Zusammenfassung
Die folgende Arbeit fasst Nutzen und Risiken der bisher bekannten Kombinationsbehandlungen
mit Antidepressiva bei therapieresistenten Depressionen zusammen. Die Literaturrecherche
erfolgte mittels einer Medline-Datenbank-Recherche der Jahrgänge 1990 – 2006. Kombinationstherapien
zweier Antidepressiva werden im klinischen Alltag sehr häufig durchgeführt. Sinnvolle
Antidepressivakombinationen nutzen den Vorteil komplementärer Wirkmechanismen, um
einen synergistischen Nutzen zu erzielen. Vorteile einer Kombinationstherapie bestehen
in der Fortführung einer partiellen Response auf eine Monotherapie und dem gleichzeitig
damit verbundenen Vermeiden der Gefahr einer Verschlechterung depressiver Symptome
durch Absetzen des partiell wirksamen Antidepressivums. Nachteile dieser Strategie
bestehen in dem Risiko von Arzneimittelwechselwirkungen, einer möglichen Potenzierung
von unerwünschten Arzneimittelwirkungen und höheren Behandlungskosten. Obwohl Kombinationsstrategien
in der klinischen Praxis oft angewandt werden, gibt es nur wenig kontrollierte Studien,
um ihren Nutzen und ihre Wirksamkeit zu belegen (Evidenzlevel C, dies trifft auf alle
Kombinationstherapien zu). Wichtig erscheint darauf hinzuweisen, dass die Zugabe eines
SSRI zu einem Trizyklikum einen erhöhten Blutspiegel und eine verzögerte Metabolisierung
des Trizyklikums herbeiführen kann, was eventuell ein erhöhtes Toxizitätsrisiko der
trizyklischen Medikation nach sich führt. Die Kombination eines irreversiblen MAO-Hemmers
mit Clomipramin, einem SSRI oder einem SSNRI sollte aufgrund eines möglichen Serotonin-Syndroms
grundsätzlich vermieden werden.
Die detaillierte Kenntnis der dargestellten Kombinationsstrategien ermöglicht unter
Umständen bessere Behandlungsergebnisse bei therapieresistenten Depressionen.
Abstract
Various pharmacological strategies have been developed to treat such refractory depression,
of which combination therapies with antidepressants are one of the most important.
This article reviews both benefits and risks of all known antidepressant combination
strategies. The relevant literature was identified by means of a computerized MEDLINE
research on the years 1990 – 2006 and scanning of review articles. The use of antidepressant
combinations to overcome refractory depression is a common strategy in practice. Many
antidepressants can be usefully combined especially if they engage separate mechanisms
of action – like SSRIs with Reboxetine, Bupropion, Mirtazapine and Tricyclics – or
on the other hand – Tricyclics with MAO-Inhibitiors. Combination strategies are effective
treatment options, however they do have potential safety risks due to pharmacokinetic
and pharmacodynamic interactions. Combinations including MAOIs can cause serotonin
syndrome, and some SSRIs like Fluoxetine may elevate tricyclic plasma levels with
the consequence of an increased risk of toxicity. The distinct knowledge of available
antidepressant combination strategies may help to increase response – as well as remission
rates in therapy resistant depression. However, further research is urgently needed
to determine relative efficacy.
Schlüsselwörter
Antidepressiva - therapieresistente Depression - Kombinationen von Antidepressiva
- Antidepressivanonresponse
Key words
antidepressants - therapy resistant depression - refractory depression - combination
therapies with antidepressants
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Dr.-Mack-Str. 1
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Email: m.schmauss@bkh-augsburg.de
