Postgraduate corner: Continuing medical education

Abstract

Byline: Chittaranjan. Andrade CME Questions A) The premenstrual syndrome describes the cognitive, emotional, and physical symptoms that women commonly experience shortly before the onset of menstruation. The disorder has been known by different names, including late luteal phase dysphoric disorder (LLPDD) and premenstrual dysphoric disorder (PMD or PMDD). Many treatments have been described; these include antidepressant drugs, diuretics, oral contraceptives, calcium, vitamin supplements, exercise, and others. With this background, mark True or False against each of the following statements: *SSRIs are no better than placebo for PMD. *Antidepressant medication is effective in PMD even if administered only during the luteal phase of the menstrual cycle. B) Topiramate is one of the most recent treatments to be introduced for the management of alcohol dependence. How does it act? Alcohol increases inhibitory GABAergic neurotransmission and decreases excitatory glutamatergic neurotransmission; dopamine, at least in part, mediates the rewarding effects associated with alcohol intake. Topiramate exerts similar GABAergic and glutamatergic effects. It increases GABAergic neurotransmission by action at a nonbenzodiazepine site on the GABA-A receptor and decreases glutamatergic activity by blocking AMPA and kainate receptors. However, unlike alcohol, topiramate indirectly inhibits the release of dopamine in the mesocorticolimbic system. Thus, topiramate can substitute for the GABAergic and glutamatergic effects of alcohol, thereby blunting the neuronal hyperexcitability associated with alcohol discontinuation. And, topiramate can block alcohol-mediated dopamine release, thereby decreasing the rewarding effects of the beverage. Both these actions can be therapeutic in alcohol-dependent patients. With this background, mark True or False against each of the following statements: *Topiramate therapy is preferably instituted after withdrawal from alcohol. *In alcohol-dependent patients, the target dose of topiramate is 100 mg/day. *From a medical and psychological perspective, controlled drinking could be an acceptable goal of topiramate therapy. *Smoking behavior may decrease in alcohol-dependent patients who receive topiramate. *The efficacy of topiramate remains to be proven in alcohol-dependent patients in conventional clinical practice. View Answer CME Answers A) Treatment of premenstrual dysphoric disorder Answers: 1. False; 2. True. 1. Efficacy of SSRIs in PMD SSRIs are well-established, FDA-approved treatments for PMD. Shah et al .[sup] [1] described a systematic review and meta-analysis of SSRI treatment for the premenstrual syndrome. There were 29 studies of 2964 women which were eligible for analysis. SSRIs were found superior to placebo (odds ratio, 0.40; 95% confidence intervals, 0.31-0.51). No SSRI appeared better than another. 2. Luteal phase treatment for PMD SSRIs have been used in continuous treatment regimens as well as in intermittent dosing schedules. In the former context, they are administered all through the menstrual cycle. In the latter context, they are administered only during the second half of the cycle, that is, during the luteal phase, or even during the late luteal phase, only. In their meta-analysis, Shah et al .[sup] [1] found that luteal phase SSRI dosing was effective, but less so than continuous dosing. B) Topiramate for alcohol dependence Answers: 1. False; 2. False; 3. True; 4. True; 5. True. 1. Topiramate and alcohol discontinuation Two large, randomized, double-blind, placebo-controlled studies have demonstrated the efficacy of topiramate in the alcohol-dependence syndrome.[sup] [2],[3] In neither trial was abstinence from alcohol a prerequisite for the initiation of topiramate therapy. In fact, one of the important advantages of topiramate is that it can be prescribed even to patients who continue to drink. …