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Professor, Department of Neuropsychiatry, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430-8103, fax 806/743-2784, parviz.malekahmadi{at}ttuhsc.edu
Associate Professor, Department of Family and Community Medicine, School of Medicine, Texas Tech University Health Sciences Center
Published Online, October 17, 2006. www.theannals.com, DOI 10.1345/aph.1H133
To our knowledge, we report the first published use of venlafaxine, a serotonin/norepinephrine-reuptake inhibitor (SNRI), in a patient with chronic hepatitis C and interferon alfa-induced depression.
Case Report. A 41-year-old man with chronic hepatitis C was started on peginterferon alfa-2a2 180 µg weekly and ribavirin 1000 mg daily approximately 6 months after initial diagnosis. Three weeks later he experienced an unusual symptom combination of mood-incongruent visual hallucinations and depression.
His history was significant for epilepsy, hypothyroidism, and well-controlled hypertension. He reported no history of hallucinations or depression. One sibling was reportedly treated for anxiety and depression. A family history for depression has been considered a risk factor for interferon alfa-induced depression.1 The patient's medications consisted of phenytoin, levothyroxine, hydrochlorothiazide, and diltiazem.
Two weeks after the index examination, the patient reported no hallucinations but did report worsening of depression. Escitalopram 10 mg/day was not tolerated. Sertraline 50 mg/day for 2 weeks improved the depression. Four weeks later, he reported irritability (which might have coincided with the peak effects of interferon) and the sertraline dose was increased to 75 mg/day. Two months later, he reported a worsening of depression (possibly due to a subtherapeutic dosage of sertraline) but did not wish to take a higher dose of sertraline. Venlafaxine 37.5 mg/day was started and then titrated to 150 mg/day. Two weeks later he reported remission of depression. The dosage of venlafaxine and interferon remained unchanged throughout the course of treatment. He tolerated venlafaxine without adverse effects, including any change in blood pressure. After completing interferon therapy, venlafaxine was gradually withdrawn without recurrence of depression.
Discussion. Given the patient's history of substance abuse, his visual hallucinations (which were gradually resolved) were likely to be flashbacks triggered by interferon. However, the depression worsened over time. Because the patient had a longstanding history of substance abuse and refused testing, even though he claimed sobriety after he was diagnosed with chronic hepatitis C, substance abuse mood disorder cannot be ruled out as a basis for venlafaxine response.
The use of SSRIs for interferon alfa-induced depression is supported by a controlled study in which prophylactic paroxetine was found effective at preventing depression in interferon alfa-treated patients with melanoma.3 Our patient had a partial response to sertraline and might have had a better response had he not refused a higher dose. Low-dose venlafaxine (75 mg/day) inhibits serotonin reuptake. Inhibition of norepinephrine reuptake begins at doses higher than 150 mg/day.4 Our patient's favorable response to venlafaxine 150 mg/day may have been related to inhibition of serotonin reuptake. Milnacipran, an SNRI, was efficacious in treatment of interferon alfa-induced depression in a patient with renal malignancy.5 The possibility that norepinephrine plays a role in interferon alfa-induced depression cannot be ruled out.
References
-2b and
ribavirin therapy for patients with chronic hepatitis C.Psychosomatics
2003;44:104-12.
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