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Panminerva Medica 2002 Giugno;44(2):83-91

lingua: Inglese

Management of treatment resistant obsessive-compulsive disorder. Algorithms for pharmacotherapy

Albert U., Bergesio C., Pessina E., Maina G., Bogetto F.

From the Anxiety and Mood Disorders Unit Department of Neurosciences, University of Turin, Turin, Italy


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Treatment ­resistant OCD sub­jects, ­defined as ­those ­patients who ­undergo an ade­quate ­trial of SRI (clo­mip­ra­mine or ­SSRI) and do not ­respond or ­show unsat­is­fac­tory ­results, ­account for 40-50% of all ­patients. Once the appro­pri­ate­ness of the ­trial has ­been ­assessed, sev­eral ­options ­exist for the cli­ni­cians. If clo­mip­ra­mine or cital­o­pram ­have ­been ­used, an appro­priate ­strategy con­sists in ­giving the ­same ­drug intra­ve­nously. Double-­blind ­studies ­exist on the effi­cacy of clo­mip­ra­mine IV, ­while ­data are ­missing for cital­o­pram. Another ­option ­that ­should be con­sid­ered ­first, ­although ­data are ­scarce, is the addi­tion of a cog­ni­tive behav­ioral ­therapy, ­when avail­able, in the ­forms of expo­sure and ­response pre­ven­tion. When ­such ­options are not suit­able or avail­able, aug­men­ta­tion of the ­ongoing SRI ­with ­another com­pound rep­re­sents the pref­er­able ­strategy. Double-­blind, pla­cebo-con­trolled ­studies ­have ­shown the effi­cacy of ­adding pin­dolol (7.5 mg/d), ris­per­i­done (2 mg/d) and olan­za­pine (5-10 mg/d). Other ­agents ­have ­been pro­posed, but ­data ­emerging ­from ­double-­blind ­studies ­were neg­a­tive or con­tra­dic­tory. Another ­option avail­able is ­switching ­from CMI to ­SSRI, or ­vice ­versa, or ­from ­SSRI to ­SSRI. Data ­regarding ­such treat­ment ­strategy, how­ever, are ­highly pre­lim­i­nary, ­based on a ­couple of ­open ­label ­reports and on ­studies per­formed in treat­ment ­resistant depres­sion. An unre­solved ques­tion is ­whether aug­men­ta­tion ­should be pre­ferred to ­switching. No ­data ­exist in OCD; a prac­tical ­approach ­would sug­gest aug­men­ta­tion ­first, con­sid­ering ­that ­response ­should be ­obtained ­faster ­than by ­switching com­pound. When all the avail­able and effec­tive strat­e­gies ­prove unef­fec­tive, cli­ni­cians ­should con­sider ­switching the ­patient to ­other com­pounds in mono­therapy, ­such as ven­la­faxine, suma­triptan, inos­itol, ­although ­research is ­strongly ­needed ­before con­clu­sions on the effi­cacy of ­such com­pounds can be ­drawn.

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