Tianeptine

Coaxil redirects here. For the transmission line for radio frequency signals, see Coaxial cable.
Tianeptine
Systematic (IUPAC) name
(RS)-7-(3-chloro-6-methyl-6,11-dihydrodibenzo[c,f][1,2]thiazepin-11-ylamino)heptanoic acid S,S-dioxide
Clinical data
AHFS/Drugs.com International Drug Names
Pregnancy cat.  ?
Legal status Prescription only
Routes Oral
Pharmacokinetic data
Bioavailability 70-99%[1]
Metabolism Hepatic
Half-life 2.5 hours[1]
Excretion Renal[1]
Identifiers
CAS number 66981-73-5 YesY
ATC code N06AX14
PubChem CID 68870
ChemSpider 62102 YesY
UNII 0T493YFU8O YesY
KEGG D02575 YesY
Chemical data
Formula C21H25ClN2O4S 
Mol. mass 436.953 g/mol
SMILES eMolecules & PubChem
 YesY(what is this?)  (verify)

Tianeptine (INN) (Stablon, Coaxil, Tatinol) is a drug used for treating major depressive episodes (mild, moderate, or severe). It has structural similarities to the tricyclic antidepressants, but it has different pharmacological properties. Tianeptine is a selective serotonin reuptake enhancer (SSRE), opposite to the action of SSRIs. One review points to the cancellative effects of tianeptine and fluoxetine coadministration on serotonin reuptake.[2] Another suggests that long-term administration of tianeptine has no effect on serotonin pathways.[3] Tianeptine enhances the extracellular concentration of dopamine in the nucleus accumbens[4] and modulates the D2 and D3 dopamine receptors,[5] but this effect is modest and almost certainly indirect.[3] There is also action on the NMDA and AMPA receptors. Recent reviews point to this pathway as a hypothesized mechanism of action, based on tianeptine's effect of promoting stress-associated impaired neuroplasticity.[3][2]

Tianeptine reduces the effects of serotonin in the limbic system and the pre-frontal cortex, giving rise to a mood elevation, unlike the mood blunting associated with SSRIs.[citation needed] Like SSRIs, however, tianeptine's onset-of-action delay is approximately 2–6 weeks with improvements sometimes noticeable in as soon as one week. Its short-lived, but pleasant, stimulant effect experienced by some patients is shared with its predecessor, amineptine, whose side effects related to dopamine uptake inhibitor activity resulted in Servier's research into tianeptine.[citation needed] Suggested dosage is three times daily, due to its short duration of action.

Tianeptine has strong antidepressant and anxiolytic properties with a relative lack of sedative, anticholinergic and cardiovascular adverse effects, thus suggesting it is particularly suitable for use in elderly patients and in those following alcohol withdrawal; such patients can be more sensitive to the adverse effects of psychotropic drugs.[2] Recent interesting results indicate anticonvulsant and analgesic activity of tianeptine and its possible interaction with adenosine A1 receptors.[6]

Currently, Tianeptine is approved in France and manufactured and marketed by Laboratoires Servier SA; it is also marketed in a number of other European countries under the trade name "Coaxil" as well as in Asia and Latin America as "Stablon" and "Tatinol" but it is not available in the UK or US.

Contents

Uses

Approved

Tianeptine shows efficacy against serious depressive episodes (major depression), comparable to amitriptyline, imipramine and fluoxetine, but with far fewer side effects. It was shown to be more effective than maprotiline in a group of patients with co-existing depression and anxiety. Tianeptine also displays significant anxiolytic properties and is useful in treating a spectrum of anxiety disorders including panic disorder, as evidenced by a study in which those administered 35% CO2 gas (carbogen) on paroxetine (Paxil) or tianeptine (Stablon) therapy showed equivalent panic-blocking effects.[7]

Investigational and ongoing research

Tianeptine has been reported to be very effective for asthma starting in August 1998, when Dr. Fuad Lechin and colleagues at the Central University of Venezuela Institute of Experimental Medicine in Caracas published the results of a 52-week randomized controlled trial of asthmatic children; the children in the groups that received tianeptine had a sharp decrease in clinical rating and increased lung function.[8] Two years earlier, they had found a close, positive association between free serotonin in plasma and severity of asthma in symptomatic patients.[9] As tianeptine was the only agent known to both reduce free serotonin in plasma and enhance uptake in platelets, they decided to use it to see if reducing free serotonin levels in plasma would help.[8] By November 2004, there had been two double-blind placebo-controlled crossover trials, and a 25,000+ patient open-label study lasting over seven years, all showing effectiveness.[10] A 2005 study in Egypt demonstrated tianeptine to be effective in men with depression and erectile dysfunction.[11] Tianeptine also has anticonvulsant and analgesic effects,[6] and a clinical trial in Spain that ended in January 2007 has shown that tianeptine is effective in treating pain due to fibromyalgia.[12] Tianeptine is also being studied in the treatment of ADD/ADHD.

