Selegiline, also known as L-deprenyl and sold under the brand names Eldepryl, Zelapar, and Emsam among others, is a medication which is used in the treatment of Parkinson's disease and major depressive disorder. It has also been studied and used off-label for a variety of other indications, but has not been formally approved for any other use. The medication, in the form licensed for depression, has modest effectiveness for this condition that is similar to that of other antidepressants. Selegiline is provided as a swallowed tablet or capsule or an orally disintegrating tablet (ODT) for Parkinson's disease and as a patch applied to skin for depression.
Side effects of selegiline occurring more often than with placebo include insomnia, dry mouth, dizziness, anxiety, abnormal dreams, and application site reactions (with the patch form), among others. At high doses, selegiline has the potential for dangerous food and drug interactions, such as tyramine-related hypertensive crisis (the so-called "cheese reaction") and risk of serotonin syndrome. However, doses within the approved clinical range appear to have little to no risk of these interactions. In addition, the ODT and transdermal patch forms of selegiline have reduced risks of such interactions compared to the conventional oral form. Selegiline has no known misuse potential or dependence liability and is not a controlled substance except in Japan.
Selegiline acts as a monoamine oxidase inhibitor (MAOI) and thereby increases levels of monoamine neurotransmitters in the brain. At typical clinical doses used for Parkinson's disease, selegiline is a selective and irreversible inhibitor of monoamine oxidase B (MAO-B), increasing brain levels of dopamine. At higher doses, it loses its specificity for MAO-B and also inhibits monoamine oxidase A (MAO-A), which increases serotonin and norepinephrine levels in the brain as well. In addition to its MAOI activity, selegiline is a catecholaminergic activity enhancer (CAE) and enhances the impulse-mediated release of norepinephrine and dopamine in the brain. This action may be mediated by TAAR1 agonism. After administration, selegiline partially metabolizes into levomethamphetamine and levoamphetamine, which act as norepinephrine releasing agents (NRAs) and may contribute to its therapeutic and adverse effects as well. The levels of these metabolites are much lower with the ODT and transdermal patch forms of selegiline. Chemically, selegiline is a substituted phenethylamine and amphetamine, a derivative of methamphetamine, and the purified levorotatory enantiomer of deprenyl (the racemic mixture of selegiline and D-deprenyl).
Deprenyl was discovered and studied as an antidepressant in the early 1960s by Zoltan Ecseri, József Knoll, and other colleagues at Chinoin Pharmaceutical Company in Hungary. Subsequently, selegiline was purified from deprenyl and was studied and developed itself. Selegiline was first introduced for medical use, to treat Parkinson's disease, in Hungary in 1977. It was subsequently approved in the United Kingdom in 1982 and in the United States in 1989. The ODT was approved for Parkinson's disease in the United States in 2006 and in the European Union in 2010, while the patch was introduced for depression in the United States in 2006. Selegiline was the first selective MAO-B inhibitor to be discovered and marketed. In addition to its medical use, there has been interest in selegiline as a potential anti-aging drug and nootropic. However, effects of this sort are controversial and uncertain. Generic versions of selegiline are available in the case of the conventional oral form, but not in the case of the ODT or transdermal patch forms.
Medical uses
Parkinson's disease In its oral and ODT forms, selegiline is used to treat symptoms of Parkinson's disease (PD). It is most often used as an adjunct to medications such as levodopa (L-DOPA), although it has been used off-label as a monotherapy. The rationale for adding selegiline to levodopa is to decrease the required dose of levodopa and thus reduce the motor complications of levodopa therapy. Selegiline delays the point when levodopa treatment becomes necessary from about 11months to about 18months after diagnosis. There is some evidence that selegiline acts as a neuroprotective and reduces the rate of disease progression, though this is disputed. In addition to parkinsonism, selegiline can improve symptoms of depression in people with Parkinson's disease. There is evidence that selegiline may be more effective than rasagiline in the treatment of Parkinson's disease. This may be due to pharmacological differences between the drugs, such as the catecholaminergic activity enhancer (CAE) actions of selegiline which rasagiline lacks.
Depression Selegiline is used as an antidepressant in the treatment of major depressive disorder (MDD). Both the oral selegiline and transdermal selegiline patch formulations are used in the treatment of depression. However, oral selegiline is not approved for depression and is used off-label for this indication, while the transdermal patch is specifically licensed for treatment of depression. Both standard clinical doses of oral selegiline (up to 10mg/day) and higher doses of oral selegiline (e.g., 30 to 60mg/day) have been used to treat depression, with the lower doses selectively inhibiting MAO-B and the higher doses producing dual inhibition of both MAO-A and MAO-B. Unlike oral selegiline, transdermal selegiline bypasses first-pass metabolism, thereby avoiding inhibition of gastrointestinal and hepatic MAO-A and minimizing the risk of food and drug interactions, whilst still allowing for selegiline to reach the brain and inhibit MAO-B.
