia (trouble achieving orgasm).[39] Central and peripheral 5-HT3 receptor stimulation is believed to result in the gastrointestinal effects observed with SSRI treatment.[39] Compared to other SSRIs it has a lower incidence of diarrhoea, a higher incidence of anticholinergic effects (e.g. dry mouth, constipation, blurred vision, etc.), sedation/somnolence/drowsiness, sexual side effects and weight gain.[40]

Sexual side effects often include difficulty becoming aroused, lack of interest in sex, and anorgasmia. Genital anaesthesia,[41] loss of or decreased response to sexual stimuli, and ejaculatory anhedonia are also possible. Although usually reversible, these sexual side effects can last for months or years after the drug has been completely withdrawn.[42] This is known as post SSRI sexual dysfunction.

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 also gave a warning to prescribers recommending close monitoring of adult patients at high risk of suicidal behaviour and/or suicidal thoughts. CHMP does not prohibit use of paroxetine with high risk adults but urges extreme caution. Due to reports of adverse withdrawal reactions upon terminating treatment, CHMP recommends to reduce gradually over several weeks or months if the decision to withdraw is made.[43] See also Discontinuation syndrome (withdrawal).

Mania or hypomania may occur as a serious side effect of paroxetine,[44][45][46] affecting up to 8% of psychiatric patients treated. This side effect can occur in individuals with no history of mania but it may be more likely to occur in those with bipolar or with a family history of mania.[47] Cases of akathisia[48][49] and activation syndrome[50][51] have been observed during paroxetine treatment. As described in the UK notice of Paxil, alcohol abuse can also appear.[25] Rarely serotonin syndrome, a severe adverse effect may occur.[52][53] In males, paroxetine is also linked to sperm DNA fragmentation.[54] Paroxetine is associated with an increased risk of hyperacusis as compared with some similar medications.[55]

Schmitt et al. (2001) suggested that paroxetine negatively affects long-term memory, but not short-term, although the result has not been independently verified. 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.[56] Serotonin reuptake inhibitors, like paroxetine, may also impair vigilance, perhaps by interacting with the 5-HT2C receptors which regulate the release of dopamine in the prefrontal cortex.[57]

Suicide[edit]

Paroxetine may increase the risk of suicidal ideation and suicidal behaviour in children and adolescents. Because suicide is rare, it is difficult to test its relationship with the use of paroxetine. Some studies instead analyze suicidality, which generally refers to suicidal ideation and suicidal behaviour. The FDA conducted a statistical analysis of paroxetine clinical trials in children and adolescents in 2004, finding an increase in "suicidality" and ideation as compared to placebo; the trend for increased "suicidality" was observed in both trials for depression and for anxiety disorders.[18] A University of North Carolina review of SSRIs found the average risk of suicide among adolescents was 4%, versus 2% on placebo, and among all patients "the greatest risk of self-harm was among paroxetine users."[58]

Discontinuation syndrome[edit]

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.[59] 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.[60][61] 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.[9][62][63]

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."[64]

Overdose[edit]

Acute overdosage is often manifested by emesis, lethargy, ataxia, tachycardia and seizures. Plasma, serum or blood concentrations of paroxetine may be measured to monitor therapeutic administration, confirm a diagnosis of poisoning in hospitalized patients or to aid in the medicolegal investigation of fatalities. Plasma paroxetine concentrations are generally in a range of 40–400 μg/L in persons receiving daily therapeutic doses and 200–2000 μg/L in poisoned patients. Postmortem blood levels have ranged from 1–4 mg/L in acute lethal overdose situations.[65][66] It is usually considered, along with the other SSRIs, sertraline and fluoxetine to be a low-risk drug in cases of overdose.[67]

Interactions[edit]

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 that 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.[25]

Paroxetine is interacts with the following cytochrome P450 enzymes:[40]

  • CYP2D6 for which it is both a substrate and a potent inhibitor.[1][40] Its interaction with the CYP2D6 substrate (which is activated by CYP2D6 into its pharmacologically active form) and breast cancer medication, tamoxifen, is so great that the risk of mortality from breast cancer is increased by 24–91% (depending on the time and extent of coexposure) in patients coadministered paroxetine during tamoxifen treatment.[68]
  • CYP2B6 (strong) inhibitor.
  • CYP3A4 (weak) inhibitor.
  • CYP1A2 (weak) inhibitor.
  • CYP2C9 (weak) inhibitor.
  • CYP2C19 (weak) inhibitor.

Pharmacology[edit]

Paroxetine is the most potent and one of the most specific selective serotonin (5-hydroxytryptamine, 5-HT) reuptake inhibitors (SSRI).[69] It also binds to the allosteric site of the serotonin transporter, similarly, but less potently than escitalopram.[70] This activity of the drug on brain neurons is thought to be responsible for its antidepressant effects. Paroxetine inhibits the reuptake of norepinephrine more than the other SSRIs, just as sertraline inhibits the reuptake of dopamine more than the other SSRIs.[40]

Its affinities are as follows:[71][39]

Paroxetine has been shown to have antimicrobial activity against several groups of microorganisms, mainly Gram positive microorganisms. It also shows synergistic activity when combined with some antibiotics against several bacteria.[72] Additionally, paroxetine has demonstrated antifungal activity, being most potent against the hypersusceptible Candida albicans strain DSY1204.[73]

Formulations[edit]

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.[74]

Society and culture[edit]

Controversy[edit]

For 10 years, GlaxoSmithKline marketing of the drug stated that it was "not habit forming", which numerous experts and at least one court found to be incorrect.[75][76][77] In 2002, the U.S. FDA published a new product warning about the drug, and the International Federation of Pharmaceutical Manufacturers Associations said GSK had misled the public about paroxetine and breached two of the Federation's codes of practice.[78] 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.