It is currently being researched for its effectiveness in irritable bowel syndrome.[13]

Tianeptine has been found to be effective in depression in Parkinson's disease[14] and in post-traumatic stress disorder[15] of which it was as safe and effective as fluoxetine (Prozac, an SSRI) and moclobemide (Aurorix, an MAO-A inhibitor).[16]

Contraindications

According to Servier International, tianeptine is contraindicated in children under 15 years of age, people taking MAOIs, and pregnant or lactating women.[17] However, as of 2005, there are no studies published showing increased risk of birth defects.[18]

Stablon box and blister pack.

Side effects

Tianeptine was both studied for short-term (3 month) and long-term treatment (12 months) and equally well tolerated. The studies encompassed 1,300 to nearly 3,000 patients each.

Side effects are as follows (amitriptyline vs tianeptine):

  • Dry mouth (38% vs 20%)
  • Constipation (19% vs 15%)
  • Dizziness/syncope (23% vs 13%)
  • Drowsiness (17% vs 10%)
  • Postural hypotension (8% vs 3%)
  • Insomnia and vivid dreams (7% vs 20%)

Costa e Silva and colleagues at the Jardim Botanico in Rio de Janeiro, Brazil reported a greater frequency of headaches in the tianeptine group as compared with placebo.[19]

Sema Gülen Yıldırım and colleagues reported in 2004 of a case of hypomania caused by tianeptine.[20]

Interestingly, tianeptine along with its two metabolites (S8849, S3139) does not affect the reuptake of monoamines (DA, 5-HT, and noradrenaline) in vitro. Results from in vivo studies confirm that serotonin reuptake is enhanced — while dopamine and noradrenaline are unaffected — suggesting a mechanism independent of SERT.[21] No data is available regarding effects of the drug on postsynaptic receptors.

Usual doses

The recommended dosage is three tablets daily, one in the morning, one at midday, and one in the evening before the main meals of the day. In chronic alcoholics, whether cirrhotic or not, no alteration of dosage is necessary. In subjects over 70 years of age, and in subjects with renal insufficiency, the dosage should be restricted to two tablets per day.[22]

Coping with suicide risks

As is generally true for activating/nonsedating antidepressants, particularly agitated patients or those developing increase of energy together with suicidal thoughts before remission occurs will normally need initial comedication (1 to 4 weeks) with an effective sedating drug such as a benzodiazepine, barbiturate or neuroleptic. Additionally, hospitalisation of these patients is desirable (close observation possible). These measures to lower the risk of suicide should be continued until remission of depression is stable.

Abuse and addiction potential

Abuse of tianeptine is rare and thus far has only been seen in patients with pre-existing multi-substance abuse disorders. 141 cases of abuse were identified between 1989 and 2004, correlating to an incidence of 1 to 3 cases per 1000 patients treated with tianeptine. The main reason for abuse is to achieve an anxiolytic effect. According to Servier, cessation of treatment with tianeptine is difficult, due to the possibility of withdrawal symptoms in a patient.[23][24]

One patient reportedly consumed a total of 240 12.5 mg tablets (3000 mg) per day for several months and was later successfully detoxified in an inpatient setting. The report indicated that a tolerance was developed and there were physical withdrawal symptoms.[25]

In 2007, according to French Health Products Safety Agency, tianeptine's manufacturer Servier agreed to modify the drug's label, following problems with dependency.[26]

Singapore's Ministry of Health has restricted the use of tianeptine to psychiatrists due to its abuse potential,[27] while Bahrain has classified it a controlled substance due to increasing reports of misuse and abuse by patients.[28]

Tianeptine (under "Coaxil" brand name) has been intravenously injected by drug users in Armenia and Russia.[29][30] This method of administration reportedly causes an opioid-like effect and is sometimes used in an attempt to lessen opioid withdrawal symptoms.[29] As tianeptine tablets do not fully dissolve and often the solution is not filtered well, particles in the injected fluid can block small blood vessels, leading to thrombosis and then severe necrosis.

