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Bleich L, Grohmann R, Greil W, Dabbert D, Erfurth A, Toto S, Seifert J. Clozapine-associated adverse drug reactions in 38,349 psychiatric inpatients: drug surveillance data from the AMSP project between 1993 and 2016. J Neural Transm (Vienna) 2024; 131:1117-1134. [PMID: 39136776 PMCID: PMC11365862 DOI: 10.1007/s00702-024-02818-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 07/31/2024] [Indexed: 09/02/2024]
Abstract
Clozapine is a second-generation antipsychotic drug that offers superior treatment results in patients with schizophrenia but is also associated with significant risks. This study analyzes data on pharmacotherapy with clozapine and the associated adverse drug reactions (ADRs) in an inpatient setting including 38,349 patients. Data about the use of clozapine and reports of severe ADRs within the period 1993-2016 were obtained from the multicentered observational pharmacovigilance program "Arzneimittelsicherheit in der Psychiatrie" (AMSP). In total, 586 severe clozapine-associated ADRs were documented (1.53% of all patients exposed). Patients aged ≥65 years had a higher risk of ADRs than patients aged <65 years (1.96 vs. 1.48%; p = 0.021). Significantly more ADRs were attributed to clozapine alone (396; 67.6% of all 586 ADRs) than to a combination with other drugs. The most frequent ADRs were grand mal seizures (0.183% of all 38,349 patients exposed), delirium (0.180%), increased liver enzymes (0.120%), and agranulocytosis (0.107%). We detected 24 cases (0.063%) of clozapine-induced extrapyramidal symptoms, of which 8 (0.021%) were attributed to clozapine alone. Five ADRs resulted in death (0.013%): 2 due to agranulocytosis (41 cases total) (mortality = 4.88%) and 3 due to paralytic (sub)ileus (16 cases) (mortality = 18.75%). The median dose of clozapine in all patients treated was 300 mg/day, in patients who developed ADRs 250 mg/day. The main risk factor for an ADR was pre-existing damage of the affected organ system. Overall, the results of this study highlight the importance of alertness-especially of frequently overlooked symptoms-and appropriate monitoring during treatment with clozapine, even at low doses.
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Affiliation(s)
- Lene Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, 30625, Hannover, Germany.
- University Medical Center Göttingen, 37075, Göttingen, Germany.
| | - Renate Grohmann
- Department of Psychiatry and Psychotherapy, LMU University Hospital, 80336, Munich, Germany
| | - Waldemar Greil
- Department of Psychiatry and Psychotherapy, LMU University Hospital, 80336, Munich, Germany
- Psychiatric Private Hospital, Sanatorium Kilchberg, 8802, Kilchberg, Switzerland
| | - Dominik Dabbert
- Department of Forensic Psychiatry and Psychotherapy, Klinik Bremen-Ost, 28325, Bremen, Germany
| | - Andreas Erfurth
- 1st Department of Psychiatry and Psychotherapeutic Medicine, Klinik Hietzing, 1130, Vienna, Austria
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, 30625, Hannover, Germany
| | - Johanna Seifert
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, 30625, Hannover, Germany
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2
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Biso L, Aringhieri S, Carli M, Scarselli M, Longoni B. Therapeutic Drug Monitoring in Psychiatry: Enhancing Treatment Precision and Patient Outcomes. Pharmaceuticals (Basel) 2024; 17:642. [PMID: 38794212 PMCID: PMC11124530 DOI: 10.3390/ph17050642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/09/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024] Open
Abstract
Psychiatric disorders often require pharmacological interventions to alleviate symptoms and improve quality of life. However, achieving an optimal therapeutic outcome is challenging due to several factors, including variability in the individual response, inter-individual differences in drug metabolism, and drug interactions in polytherapy. Therapeutic drug monitoring (TDM), by measuring drug concentrations in biological samples, represents a valuable tool to address these challenges, by tailoring medication regimens to each individual. This review analyzes the current landscape of TDM in psychiatric practice, highlighting its significance in optimizing drug dosages, minimizing adverse effects, and improving therapeutic efficacy. The metabolism of psychiatric medications (i.e., mood stabilizers, antipsychotics, antidepressants) often exhibits significant inter-patient variability. TDM can help address this variability by enhancing treatment personalization, facilitating early suboptimal- or toxic-level detection, and allowing for timely interventions to prevent treatment failure or adverse effects. Furthermore, this review briefly discusses technological advancements and analytical methods supporting the implementation of TDM in psychiatric settings. These innovations enable quick and cost-effective drug concentration measurements, fostering the widespread adoption of TDM as a routine practice in psychiatric care. In conclusion, the integration of TDM in psychiatry can improve treatment outcomes by individualizing medication regimens within the so-called precision medicine.
