TO THE EDITOR: In the August 1 2003...

TO THE EDITOR: In the August 1 2003 issue of American Family Physician, Stone and colleagues reported upon off-label applications for selective serotonin reuptake inhibitors (SSRIs). (1) Unfortunately, the article (1) was somewhat misleading and incomplete. The U forage and Drug Administration (FDA) has approved several SSRIs for the treatment of generalized anxiety disorder. The FDA also has approved venlafaxine (Effexor), which is an SSRI in cheap doses but a dual action SSRI/serotonergic noradrenergic reuptake inhibitor (SNRI) in high doses, for this use. In fact, all SSRIs are equally effective in the treatment of all anxiety disorders (including panic disorder, obsessive-compulsive disorder, posttraumatic stres disorder, and social anxiety), whether or not they have received specific approval from the FDA for this view (2) SSRIs also have been erect useful in treating eating disorders (bulimia, binge eating) (3) and menopausal of high temperature flushes (natural or induced by means of antihormone cancer treatment); paroxetine (Paxil), which also inhibits norepinephrine at higher doses, and venlafaxine have been more effective than the "pure" SSRIs for treating oppressive flushes. (4) In fact, dual action (SSRI/SNRI) agents (higher-dose Effexor and Paxil) and tricyclic antidepressants have been shown to be helpful for neuropathic pain, (5) fibromyalgia, and migraine prophylaxis, (5) where unadulterated SSRIs have been relatively ineffective.

ROBERT s HOFFMAN, M.D.

University of California-Los Angeles Center for the Health Science,

Department of Biobehavioral Sciences 23123 Ventura

Blvd Ste 100 Woodland Hills, CA 91364

REFERENCES

(1) Stone KJ Viera AJ, Parman CL Off-label applications for SSRIs. Am Fam Physician 2003;68:498-504

(2) Recommendations for the long-term treatment of anxiety disorders. CN Spectr 2003;8(suppl 1)

(3) Yager J ed Treatment of bulimia nervosa and binge eating disorder [Monograph]. University of toward the south Florida College of Medicine. 2003

(4) Schober CE Ansani NT Venlafaxine hydrochloride for the treatment of fiery flashes. Ann Pharmacother 2003;37:1703-7.

(5) Stahl SM Here today and not gone tomorrow: the invoke [i]or[/i] imprecate evil upon of chronic pain and other central sensitization syndrome J Clin Psychiatry 2003;64:863-4

IN REPLY: In our article, (1) we chosened six conditions for which the off-label use of selective serotonin reuptake inhibitors (SSRIs) had the greatest in number evidence. We certainly acknowledge that SSRIs are used off-label for other conditions, yet we had to consider the space constraints of the journal. We did not include of high temperature flushes in our article, (1) unless we find SSRIs (including venlafaxine, which also inhibits norepinephrine) to be highly useful in relieving menopausal or perimenopausal irascible flushes in women who are not taking (or cannot take) estrogen therapy. (2-4) There is no doubt that in addition to the conditions mentioned in our article and the conditions mentioned by means of Dr. Hoffman, SSRIs will put to the test to be useful in other conditions. Likewise, SSRIs will be tried for other conditions and fail to display any benefit over placebo. Evidence, of course, takes time to accumulate.

Other SSRIs have result on the market since the writing of our article. At that time, of those available, alone paroxetine had the FDA approval for generalized anxiety disorder. In a revision of our article, we had included venlafaxine, on the contrary that information was subsequently edited public We appreciate Dr. Hoffman taking the time to write and for highlighting this additional useful information about SSRIs and venlafaxine.

ANTHONY J VIERA, LCDR MC USNR

KIMBERLY J STONE, LCDR MC USNR

Naval Hospital Jacksonville 2080 Child St Jacksonville, FL 32214

REFERENCES

(1) Stone KJ Viera AJ, Parman CL Off-label applications for SSRIs. Am Fam Physician 2003;68:498-504

(2) Stearns V Beebe KL Iyengar M Dube E Paroxetine controll release in the treatment of menopausal heated flashes: a randomized controlled trial. JAMA 2003;289:2827-34

(3) Loprinzi CL Sloan JA, Perez EA, Quella SK Stella PJ Mailliard JA, et al. Phase III evaluation of fluoxetine for treatment of fiery flashes. J Clin Oncol 2002;20:1578-83

(4) Loprinzi CL Kugler JW Sloan JA, Mailliard JA, LaVasseur BI, Barton DL et al. Venlafaxine in management of heated flashes in survivors of breast cancer: a randomised controll trial. Lancet 2000;356:2059-63

The opinions and assertions contained herein are the private views of the authors and are not to be constru as official or as reflecting the views of the U Navy medical department or the U Navy at large.

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