Mechanism of action

Initial studies found that upon acute and sustained administration, tianeptine decreased the extracellular levels of serotonin. However tiapentine has low affinity for serotonin transporters, so this effect appears to be indirect. Further, the validity of the data from older studies has been contested on the basis of technical limitations; more recent studies found that long-term administration of tianeptine does not elicit any marked alterations (neither increases nor decreases) in extracellular levels of serotonin in rats, and tianeptine also had no effect on spontaneous firing rate of serotonergic neurons.[3] However, coadministration of tianeptine and fluoxetine inhibited tianeptine's effect on long-term potentiation in hippocampal CA1 area. This is considered an argument for the opposite effects of tianeptine and fluoxetine on serotonin uptake.[2]

In contrast to SSRIs and tricyclic antidepressants, tianeptine modestly enhances the mesolimbic release of dopamine, but it is also unclear how this occurs because tiapentine itself has no effect on dopamine transporters, nor does it affect D1, D2, D3, D4 and D5 receptors.[3]

Perhaps the most studied hypothesis is that Tianeptine has a protective effect against stress induced neuronal remodeling. This is all based largely on preclinical studies.[3]

See also

References

  1. ^ a b c Royer RJ, Albin H, Barrucand D, Salvadori-Failler C, Kamoun A (1988). "Pharmacokinetic and metabolic parameters of tianeptine in healthy volunteers and in populations with risk factors". Clinical Neuropharmacology 11 Suppl 2: S90–6. PMID 3180120. 
  2. ^ a b c d Kasper S, McEwen BS (2008). "Neurobiological and clinical effects of the antidepressant tianeptine". CNS Drugs 22 (1): 15–26. doi:10.2165/00023210-200822010-00002. PMID 18072812. 
  3. ^ a b c d e f McEwen, B. S.; Chattarji, S.; Diamond, D. M.; Jay, T. M.; Reagan, L. P.; Svenningsson, P.; Fuchs, E. (March 2010). "The neurobiological properties of tianeptine (Stablon): from monoamine hypothesis to glutamatergic modulation". Molecular Psychiatry 15 (3): 237–249. doi:10.1038/mp.2009.80. PMC 2902200. PMID 19704408. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2902200.  edit
  4. ^ Invernizzi R, Pozzi L, Garattini S, Samanin R (March 1992). "Tianeptine increases the extracellular concentrations of dopamine in the nucleus accumbens by a serotonin-independent mechanism". Neuropharmacology 31 (3): 221–7. doi:10.1016/0028-3908(92)90171-K. PMID 1630590. 
  5. ^ "( Stablon, Coaxil ) and the dopamine D(2) and D(3) receptors". Tianeptine. http://www.tianeptine.com/dopamined2d3.html. Retrieved 2010-08-13. 
  6. ^ a b Uzbay TI (May 2008). "Tianeptine: potential influences on neuroplasticity and novel pharmacological effects". Progress in Neuro-psychopharmacology & Biological Psychiatry 32 (4): 915–24. doi:10.1016/j.pnpbp.2007.08.007. PMID 17826881. 
  7. ^ Schruers K, Griez E (December 2004). "The effects of tianeptine or paroxetine on 35% CO2 provoked panic in panic disorder". Journal of Psychopharmacology 18 (4): 553–8. doi:10.1177/0269881104047283. PMID 15582922. 
  8. ^ a b Lechin F, van der Dijs B, Orozco B, et al. (October 1998). "The serotonin uptake-enhancing drug tianeptine suppresses asthmatic symptoms in children: a double-blind, crossover, placebo-controlled study". Journal of Clinical Pharmacology 38 (10): 918–25. PMID 9807972. http://jcp.sagepub.com/cgi/pmidlookup?view=long&pmid=9807972. 
  9. ^ Lechin F, van der Dijs B, Orozco B, Lechin M, Lechin AE (September 1996). "Increased levels of free serotonin in plasma of symptomatic asthmatic patients". Annals of Allergy, Asthma & Immunology 77 (3): 245–53. doi:10.1016/S1081-1206(10)63263-2. PMID 8814052. 
  10. ^ Lechin F, van der Dijs B, Lechin AE (November 2004). "Treatment of bronchial asthma with tianeptine". Methods and Findings in Experimental and Clinical Pharmacology 26 (9): 697–701. doi:10.1358/mf.2004.26.9.872567. PMID 15632955. 
  11. ^ El-Shafey H, Atteya A, el-Magd SA, Hassanein A, Fathy A, Shamloul R (September 2006). "Tianeptine can be effective in men with depression and erectile dysfunction". The Journal of Sexual Medicine 3 (5): 910–7. doi:10.1111/j.1743-6109.2005.00141.x. PMID 16942535. 
