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<p style="text-align: right; margin: 10px 0 5px; font-size: 10em;">See reply by <a href="/PCC/article/Pages/dr-bhatia-and-colleagues-reply.aspx" target="_top">Bhatia et al </a> and case report by <a href="/PCC/article/Pages/covid-pandemicinduced-panic-disorder.aspx" target="_top">Bhatia et al</a></span></p>
<p class="ltrs-br-ltr-br-title"><span class="bold">Use of Pharmacologic Agents With Weight Gain Potential for Panic Disorder Amid the COVID-19 Pandemic</span></p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold">To the Editor:</span> We compliment Bhatia et al<span class="htm-cite"><a href="#ref1">1</a></span> for their description of a case of panic disorder due to the news of the coronavirus disease 2019 (COVID-19) pandemic, which highlighted the importance of also focusing on the psychiatric aspect of care amid the unprecedented crisis. With this letter, we would like to raise the issue of weight gain associated with the use of pharmacologic agents for panic disorders, since it has recently been discovered that obesity may be one of the driving factors in the risk of acquisition of and severity of illness with COVID-19.<span class="htm-cite"><a href="#ref2">2</a></span></p>
<p class="ltrs-br-ltr-br-body-text">The patient in this case<span class="htm-cite"><a href="#ref1">1</a></span> had been treated with paroxetine, a selective serotonin reuptake inhibitor (SSRI). SSRIs can have a clinically significant impact on the body weight of their users. The effect depends on the specific SSRI prescribed and the duration of treatment. While users of SSRIs for a short-term basis usually notice no appreciable effect on their body weight, short-term therapy is not clinically appropriate for most patients with panic disorder due to fear of relapse. Treatment with SSRIs for the long term, which is commonly used in patients with panic disorder, may result in weight gain. Weight gain from SSRIs may be due to improved appetite, increased carbohydrate craving, and changes in serotonin 2C receptor activity. Paroxetine, which was prescribed for the patient described in the case report,<span class="htm-cite"><a href="#ref1">1</a></span> may have the most noticeable effect on weight gain among the SSRIs, for which up to a 3.6% increment in baseline body weight has been described.<span class="htm-cite"><a href="#ref3">3</a></span> It has also been previously reported that up to one-quarter of patients receiving paroxetine experienced clinically significant weight gain ≥<span class="thinspace"> </span>7%.<span class="htm-cite"><a href="#ref4">4</a></span></p>
<p class="ltrs-br-ltr-br-body-text">On the other hand, fluoxetine may be the least problematic SSRI with regard to body weight since it has been associated with weight loss.<span class="htm-cite"><a href="#ref3">3</a>,<a href="#ref4">4</a></span> Furthermore, there is one additional disadvantage with the use of paroxetine compared to fluoxetine. Due to its short half-life and nonlinear rapid decline, paroxetine is associated with a high risk for antidepressant discontinuation syndrome in the case of abrupt discontinuation compared to fluoxetine, which is essentially free of such risk owing to its especially long half-life.<span class="htm-cite"><a href="#ref5">5</a></span> Indeed, antidepressant discontinuation syndrome could include flu-like symptoms, fatigue, headache, and dyspnea, which may be confused with the symptoms of COVID-19.</p>
<p class="ltrs-br-ltr-br-body-text">Likewise, venlafaxine, which is a serotonin-norepinephrine reuptake inhibitor used for the treatment of panic disorder, has been associated with weight changes in both the short and long term. A pooled analysis<span class="htm-cite"><a href="#ref6">6</a></span> of randomized trials and observational studies lasting 4 to 12 weeks suggested that short-term treatment with venlafaxine is associated with a weight loss of 0.5 kg. However, a retrospective study<span class="htm-cite"><a href="#ref7">7</a></span> of 49 patients receiving venlafaxine for an average of 18 months reported a mean weight gain of 7 kg. Moreover, due to their actions on dopamine and histamine receptors, the 2 tricyclic antidepressants used for the treatment of panic disorder, namely imipramine and clomipramine, can also lead to weight gain.</p>
<p class="ltrs-br-ltr-br-body-text">The acknowledgment of the potential for pharmacologic agents for the treatment of panic disorder to cause significant weight gain will help in the appropriate selection and modification of pharmacologic therapy during the COVID-19 crisis, especially for patients who have other comorbidities such as diabetes and hypertension that put them at risk of COVID-19 acquisition. Fluoxetine may be particularly favored for the treatment of panic disorder with regard to body weight, but navigation to the right pharmacologic agent also depends on the patient’s response to a particular agent. Clinicians involved in the management of panic disorder should also encourage therapeutic lifestyle changes to lose extra weight or prevent weight gain, especially amid the COVID-19 pandemic.</p>
<p class="references_references-heading"><span class="bold">References</span></p>
