title: Imipramine dose in relation to therapeutic plasma level: are clinical trials using imipramine as a positive control flawed?
abstract: BACKGROUND
  Imipramine has often been used as positive control in studies investigating the efficacy of new antidepressants. Imipramine-controlled studies in general employ a fixed-dose design. It is unclear how many patients would achieve effective plasma levels with such a design.
  
  
  OBJECTIVE
  The objectives of this study were to assess the range of doses necessary to attain a therapeutic plasma level in the imipramine arms of two double-blind, fixed-plasma-level studies and to compare them with doses administered in efficacy studies with imipramine as a positive control.
  
  
  METHODS
  During two double-blind studies, imipramine doses were adjusted to a predefined fixed plasma level. Here we report an analysis of the range of doses necessary to attain that level in the imipramine arms of the studies. We also computed the cumulative percentage of patients with therapeutic plasma levels (> or = 200 ng/ml) at various imipramine doses in order to compare them with doses administered in efficacy studies with imipramine as a positive control.
  
  
  RESULTS
  Target plasma levels were attained with a mean daily dose of 248 mg, with a dose range of 50-450 mg. We calculated a possible increase in efficacy of imipramine of about 20% if doses had been adjusted to therapeutic plasma levels in clinical trials using it as a positive control.
  
  
  CONCLUSIONS
  The absence of significant differences in efficacy between selective serotonin re-uptake inhibitors (SSRIs) and imipramine in these trials is at least in part due to improper dosing of the latter; imipramine with therapeutic drug monitoring may be more effective than SSRIs.
authors.affiliation: Department of Psychiatry, Erasmus Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands. t.birkenhager@erasmusmc.nl
authors.forename: Tom K
authors.initials: TK
authors.lastname: Birkenhäger
authors.forename: Walter W
authors.initials: WW
authors.lastname: van den Broek
authors.forename: Peter
authors.initials: P
authors.lastname: Moleman
authors.forename: Arnold G
authors.initials: AG
authors.lastname: Vulto
authors.forename: Jan A
authors.initials: JA
authors.lastname: Bruijn
mesh_terms: D000328:Adult; D000368:Aged; D000929:Antidepressive Agents, Tricyclic / Q000008:administration & dosage* / Q000493:pharmacokinetics; D003865:Major Depressive Disorder / Q000188:drug therapy*; D004305:Dose-Response Relationship, Drug; D004311:Double-Blind Method; D005260:Female; D016666:Fluvoxamine / Q000008:administration & dosage / Q000493:pharmacokinetics; D006801:Humans; D007099:Imipramine / Q000008:administration & dosage* / Q000493:pharmacokinetics; D008297:Male; D008657:Metabolic Clearance Rate / Q000502:physiology; D008803:Mianserin / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000493:pharmacokinetics; D008875:Middle Aged; D000078785:Mirtazapine; D016896:Treatment Outcome
chemical_list: D000929:Antidepressive Agents, Tricyclic; D008803:Mianserin; D000078785:Mirtazapine; D016666:Fluvoxamine; D007099:Imipramine