  12. ^ "ISRCTN16400909 - Tianeptine for the treatment of fibromyalgia: a prospective double-blind, randomised, single-centre, placebo-controlled, parallel group study". Controlled-trials.com. http://www.controlled-trials.com/ISRCTN16400909/. Retrieved 2010-08-13. 
  13. ^ "Pharmos Corporation - Synthetic Cannabinoid Platform". Pharmoscorp.com. http://www.pharmoscorp.com/development/tianeptine.html. Retrieved 2010-08-13. 
  14. ^ Levin OS (May 2007). "Coaxil (tianeptine) in the treatment of depression in Parkinson's disease". Neuroscience and Behavioral Physiology 37 (4): 419–24. doi:10.1007/s11055-007-0029-0. PMID 17457538. 
  15. ^ Aleksandrovskiĭ IuA, Avedisova AS, Boev IV, et al. (2005). "[Efficacy and tolerability of coaxil (tianeptine) in the therapy of posttraumatic stress disorder]" (in Russian). Zhurnal Nevrologii I Psikhiatrii Imeni S.S. Korsakova 105 (11): 24–9. PMID 16329631. 
  16. ^ Onder E, Tural U, Aker T (April 2006). "A comparative study of fluoxetine, moclobemide, and tianeptine in the treatment of posttraumatic stress disorder following an earthquake". European Psychiatry 21 (3): 174–9. doi:10.1016/j.eurpsy.2005.03.007. PMID 15964747. 
  17. ^ Les Labotoires Servier (2005). "STABLON (Tianeptine) - Summary of Product Characteristics". STABLON (Tianeptine) - OVERVIEW. Servier International. Archived from the original on October 1, 2004. http://web.archive.org/web/20041001063925/http://www.servier.com/pro/Neurosciences/stablon/stablon_spc.asp. Retrieved 8 October 2005. 
  18. ^ "Google search of The National Center for Biotechnology Information website for articles containing "tianeptine" and "prenatal"". http://www.google.com/search?hl=en&lr=&safe=off&client=firefox-a&rls=org.mozilla%3Aen-US%3Aofficial&q=site%3Ancbi.nlm.nih.gov+tianeptine+prenatal&btnG=Search. Retrieved 20 October 2005. [unreliable source?]
  19. ^ Costa e Silva JA, Ruschel SI, Caetano D, et al. (1997). "Placebo-controlled study of tianeptine in major depressive episodes". Neuropsychobiology 35 (1): 24–9. doi:10.1159/000119326. PMID 9018020. 
  20. ^ (Turkish) Yıldırım, Sema Gülen; Ayşe Devrim Başterzi and Erol Göka (2004). "Tianeptinin Neden Olduğu Hipomani; Bir Olgu Sunumu [Tianeptine Induced Mania: A Case Report]" (PDF). Klinik Psikiyatri Dergisi 7 (4): 177–180. http://www.klinikpsikiyatri.org/pdf/4/7/177.pdf. 
  21. ^ Mennini T, Mocaer E, Garattini S (November 1987). "Tianeptine, a selective enhancer of serotonin uptake in rat brain". Naunyn-Schmiedeberg's Archives of Pharmacology 336 (5): 478–82. PMID 3437921. 
  22. ^ Les Laboratoires Servier (2009). "Stablon - Summary of Product Characteristics, March 2009". http://www.servier.com/Pro/Neurosciences/Stablon/Stablon.aspx?id=632. Retrieved 21 February 2010. 
  23. ^ APM Health Europe (2007). "Addiction leads to warning on Servier's antidepressant Stablon". http://health.apmnews.com/depechesPublieesDepeches.php?annee=2007&mois=5&jour=21. Retrieved 24 July 2008. 
  24. ^ Dr. Valerie Gibaja (2006). "Use, Drug Abuse and Tianeptine (in French)" (PDF). http://www.chu-toulouse.fr/IMG/pdf/Actes_des_Xemes_rencontres_version_finale.pdf. Retrieved 24 July 2008. 
  25. ^ The Good Drug Guide - BioPsychiatry.com (2006). "A Case of Tianeptine Abuse". http://www.biopsychiatry.com/tianeptine-excess.htm. Retrieved 14 March 2008. 
  26. ^ French Health Products Safety Agency (Afssaps) (2007). "Important Information on Drug: Update of the Summary of Product Characteristics Stablon , 16 May 2007 (French)". http://agmed.sante.gouv.fr/htm/10/filltrpsc/lp070502.htm. Retrieved 24 July 2008. 
  27. ^ World Health Organisation (2001). "Pharmaceuticals: Restrictions in use and availability, March 2001" (PDF). http://www.who.int/medicinedocs/pdf/s2203e/s2203e.pdf. Retrieved 24 July 2008. 
  28. ^ World Health Organisation (2003). "Pharmaceuticals: Restrictions in use and availability, April 2003" (PDF). http://whqlibdoc.who.int/hq/2003/EDM_QSM_2003.5.pdf. Retrieved 24 July 2008. 
  29. ^ a b Richard Ives (2008). "Assessment Mission Report for the SCAD V Programme, Component on Prevention and on Media Work" (PDF). http://scadarmenia.org/docs/eng/mission_report_prevention.pdf. Retrieved 4 November 2008. 
  30. ^ Flavio Mirella, et al. (2005). "Illicit Drug Trades in the Russian Federation" (PDF). http://www.unodc.org/pdf/russia/Publications/drug%20trends%202005_eng.pdf. Retrieved 4 November 2008. 

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