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." Paroxetine prescribing information posted at GlaxoSmithKline now acknowledges the occurrence of a discontinuation syndrome, including serious discontinuation symptoms.[25]

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, after GSK had specifically advertised the drug as non-habit forming.

In February 1998, 60-year-old Donald Schell was diagnosed with an anxiety state and placed on Paxil. Within forty-eight hours of being put on Paxil Schell killed his wife, daughter, infant granddaughter, and himself. Tim Tobin, Schell’s son-in-law, took legal action against SmithKline Beecham. Psychiatrist David Healy was retained as an expert witness in the case. The Tobin case was heard in Cheyenne, Wyoming from May 21 to June 6, 2001. On the stand SmithKline Beecham representative Ian Hudson indicated that no matter how many physicians or clinicians reported to the company that they thought suicide was related to the Paxil, SmithKline Beecham would deny causation. The jury returned a guilty verdict against SmithKline Beecham and awarded Tobin $6.4 million.[79][80][81][82] This was the first verdict returned guilty against a pharmaceutical company regarding adverse behavioral effects of a psychotropic drug".[79]

In 2001, GSK increased its American TV advertising of Paxil after the September 11 attacks; in October 2001, GSK spent nearly twice as much as in October 2000.[83] The difficulty of withdrawal from paroxetine, and GSK's concealment of it, was later reported on ABC.[84]

Since 2001 in the UK, 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.[85][86]

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).[87] 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".[88]

In June 2004, FDA published a violation letter to GSK in response to a "false or misleading" TV ad for Paxil CR; FDA stated, "This ad is concerning from a public health perspective because it broadens the use of Paxil CR [beyond the conditions it was approved for] while also minimizing the serious risks associated with the drug."[89] GSK claimed the ad had been previously reviewed by FDA, but said the ad would not run again.[90]

On January 29, 2007, the BBC broadcast a fourth documentary in its Panorama series about the drug Seroxat.[91] 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. Results from Study 329, one of the trials, were reported[92] in a way that misled readers about paroxetine's safety and efficacy, and contributed to repeated distortions in the assessment of the drug's value in paediatric depression in the scientific literature.[93][unreliable source?]

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 2008, Nemeroff stepped down as department chair 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."[94]

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. The book chronicles the lives of two women – a prosecutor and a whistleblower – who exposed deception in the research and marketing of Paxil. The book shows the connections between pharmaceutical giant GlaxoSmithKline, a top Ivy League research institution, and the government agency designed to protect the public – conflicted relationships that arguably compromised the health and safety of vulnerable children. Side Effects received the NASW Science in Society Award for 2009.[95][96]

In 2012 the U.S. Justice Department announced that GSK had agreed to plead guilty and pay a $3 billion fine, in part for promoting the use of Paxil for children.[97]

Sales[edit]

In 2007, paroxetine was ranked 94th on the list of bestselling drugs, with over $1 billion in sales. In 2006, paroxetine was the fifth-most prescribed antidepressant in the United States retail market, with more than 19.7 million prescriptions.[98] In 2007, sales had dropped slightly to 18.1 million but paroxetine remained the fifth-most prescribed antidepressant in the U.S.[99][100]

Trade names[edit]

Aropax, Brisdelle, Deroxat, Paxil,[101] Pexeva, Paxtine, Seroxat,[102] and Sereupin.

In 1999 paroxetine was the second SSRI(after fluvoxamine) to be approved in Japan.[103] Paroxetine became the first and non-hormonal prescription therapy for menopausal hot flashes approved by FDA.[23]

Research[edit]

Several studies have suggested that paroxetine can be used in the treatment of premature ejaculation. In particular, intravaginal ejaculation latency time (IELT) was found to increase with 6–13-fold, which was somewhat longer than the delay achieved by the treatment with other SSRIs (fluvoxamine, fluoxetine, sertraline, and citalopram).[104][105][106] 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.[106] The reason it causes a delay in ejaculation is because it greatly reduces sex drive, in some cases, causing an inability to gain an erection or ejaculate. SSRIs are also effective in the treatment of severe premenstrual syndrome;[107] however, paroxetine is contraindicated in women who may become pregnant due to its teratogenicity and its high risk of withdrawal syndrome in both adults and neonates. See Paroxetine and pregnancy.

There is also evidence that paroxetine may be effective in the treatment of compulsive gambling[108] and hot flashes.[109]

Benefits of paroxetine prescription for diabetic neuropathy[110] or chronic tension headache.[111] are uncertain.

Emerging evidence shows that antipsychotics can be used as a supplement or alternative to paroxetine in patients with generalised anxiety disorder.[5]

Although the evidence is conflicting, paroxetine may be effective for the treatment of dysthymia, a chronic disorder involving depressive symptoms for most days of the year.[112]

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