A 2023 systematic review and meta-analysis evaluated the effectiveness and safety of selegiline in the treatment of psychiatric disorders including depression. It included both randomized and non-randomized published clinical studies. The meta-analysis found that selegiline was more effective than placebo in terms of reduction in depressive symptoms ( = −0.96, k = 10, n = 1,308), response rates for depression improvement ( = 1.61, k = 9, n = 1,238), and response rates for improvement of depression with atypical features ( = 2.23, k = 3, n = 136). Oral selegiline was significantly more effective than the selegiline patch in terms of depressive symptom improvement ( = −1.49, k = 6, n = 282 vs. = −0.27, k = 4, n = 1,026, respectively; p = 0.03). However, this was largely due to older and less methodologically rigorous trials that were at high risk for bias. Oral selegiline studies also often employed much higher doses than usual, for instance 20 to 60mg/day. The quality of evidence of selegiline for depression was rated as very low overall, very low for oral selegiline, and low to moderate for transdermal selegiline. For comparison, meta-analyses of other antidepressants for depression have found a mean effect size of about 0.3 (a small effect), which is similar to that with transdermal selegiline.
In two pivotal regulatory clinical trials of 6 to 8weeks duration, the selegiline transdermal patch decreased scores on depression rating scales (specifically the 17- and 28-item ) by 9.0 to 10.9points, whereas placebo decreased scores by 6.5 to 8.6points, giving placebo-subtracted differences attributable to selegiline of 2.4 to 2.5points. A 2013 quantitative review of the transdermal selegiline patch for depression, which pooled the results of these two trials, found that the placebo-subtracted number needed to treat (NNT) was 11 in terms of depression response (>50% reduction in symptoms) and 9 in terms of remission of depression (score of ≤10 on the ). For comparison, other antidepressants, including fluoxetine, paroxetine, duloxetine, vilazodone, adjunctive aripiprazole, olanzapine/fluoxetine, and extended-release quetiapine, have NNTs ranging from 6 to 8 in terms of depression response and 7 to 14 in terms of depression remission. On the basis of these results, it was concluded that transdermal selegiline has similar effectiveness to other antidepressants. NNTs are measures of effect size and indicate how many individuals would need to be treated in order to encounter one additional outcome of interest. Lower NNTs are better, and NNTs corresponding to Cohen's d effect sizes have been defined as 2.3 for a large effect (d = 0.8), 3.6 for a medium effect (d = 0.5), and 8.9 for a small effect (d = 0.2). The effectiveness of transdermal selegiline for depression relative to side effects and discontinuation was considered to be favorable.
While several large regulatory clinical trials of transdermal selegiline versus placebo for depression have been conducted, there is a lack of trials comparing selegiline to other antidepressants. Although multiple doses of transdermal selegiline were assessed, a dose–response relationship for depression was never established. Transdermal selegiline has shown similar clinical effectiveness in the treatment of atypical depression relative to typical depression and in the treatment of anxious depression relative to non-anxious depression.
Transdermal selegiline does not cause sexual dysfunction and may improve certain domains of sexual function, for instance sexual interest, maintaining interest during sex, and sexual satisfaction. These benefits were apparent in women but not in men. The lack of sexual dysfunction with transdermal selegiline is in contrast to many other antidepressants, such as the selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs), which are associated with high rates of sexual dysfunction.
Transdermal selegiline patches have been underutilized in the treatment of depression compared to other antidepressants. A variety of factors contributing to this underutilization have been identified. One major factor is the very high cost of transdermal selegiline, which is often not covered by insurance and frequently proves to be prohibitive. Conversely, other widely available antidepressants are much cheaper in comparison.
Available forms Selegiline is available in the following three pharmaceutical forms: Oral tablets and capsules 5mg (brand names Eldepryl, Jumex, and generics) – indicated for Parkinson's disease Orally disintegrating tablets (ODTs) 1.25mg (brand name Zelapar) – indicated for Parkinson's disease Transdermal patches 6, 9, and 12mg/24hours (brand name Emsam) – indicated for major depressive disorder
The transdermal patch form is also known as the "selegiline transdermal system" or "STS" and is applied once daily. They are 20, 30, or 40cm2 in size and contain a total of 20, 30, or 40mg selegiline per patch (so 20mg/20cm2, 30mg/30cm2, and 40mg/40cm2), respectively. The selegiline transdermal patch is a matrix-type adhesive patch with a three-layer structure. It is the only approved non-oral MAOI, having reduced dietary restrictions and side effects in comparison to oral MAOIs, and is also the only approved non-oral first-line antidepressant. The selegiline patch can be useful for those who have difficulty tolerating oral medications.
Contraindications