Milnacipran: new preparation. Tricyclics remain first-line antidepressants

Several placebo-controlled trials have shown that milnacipran, 100 mg/day in two doses, is an effective antidepressant in both the ambulatory and hospital settings. Comparative trials against tricyclic antidepressants (imipramine and clomipramine) failed to show that milnacipran was any more effective. Milnacipran has not been compared with specific or non specific MAOI antidepressants. As regards non tricyclic-non MAOI antidepressants, milnacipran has been compared only to two specific serotonin reuptake inhibitors, fluvoxamine and fluoxetine. The trials cannot convince us of a difference in efficacy between the two types of treatment. The claimed superiority of milnacipran over serotonin reuptake inhibitors is not based on firm evidence of better efficacy or fewer adverse effects. The overall tolerability of milnacipran is similar to that of fluoxetine and fluvoxamine. Relative to the tricyclic antidepressants, milnacipran has fewer atropinic effects (sedation and sweating). In contrast, it cause more dysuria, and cannot, therefore, replace tricyclics in elderly men with prostate disorders. Tricyclics remain the preferred first-line antidepressant drugs. When they are contraindicated or poorly tolerated, many other antidepressants with well-documented risk-benefit ratios are available.