열성홍조 치료를 위한 SSRI와 SNRI의 이용
SSRIs and SNRIs for Management of Hot Flushing
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초록
호르몬 치료 받기를 꺼려하거나, 60대 이상의 여성이 지속적이고 심한 열성홍조를 호소하거나, 유방암의 병력이 있는 여성에서 열성홍조의 치료를 위해 에스트로겐/프로게스테론 이외의 치료를 고려해야할 때 사용할 수 있는 약물로 SSRI/SNRI가 있다. 열성홍조에 관한 메타분석과 임상시험을 종합해볼 때, paroxetine은 일반형에서 30∼40%, 서방형에서 60∼70% (대조군보다 13∼41% 더 효과적) 열성홍조 감소를 보이고, venlafaxine은 30∼60% (대조군보다 33%), desvenlafaxine은 30∼70%의 효과를 보인다. Fluoxetine과 citalopram은 효과가 덜하며, 각각 20% (대조군보다 13%), 40∼50%의 열성홍조 감소를 보인다. Sertraline은 대조군보다는 3∼18% 감소를 보이지만, 전체적으로 볼 때는 효과가 없는 것으로 나타났다. 또한 citalopram 20 mg, paroxetine 10 mg, venlafaxine 37.5∼150 mg, desvenlafaxine 100∼200 mg 군에서는 열성홍조 호전 외에도 수면, 기분, 활력지수, 삶의 질 향상 등의 부가적인 이점이 있었다. Citalopram 20 mg, fluoxetine 20 mg, paroxetine 10 mg, venlafaxine 75∼150 mg, desvenlafaxine 150 mg이 효능과 부작용 두 측면을 모두 고려할 때 추천할만한 용량이다. 그러나 SSRI/SNRI는 tamoxifen이 중간 활성물질인 endoxifen로 전환되는 것을 방해하기 때문에, tamoxifen을 복용하는 유방암 환자에서는 SSRI/SNRI을 사용하면 안 된다. 억제 정도는 paroxetine이 가장 강하고, fluoxetine, sertraline, citalopram, venlafaxine 순서이다. 또한 유방암 환자에서 paroxetine을 사용할 경우 유방암 관련 사망률의 증가가 보고되어, 유방암에서는 paroxetine의 사용이 추천되지 않는다. 결론적으로 호르몬 치료를 받을 수 없는 여성에서는 차선책으로 SSRI, SNRI가 유용하게 시도될 수 있다.
Abstract
For postmenopausal women who fear hormone therapy, women 60 years of age with continuous, severe hot flushing or women with a history of breast cancer, we should consider selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs) as therapeutic agents. Base on the results from a meta-analysis and clinical trials regarding hot flushing, paroxetine and the conetrolled-release formultation of paroxetine have been shown to effectively reduce hot flushing by 30∼40% and 60∼70%, respectively, and 13∼41% more reductions as compared to placebo. Venlafaxine reduced hot flushes by 30∼60% (133% reductions compared to placebo), and desvenlafaxine reduced hot flushes by 30∼70%. Fluoxetine and citalopram were shown to be less effective than paroxetine and venlafaxine, by 20% (113% reductions compared to placebo) and 40∼50%, respectively. Sertraline reduced hot flushes 3∼18% compared to the placebo group, but was considered ineffective. Citalopram (20 mg), paroxetine (10 mg), venlafaxine (37.5∼150 mg), and desvenlafaxine (100∼200 mg) not only reduced vasomotor symptoms, but demonstrated additional beneficial outcomes with respect to sleep disturbances, mood, the vigor index, and improved quality of life. Citalopram (20 mg), fluoxetine (20 mg), paroxetine (10 mg), venlafaxine (75∼150 mg), and desvenlafaxine (150 mg) are recommended at the corresponding doses after weighing the risks and benefits of these medications. SSRIs and SNRIs were shown to interrupt the conversion of tamoxifen into the active metabolite, endoxifen, and thus SSRIs and SNRIs must not be used in breast cancer patients who are taking tamoxifen. Paroxetine suppressed vasomotor symptoms most potently, followed by fluoxetine, sertraline, citalopram, and venlafaxine. (J Korean Soc Menopause 2011;17:68-74)
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