前沿第二十八期:抑郁症治疗需用好非典型抗精神病药这张牌

2017-06-21 10:51 来源:《前沿》杂志 作者:刘向欣 贾福军
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尽管目前抗抑郁药选择较多,但依然有大量患者因治疗效果不佳或无法耐受药物副作用而导致治疗失败 [1,2];实际上,只有约三分之一患者能够达到真正的症状缓解 [3]

抗抑郁的第二张牌:非典型抗精神病药

在美国,仅 2007~2008 年就有近 4000 万抑郁症患者服用非典型抗精神病药物(Second Generation Antipsychotics, SGAs)[4]。美国食品与药品管理局(FDA)已经批准阿立哌唑、喹硫平以及奥氮平用于难治性抑郁症的联合治疗 [5]

不仅对难治性抑郁,目前 SGAs「增效」治疗重性抑郁的研究也较多 [6,7,8]。其中,Brexpiprazole(依匹哌唑)由于疗效确切,已被 FDA 批准用于重性抑郁症的增效治疗。

杀敌一千,自损八百?

尽管 SGAs 作为抑郁急性期增效药物的疗效已得到公认,但其长期疗效及不良反应情况仍缺乏长期安慰剂对照研究。

1. 谁动了我的「体重」

众所周知,奥氮平相关的体重增加比较明显 [9];但一些较新上市的 SGAs 对体重影响较小,如齐拉西酮。体重增加是个长期问题,任何一种 FDA 批准用于增效的 SGA,均经历过至少一项长期研究的考验 [10]

一项为期 50 周、针对氟西汀的研究发现,抑郁患者体重增加与入组时基线水平食欲下降以及恢复过程中食欲改善相关 [11]

那么问题来了,患者体重增加是由于症状缓解后食欲改善的正常反应?还是药物引起的副反应?我们需要更加长程的对照研究进一步验证。

2. 迟发性运动障碍:中奖概率极低

迟发性运动障碍(TD)也是潜在的安全性问题,但在针对 SGAs 的长期开放标签研究中,TD 的发生率非常低,仅为 0.0%~0.4%[12,13]

选择的天秤:抑郁复发与治疗不耐受 

一项为期 26 周的复发预防研究显示,在复发所需时间方面,奥氟合剂具有显著优势,能够维持更长时间不复发;在复发率方面,奥氟合剂组有 15.8% 受试者复发,而在氟西汀+安慰剂组,这一数字为 31.8%[14]

各类用于抗抑郁增效治疗的 SGAs 药物,因不良事件而停药的比例如下表所示 [15-17]

   药物名称   因不良事件停药比例
   阿立哌唑   3.8%
   奥氮平与氟西汀合剂   11.6%
   喹硫平缓释剂(150mg/d)   8.9%
   喹硫平缓释剂(300mg/d)   15.4%
   利培酮   6.5%
   Brexpiprazole(依匹哌唑)   2.6%

齐拉西酮可以作为抑郁治疗的增效剂吗?

2015 年 6 月,一项发表在 Am J Psychiatry 杂志的研究探讨了艾司西酞普兰联合齐拉西酮增效治疗的疗效。

研究采用多中心随机双盲安慰剂对照设计,受试者在艾司西酞普兰可变剂量治疗 8 周(第一阶段)后仍持续存在抑郁症状。然后随机分入齐拉西酮增效组(艾司西酞普兰+齐拉西酮,N = 71)及安慰剂组(艾司西酞普兰+安慰剂,N = 68),并进行为期 8 周的随访评估(第二阶段)。其中,艾司西酞普兰最低剂量为 10 mg,齐拉西酮的日剂量范围为 40~160 mg。

研究结果显示,齐拉西酮增效组的临床应答率显著高于安慰剂组(35.2% vs.20.5%);但齐拉西酮增效组中,有 10 人(14%)因不耐受而退出治疗,原因包括焦虑、激越/静坐不能、镇静、失眠、QTc 间期>500ms 等,而安慰剂组则无人退出 [18]

因此,齐拉西酮增效治疗有望成为抑郁患者的选择之一,但需注意相关问题的处理:

  • 若患者存在兴奋激越或焦虑不安,可联合使用苯二氮卓类或β-受体阻滞剂;

  • 若出现静坐不能或类帕金森症,可使用β-受体阻滞剂或抗胆碱能药物;

  • 有明显心血管病史应避免使用齐拉西酮;

  • 使用期间应监测 QT 间期,若 QT 间期持续超过 500ms 应停用;

  • 低剂量时(小于 80 mg/d)容易出现激活性症状,少数患者出现睡眠障碍,可逐渐加量至治疗剂量,一般随剂量增加症状会逐渐改善 [19]


参考文献:

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17. Citrome L: Brexpiprazole for schizophrenia and as adjunct for major depressive disorder: a systematic review of the efficacy and safety profile for this newly approved antipsychotic: what is the number needed to treat, number needed to harm, and likelihood to be helped or harmed? Int J Clin Pract 2015; 69:978–997.

18. Papakostas GI, Fava M, Baer L, et al: Ziprasidone augmentation of escitalopram for major depressive disorder: efficacy results from a randomized, double-blind, placebo-controlled study. Am J Psychiatry.2015; 172:1251–1257

19. 黄继忠, 江开达, 司天梅等,齐拉西酮治疗精神分裂症临床应用指导建议,中国新药与临床杂志(Chin J New Drugs Clin Rem),2011 年 9 月,30(9);641-649.

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