EMSAM (deprenyl patch): how a promising antidepressant was underutilized

Abstract

The EMSAM patch is a unique monoamine oxidase inhibitor (MAOI) being the only antidepressant utilizing a transdermal delivery system. This was welcomed by clinicians who hoped that EMSAM would be better tolerated than oral MAOIs and non-MAOI antidepressants, as well as being effective for treatment in a wide spectrum of depressed patients including atypical depression, bipolar depression, and refractory depression. Unfortunately, the clinical use of EMSAM has been underutilized and its potential usefulness overlooked. This article suggests that fear of possible side effects, particularly the “cheese reaction” and serotonin syndrome, are some of the main contributors to underutilization by clinicians. These risks have been significantly exaggerated with the 6 mg/day dose not even requiring a special diet. Other contributing factors leading to underutilization are reviewed such as: the lack of studies addressing many important clinical questions; inadequate data analyses; not evaluating the effect of EMSAM on comorbid psychiatric conditions, particularly anxiety disorders; lack of antidepressant comparators versus EMSAM; no dose–response relationship examined; various depressive subtypes and conditions are unexplored, eg, bipolar depression and refractory depression; poor insurance coverage for an expensive medication; as well as minimal marketing efforts and postmarketing studies. On the other hand, many potential advantages of EMSAM are not highlighted enough in the literature and by pharmaceutical companies which might have increased clinical interest and utilization of the antidepressant. For example, the advantages of EMSAM include: avoidance of swallowing issues, as can be seen with oral antidepressants; minimal side effects, probably due to a favorable pharmacokinetic profile; minimal evidence of suicidal behavior, probably relating to the transdermal route of administration; low rates of inducing hypomanic/manic episodes; as well as significant efficacy in “anxious depression” and atypical depression. Recent efforts in conducting some post hoc analyses and presentations on EMSAM may yet stimulate further clinical interest and use of this antidepressant.

Evaluation of the Isoflavone Genistein as Reversible Human Monoamine Oxidase‐A and ‐B Inhibitor

“…The data further suggest a crucial role of C5-OH and the threonine 201 of MAO-B in MAOs inhibitory action and selective inhibition. GST was also compared with DEP, the standard therapy for PD recently used in MDD [ 6 , 16 ]. The obtained results indicated GST higher potency than DEP to inhibit h MAO-A with much less h MAO-B selectivity.…”

“…In depressive and aging PD patients, the activity of brain monoamine oxidase (MAO) is significantly elevated compared to healthy individuals [ 4 , 5 ]. Moreover, in the aging population, improving brain neurotransmitters and reducing MAO activities by using MAO inhibitors (MAOIs) were proven beneficial whereas other antidepressants mechanisms appear less effective [ 6 ].…”

“…MAO-BIs maintain a higher level of DA from its precursor L-dopa in PD patients and may even benefit Alzheimer's disease (AD) [ 9 , 10 ]. Deprenyl (DEP), a current MAO-BI used for PD, was recently approved as transdermal patches (Emsam®) for MDD treatment to become the most prevalent MAOI useful for the elderly [ 6 ].…”

Perils of Pragmatic Psychiatry: How We Can Do Better

“…Unlike preferring FGAs over SGAs, clinicians are reluctant to go beyond SSRIs and SNRIs in the treatment of depression and use Tricyclic Antidepressants (TCAs) Monoamine Oxidase Inhibitors (MAOIs) [79]. TCAs [18] and Monoamine Oxidase Inhibitors (MAOIs) are underutilized [80,81]. Selegiline patch without dietary restriction is currently recommended when patients have Treatment Resistant Depression (TRD) stage III [79], and if they have anxious and atypical depression [81].…”

“…TCAs [18] and Monoamine Oxidase Inhibitors (MAOIs) are underutilized [80,81]. Selegiline patch without dietary restriction is currently recommended when patients have Treatment Resistant Depression (TRD) stage III [79], and if they have anxious and atypical depression [81]. In a few patients, multiple dopaminergic medications, including stimulants, may be needed to treat TRD [20].…”