Initial drug treatment in Parkinson’s disease
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4669 (Published 18 September 2015) Cite this as: BMJ 2015;351:h4669Click for an interactive graphic, showing more treatments for initial management of Parkinson’s disease.
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Re: Reboxetine and MAO-B-Inhibitors
Our recommendations were based on the NICE guidance on management of depression (2009). We agree that Reboxetine is not an effective treatment as shown by the 2010 systematic review, so it is probably time the NICE guidance on management of depression is updated.
Re: Entacapone and Stalevo
Based on available evidence (systematic reviews and RCTS), levodopa, dopamine agonists and monoamine oxidase B Inhibitors are the only recommended treatments in early disease. Levodopa with entacapone and Stavelo are not licensed as monotherapy so should not be used. Further, the STRIDE PD study (Stocchi et al 2010) showed a higher frequency of dyskinesias and reduced time to onset of dyskinesias in patients treated with Stalevo compared to those on levodopa-carbidopa. So we do not advocate Stalevo in early disease.
Competing interests: S Muzerengi: None. CE Clarke has received payments for the following: Advisory Boards: AbbVie, Britannia, Lundbeck, Teva, UCB; Honoraria for speaking: AbbVie, Britannia, Chiesi, Lundbeck, Teva, UCB; Educational grants: AbbVie, Britannia, GE Healthcare, Lundbeck, Medtronic, Teva.
Dear Madam
Muzerengi and Clarke are correct to advise against use of most antidepressants in combination with the monoamine oxidase B inhibitors, Rasagiline and Selegiline (1). But it is unhelpful to state that Reboxetine can be used instead, because it is a drug that has no therapeutic effect whatsoever (2).
It is five years since a meta-analysis including unpublished trials proved that the "antidepressant" Reboxetine does not work (2). Yet, scandalously, the drug remains licensed in the United Kingdom (3) and elsewhere for treatment of depressive disorder. British guidance recommending Reboxetine (4), quoted in good faith by the authors, has never been amended. Patients continue to be exposed to its adverse effects whilst their illnesses go untreated.
It is not time for Reboxetine and all other debunked treatments to be delicensed?
I beg to remain, Madam, your most obedient servant,
Dr Richard Braithwaite
Consultant Psychiatrist
Isle of Wight NHS Trust
St Mary's Hospital
Newport
Isle of Wight
PO30 5TG
Muzerengi S, Clarke CE. Initial drug treatment in Parkinson’s disease. BMJ 2015; 351 :h4669
Eyding D, Lelgemann M, Grouven U, Härter M, Kromp M, Kaiser T, Kerekes MF, Gerken M, Wieseler B. Reboxetine for acute treatment of major depression: systematic review and meta-analysis of published and unpublished placebo and selective serotonin reuptake inhibitor controlled trials. BMJ 2010;341:c4737
Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. www.medicinescomplete.com [Accessed on 10 October 2015]
National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: treatment and management. 2009. www.nice.org.uk/guidance/cg91 [Accessed on 10 October 2015]
Competing interests: No competing interests
I found this a helpful review. I wonder why entacapone (and its fixed drug combination Stalevo) was omitted. Many experts appear to be using Stalevo first line; I am not convinced of advantage and was disappointed that this is not addressed in this paper. Could the authors comment on this?
Competing interests: No competing interests
In the section on cost effectiveness, a statement is made by the authors regarding health economic studies for anti-Parkinsonian medicines, "However these studies were funded by drug companies and results may be biased". i wonder if I submitted a pair which said "However these studies were funded by anti-pharma ideologies and may be biased" whether the statement would escape editorial scrutiny. I rather doubt it.
I presume the authors meant to use the word "biased" in a lay, non-technical sense, meaning deliberately distorted to suit a purpose. If not, then I wonder if they are aware that almost all studies have some degree of random or systematic bias. Do they also consider that entities apart from pharmaceutical (or as they have it, drug) companies may produce material which is based? Some such people publish books to the retail market decrying the industry but escape any accusations of bias themselves. It is a real pity that the BMJ has a blind spot on what is, ironically, their bias.
Competing interests: Fellow of the Faculty of Pharmaceutical Medicine
Re: Initial drug treatment in Parkinson’s disease
In a recent multicenter, double-blind, placebo-controlled, clinical trial, earlier administration of levodopa in combination with carbidopa did not have a disease-modifying effect or any alteration of dyskinesia rates.
Reference
https://www.nejm.org/doi/full/10.1056/NEJMoa1809983
Competing interests: No competing interests