Pharmacotherapy for the Treatment of Hoarding Disorder

Hoarding disorder, which is characterized by difficulty discarding or parting with possessions, is common and potentially “disabling.” In fact, this behavior usually has some harmful effects, such as emotional, physical, social, financial, and even legal implications. Also, people who hoard often exhibit irrational behavior.

In some studies, hoarding has been listed as diagnostic criteria for obsessive-compulsive personality disorder (OCPD); however, some consider hoarding a disorder in itself. There are various routes of treatment for hoarding disorder, including both psychotherapy and pharmacotherapy. For the purpose of this assignment, I will focus more on the pharmacotherapy.

Since hoarding disorder is closely associated with OCD, pharmacotherapy for the treatment of hoarding disorder is similar to treatment of OCD. Studies have shown that OCD patients respond well to the use of selective serotonin reuptake inhibtors (SSRI’s), and some of these drugs have clinical effect in patients with hoarding behavior/disorder. In one study done by Sanjaya Saxena, it was concluded that the use of paroxetine (Paxil), which is an SSRI, improved hoarding symptoms, depression, and anxiety. Furthermore, venlafaxine has also shown good response with hoarding behaviors. In fact, venlafaxine had a trend for greater reduction in hoarding symptoms than that seen with paroxetine. New treatment strategies might also include cognitive enhancers, such as donepezil, to increase attention and executive functioning in patients with hoarding disorder.

In conclusion, hoarding disorder is a common and relevant problem that can tremendously affect someone’s life, but can be treated. Hoarding disorder, along with its signs and symptoms, can be improved by pharmacologic therapy (mostly the use of SSRI’s), psychological therapy, or a combination of both.

 

http://www.uspharmacist.com/content/d/pharmacy_focus/c/58008/

Saljoughian, Manouchehr. Hoarding Disorder: Diagnosis and Treatment. US Pharm. 2015:40(11):60-62.

Genotype Screening for Dosing Nortriptyline and Venlafaxine

This journal article discusses a study currently in progress. It is designed to screen elderly patients for the CYP2D6 gene to determine the dosage of two depression medications, nortriptyline and venlafaxine. Furthermore, the study will determine if screening is cost-effective as well.

According to the journal article, the randomized controlled trial is underway in the Netherlands at several different psychiatry and geriatric mental health care institutions. The participants who are being recruited are 60 years or older and diagnosed with depression. There will be two parts to the study. The first part, which is occurring now, involves asking patients who are starting either of the medications in question for a genotype via a finger prick. If the patients have an appropriate genotype, they moved on to the second part of the study which is the actual trial. Several outcomes are being recorded during the study, according to the article. The primary outcome is the time needed to reach certain blood levels of either drug. Also, adverse drug reactions, quality of life, productivity, and cost of health care use will also be monitored and measured. Depression has to be monitored carefully to distinguish between side effects of depression versus from the medications.

The researchers say that the results of this study will assess whether genotype test can achieve the most effective dose faster while also avoiding adverse drug reactions. Usually, it takes approximately 4 weeks for a patient to reach desired drug levels. However, the researchers estimated this time can be cut in half if prescribers have access to the patients’ genotype information. However, limitations are present. Firstly, the genotype information gets in the hands of the prescribers after therapy has begun. This can be overcome due to the fact that prescribers tend to initiate a low starting dose. Secondly, the group of participants are very different. It would be difficult to limit the inclusion principles to depression patients without other physical or psychiatric disorders. In spite of this, the mixed participant group better represents real-life practice situations. The researchers feel the study will be strong because the participants are randomly allocated and significant differences in response have a better chance of being detected.

Although this trial will focus on CYP2D6’s ability to metabolize nortriptyline and venlafaxine, there are many other drugs that are metabolized by this enzyme. The article states that if this trial is successful, it could lead into regular genotype screening when initiating drug therapy.

 

Trials. 2015;16:37.

Link to Article

 

We have discussed pharmacogenetics several times thus far in our short pharmacy school careers. Next week, we will even be offered the opportunity to have our own genomes sequenced. It seems that in the next few years that genotype screening will be a regular occurrence for all patients. It already seems to be finding its way into practice for drugs like warfarin (Coumadin®). Yet, before this can happen for more drugs, trials like the one discussed in this article need to be performed and find positive results to support the effectiveness of this prescribing and dosing procedure.

This article caught my attention because the researchers began looking for participants in 2013 and were expected to search until spring of this year. I think this ties in well with what we are doing in our Drug Development course. In order to get the most accurate and diverse results, researchers must design trials that encompass different types of patients over the long term. But, what do you guys think? Do you think 3 years was a little too long to extend this trial? Why did the researchers not just publish the results from the participants during two years of the study instead?