Though not receiving front page coverage in the New York Times, like the recent Times article on Adderall discussed on this blog site by Mr. Whitaker, maybe this topic should as well. One of the longest running independent newsletters on prescription drugs just called out Cymbalta (duloxetine). Led by Sidney M. Wolfe, M.D., “Worst Pills, best Pills News” (www.worstpills.org) is a trusted resource for physicians and the public who are concerned about unknown problems with medication. Call it the Consumer Reports of medication. Dr. Wolfe is the medical protégé of the renowned consumer advocate and past Presidential candidate, Ralph Nader.
In the June, 2012 issue which I just received, Dr. Wolfe starts out with “Do NOT Use” this medication.
Now, one of the particular aspects of Cymbalta, which may have been a marketing strategy, is that it was put into a category different than all of the serotonin reuptake inhibitors. Supposedly, it was also an advance form the one previous such medication, Effexor (venlafaxine), which was touted to have dual action on inhibiting the uptake of both serotonin and epinephrine (SNRI). As we know about the other antidepressants, this is simplistic at best, erroneous at worst. TV ads directed to the public were voluminous and effective, with many patients coming in asking for Cymbalta in particular.
Not surprisingly, Cymbalta has been a commercial blockbuster, not only for those reasons, but another. Even more than other antidepressants, it is prescribed by non-psychiatrists. Why? It has become a favored drug for pain, such as that associated with Fibromyalgia. This usage was never really well-studied, although older antidepressants like Elavil also supposedly relieved pain without any significant depression. Moreover, Cymbalta was valued because it was not addictive like stronger opiate pain meds, would supposedly not cause withdrawal, and was easy to prescribe.
Dr. Wolfe cites two organizations that recommend not using Cymbalta in any circumstance. The first was the French (who are also way ahead of the USA in their more equitable healthcare system) journal of drug safety and efficacy, Prescrire, in February 2009. Now it is the American Public Health Research Group.
Except for one, the risks described by Dr. Wolfe (and let alone the questionable effectiveness) do not actually seem much different than the so-called serotonin reuptake inhibitors. However, a new one for me was “Liver toxicity and liver failure”, which even if rare, is very serious. This is the same sort of “side effect” that previously doomed the antidepressant Serzone (nefazadone).
Like many on this website, he recommends gradual discontinuation, though he also states that this is best done under medical supervision. It’s certainly given me pause about this medication, and a desire to find out more. Although I had waited quite a while before even prescribing Cymbalta, knowing the bias of the short-term studies used for FDA approval, I did end up prescribing it on a limited basis.
Now I also wonder if another antidepressant, supposedly in a category all by itself, Wellbutrin (buproprion), will be the next to evoke more concern. It was not mentioned in Mr. Whitaker’s book, nor by Dr. Wolfe, but is widely used not only for depression and anxiety, but also ADD, smoking cessation, and even occasionally for cocaine abusers.
In this same issue of Worst Pills, Best Pills News, Dr. Wolfe lists all the “Drugs That Can Impair Your Response to Heat”. This is very important and timely for the summer. Many of these medications are psychiatric, including antidepressants and antipsychotics. There are also many medications for the heart listed.
For all sorts of medications, as medicine becomes more and more like a big business, the business warning of “buyer beware” seems to be becoming more relevant for medicine.