<p class="references-references-text-1-9"><a name="ref1"></a><span class="htm-ref"> 1. </span>Bhatia MS, Goyal S, Singh A, et al. COVID-19 pandemic-induced panic disorder. <span class="italic">Prim Care Companion CNS Disord</span>. 2020;22(3):20l02626. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=32369687&dopt=Abstract" target="_blank"><span class="pubmed-crossref">PubMed</span></a> <a href="https://doi.org/10.4088/PCC.20l02626" target="_blank"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref2"></a><span class="htm-ref"> 2. </span>Popkin BM, Du S, Green WD, et al. Individuals with obesity and COVID-19: a global perspective on the epidemiology and biological relationships. <span class="italic">Obes Rev</span>. 2020;21(11):e13128. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=32845580&dopt=Abstract" target="_blank"><span class="pubmed-crossref">PubMed</span></a> <a href="https://doi.org/10.1111/obr.13128" target="_blank"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref3"></a><span class="htm-ref"> 3. </span>Maina G, Albert U, Salvi V, et al. Weight gain during long-term treatment of obsessive-compulsive disorder: a prospective comparison between serotonin reuptake inhibitors. <span class="italic">J Clin Psychiatry</span>. 2004;65(10):1365–1371. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15491240&dopt=Abstract" target="_blank"><span class="pubmed-crossref">PubMed</span></a> <a href="https://doi.org/10.4088/JCP.v65n1011" target="_blank"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref4"></a><span class="htm-ref"> 4. </span>Fava M, Judge R, Hoog SL, et al. Fluoxetine versus sertraline and paroxetine in major depressive disorder: changes in weight with long-term treatment. <span class="italic">J Clin Psychiatry</span>. 2000;61(11):863–867. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11105740&dopt=Abstract" target="_blank"><span class="pubmed-crossref">PubMed</span></a> <a href="https://doi.org/10.4088/JCP.v61n1109" target="_blank"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref5"></a><span class="htm-ref"> 5. </span>Michelson D, Amsterdam J, Apter J, et al. Hormonal markers of stress response following interruption of selective serotonin reuptake inhibitor treatment. <span class="italic">Psychoneuroendocrinology</span>. 2000;25(2):169–177. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10674280&dopt=Abstract" target="_blank"><span class="pubmed-crossref">PubMed</span></a> <a href="https://doi.org/10.1016/S0306-4530(99)00046-3" target="_blank"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref6"></a><span class="htm-ref"> 6. </span>Serretti A, Mandelli L. Antidepressants and body weight: a comprehensive review and meta-analysis. <span class="italic">J Clin Psychiatry</span>. 2010;71(10):1259–1272. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=21062615&dopt=Abstract" target="_blank"><span class="pubmed-crossref">PubMed</span></a> <a href="https://doi.org/10.4088/JCP.09r05346blu" target="_blank"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref7"></a><span class="htm-ref"> 7. </span>Uguz F, Sahingoz M, Gungor B, et al. Weight gain and associated factors in patients using newer antidepressant drugs. <span class="italic">Gen Hosp Psychiatry</span>. 2015;37(1):46–48. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=25467076&dopt=Abstract" target="_blank"><span class="pubmed-crossref">PubMed</span></a> <a href="https://doi.org/10.1016/j.genhosppsych.2014.10.011" target="_blank"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Chia Siang Kow, MPharm</span><span class="superscript">a</span></p>
<p class="ltrs-br-ltr-br-author"><a href="mailto:chiasiang_93@hotmail.com">chiasiang_93@hotmail.com</a></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Syed Shahzad Hasan, PhD</span><span class="superscript">b,c</span></p>
<p class="end-matter"><span class="superscript">a</span>School of Postgraduate Studies, International Medical University, Kuala Lumpur, Malaysia</p>
<p class="end-matter"><span class="superscript">b</span>Department of Pharmacy, University of Huddersfield, Huddersfield, United Kingdom</p>
<p class="end-matter"><span class="superscript">c</span>School of Biomedical Sciences & Pharmacy, University of Newcastle, Callaghan, Australia</p>
<p class="end-matter"><span class="bold-italic">Published online:</span> November 25, 2020.</p>
<p class="end-matter"><span class="bold-italic">Potential conflicts of interest:</span> None.</p>
<p class="end-matter"><span class="bold-italic">Funding/support:</span> None.</p>
<p class="front-matter"><span class="italic">Prim Care Companion CNS Disord 2020;22(6):20lr02805</span></p>
<p class="front-matter-rule"><span class="bold-italic">To cite:</span> Kow CS, Hasan SS. Use of pharmacologic agents with weight gain potential for panic disorder amid the COVID-19 pandemic. <span class="italic">Prim Care Companion CNS Disord. </span>2020;22(6):20lr02805.</p>
<p class="doi-line"><span class="bold-italic">To share: </span>https://doi.org/<span class="doi">10.4088/PCC.20lr02805</span></p>
<p class="end-matter">© <span class="italic">Copyright 2020 Physicians Postgraduate Press, Inc.</span></p>
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