Moclobemide - Therapeutic Uses

Therapeutic Uses

Reversible selective MAOIs such as moclobemide are widely underprescribed due to ill-informed physicians who wrongly equate the side effect profile of moclobemide with the potentially dangerous irreversible and non-selective MAOIs. MAOIs such as moclobemide are reported to have a relatively fast onset of action compared to other antidepressant drug classes, and has good long-term tolerability in terms of side effects. Moclobemide has been found to be as effective as other potent antidepressants. Psychotic depression, unipolar endogenous depression, bipolar depression, depression with and without melancholia, retarded depression as well as agitated depression all respond to moclobemide, as does neurotic depression, reactive depression. Unipolar endogenous depression is reported to have the best response to moclobemide therapy. Individuals suffering from depression who are given moclobemide are twice as likely to improve on moclobemide than on placebo. A concern of antidepressant adverse effects is sexual dysfunction, however moclobemide has actually been found to increase the libido and also improve impaired erection, ejaculation and orgasm. Cardiovascular toxicity is a concern with antidepressants such as tricyclic antidepressants as well as the irreversible MAOIs; when cardiovascular toxicity is a concern, SSRIs or the reversible MAOIs such as moclobemide are an option as they lack or have a significantly reduced level of cardiovascular toxicity in terms of adverse effect as well as in overdose.

Tolerance does not seem to occur; research has found that moclobemide retains its beneficial therapeutic properties in depression for at least a year.

• Depression; Moclobemide has demonstrated effectiveness and efficacy in the treatment and management of major depressive disorder, with both endogenous and non-endogenous depression responding; in addition moclobemide has a fast onset of action compared to other antidepressants and is significantly more tolerable than the tricyclic antidepressants. Due to a very good safety profile and very low incidence of side effects moclobemide is likely to have a high level of acceptability by individuals suffering from depression. Reversed depressive symptoms such as hypersomnia, and increased appetite, and irritability in children and in adolescents may respond particularly well to moclobemide. Moclobemide may be less effective than tricyclic antidepressants in severe depression.

• Dysthymia; moclobemide has been found to be effective in the treatment and management of this depressive disorder.

• Agitated depression; The effectiveness of moclobemide in agitated depression is equivalent to that of imipramine and sedative antidepressants such as amitriptyline, mianserin and maprotiline. The therapeutic response in agitated depressive individuals is similar to that seen in non-agitated depression; however a past history of use of antidepressants reduces the chance of successful therapeutic response. The addition of a benzodiazepine to moclobemide therapy has not been found to be of benefit in this population group.

• Elderly; Reversible MAOIs such as moclobemide may have advantages in the treatment of depression associated with Alzheimer's disease due to its effect on noradrenaline. Cognitive impairments have been found to improve in people with dementia when depression is treated with moclobemide. Due to its superior safety profile, moclobemide has been recommended as a first line agent for the treatment of depression in the elderly. Due to the side effect profile of moclobemide, it may be a better option for this sub group of people than other antidepressants. Research has found evidence that moclobemide may be able to counter cholinergic induced cognitive impairments thus making moclobemide a good choice in the depression in the elderly and those with dementia.

• Social phobia; Moclobemide has been found to be effective for the treatment of social anxiety disorder in both short and long-term placebo controlled clinical trials. Moclobemide, is as effective as other MAOIs in the treatment of social phobia, however maximal benefits can take 8 – 12 weeks to manifest. There is a high risk of treatment failure if there is co-morbid alcohol abuse, however.

• Smoking cessation; Moclobemide has been tested in heavy dependent smokers against placebo based on the theory that tobacco smoking could be a form of self medicating of major depression, and moclobemide could therefore help increase abstinence rates due to moclobemide mimicking the MAO-A inhibiting effects of tobacco smoke. Moclobemide was administered for 3 months and then stopped; at 6 months follow-up it was found those who had taken moclobemide for 3 months had a much higher successful quit rate than those in the placebo group. However, at 12 month follow-up the difference between the placebo group and the moclobemide group was no longer significant.

• Panic disorder; Moclobemide is useful in the treatment and management of panic disorder.

• ADHD. Two small studies assessing the benefit of moclobemide in people with attention deficit disorder found that moclobemide produced favourable results.

• Migraine; Moclobemide has been reported to be effective in the treament of migraine and chronic tension headache.

Similar to other MAOIs, reversible MAOIs such as moclobemide may also be effective in a range of other psychiatric disorders. Menopausal flushing may also respond to moclobemide. Moclobemide may also have benefit for some patients with Parkinson's Disease by extending and enhancing the effects of l-dopa.

In efficacy studies for the treatment of major depressive disorder, moclobemide has been found to be significantly more effective than placebo, as effective as the tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs), and somewhat less effective than the older, irreversible MAOIs phenelzine and tranylcypromine. In terms of tolerability, however, moclobemide was found to be comparable to the SSRIs and better tolerated than the TCAs and older MAOIs. There is some evidence that moclobemide on its own or in combination with other antidepressants such as SSRIs is also effective for treatment resistant depression and that the combination can be administered without the development of serotonin syndrome; however, further research is needed before such a combination can be recommended. Follow-up studies show that ongoing use of antidepressants leads to continuing improvement in depression over time; and also have demonstrated that moclobemide retains its therapeutic efficacy as an antidepressant for at least a year. This long-term efficacy is equivalent to that seen with other antidepressant classes.

People on irreversible MAOIs have to discontinue these antidepressants two weeks before general anesthesia, however, the use of moclobemide due to its reversible nature, would allow such patients to possibly continue antidepressant therapy.

A dexamethasone suppression test (DST) and plasma and urine methoxyhydroxyphenylglycol (MHPG) test can be used to estimate who is likely to respond to moclobemide antidepressant therapy.