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Affiliation(s)
- Letizia Biso
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
| | - Stefano Aringhieri
- Mental Health and Pathological Addiction Department, AUSL Romagna Forlì-Cesena, 47121 Forlì, Italy;
| | - Marco Carli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
| | - Marco Scarselli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
| | - Biancamaria Longoni
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
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3
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Jiménez-Fernández S, Gurpegui M, Correll CU, de Leon J, Schoretsanitis G. A Systematic Review of Clozapine Concentration-Dose Ratio from Therapeutic Drug Monitoring Studies in Children and Adolescents Treated with Clozapine for Mental Disorders. Ther Drug Monit 2024; 46:170-180. [PMID: 38018845 PMCID: PMC10930379 DOI: 10.1097/ftd.0000000000001154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/14/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Therapeutic drug monitoring of clozapine in children and adolescents has received insufficient attention. Calculation of concentration-to-dose (C/D) ratios from trough steady-state concentrations estimate drug clearance. METHODS A systematic electronic literature search was conducted in 3 article databases from inception until January 10, 2023, and articles reporting clozapine concentrations in children and adolescents were retrieved. The pharmacokinetic quality of the studies was assessed, and clozapine C/D ratios were calculated using the sample mean clozapine dose and concentration. RESULTS Of the 37 articles of potential interest, only 7 reported clozapine trough and steady-state concentrations. After excluding case reports and a study confounded by fluvoxamine, 4 studies on psychosis from Europe and the United States were included. The clozapine C/D ratios were similar to published adult values and ranged from 0.82 to 1.24 with a weighted mean of 1.08 ng/mL per mg/d. The weighted means were 334 mg/d for the dose and 380 ng/mL for the concentration. The stratified analysis of the weighted mean clozapine C/D ratios from 2 studies showed lower values in 52 male (1.05 ng/mL per mg/d) than in 46 female (1.46 ng/mL per mg/d) children and adolescents, with values similar to those reported for European adult nonsmokers. Two female adolescents had high clozapine C/D ratios (2.54 ng/mL per mg/d), an Asian American patient with borderline obesity and a patient with intellectual disability with low dosage (mean = 102 mg/d) and concentration (mean = 55 ng/mL). CONCLUSIONS Reports on clozapine therapeutic drug monitoring in children and adolescents are limited in number and quality. Future studies should focus on basic pharmacokinetic issues, such as stratification by sex, smoking, and relevant comedications with inductive or inhibitory properties.
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Affiliation(s)
- Sara Jiménez-Fernández
- Child and Adolescent Mental Health Unit, Virgen de Las Nieves University Hospital, Granada, Spain
- CTS-549 Research Group (Psychiatry and Neurosciences), Junta de Andalucía, Spain
| | - Manuel Gurpegui
- CTS-549 Research Group (Psychiatry and Neurosciences), Junta de Andalucía, Spain
- Granada Center for Psychiatric Studies, Granada, Spain
| | - Christoph U. Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, New York
| | - Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, Kentucky
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain; and
| | - Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, New York
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland
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4
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Panić B, Jovanović M, Lukić V, Vučićević K, Miljković B, Milovanović S. Association of clozapine and norclozapine levels with patient and therapy characteristics-focus on interaction with valproic acid. Eur J Clin Pharmacol 2023; 79:1557-1564. [PMID: 37733278 DOI: 10.1007/s00228-023-03569-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/15/2023] [Indexed: 09/22/2023]
Abstract
PURPOSE The goal of the study was to examine clozapine (CLZ) and norclozapine (NCLZ) therapeutic drug monitoring (TDM) data and associated sources of pharmacokinetic variability, particularly the impact of valproic acid (VPA) use. METHODS This study included 126 patients with psychiatric disorders on mono- or co-therapy with CLZ. Patients' data during routine TDM were collected retrospectively from clinical records. The descriptive and statistical analysis was computed using IBM SPSS Statistics software (version 22, NY, USA). Multiple linear regression, based on the last observations, was used to assess correlation between demographic characteristics, life habits and co-therapy with dose-corrected serum levels (C/D) of CLZ and NCLZ, as well as CLZ/NCLZ. RESULTS A total of 295 CLZ concentrations were measured in 126 patients, with a mean of 275.5 ± 174.4 µg/L, while 124 NCLZ concentrations were determined in 74 patients, with a mean of 194.6 ± 149.8 µg/L. A statistically significant effect on ln-transformed CLZ C/D was confirmed for sex and smoking, whereas sex, smoking and VPA therapy were associated with ln-transformed NCLZ C/D. According to the final models, lower values of NCLZ C/D for about 45.9% can be expected in patients receiving VPA. Concomitant use of VPA was the only factor detected to contribute in CLZ/NCLZ variability. CONCLUSION The results of this study may help clinicians interpret TDM data and optimize CLZ dosing regimens, especially in patients concomitantly treated with VPA. Our results show that VPA primarily decreases NCLZ levels, while alteration of the parent drug is not statistically significant.
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Affiliation(s)
- Bojana Panić
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221, Belgrade, Serbia
| | - Marija Jovanović
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221, Belgrade, Serbia.
| | - Vera Lukić
- Institute of Forensic Medicine "Milovan Milovanović", Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Katarina Vučićević
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221, Belgrade, Serbia
| | - Branislava Miljković
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221, Belgrade, Serbia
| | - Srđan Milovanović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Psychiatry, University Clinical Center of Serbia, Belgrade, Serbia
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5
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Liang J, Ringeling LT, Hermans RA, Bayraktar I, Bosch TM, Egberts KM, Kloosterboer SM, de Winter B, Dierckx B, Koch BCP. Clinical pharmacokinetics of antipsychotics in pediatric populations: a scoping review focusing on dosing regimen. Expert Opin Drug Metab Toxicol 2023; 19:501-509. [PMID: 37668177 DOI: 10.1080/17425255.2023.2252340] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 09/06/2023]
Abstract
INTRODUCTION Achieving optimal clinical responses and minimizing side effects through precision dosing of antipsychotics in children and adolescents with psychiatric disorders remains a challenge. Identifying patient characteristics (covariates) that affect pharmacokinetics can inform more effective dosing strategies and ultimately improve patient outcomes. This review aims to provide greater insight into the impact of covariates on the clinical pharmacokinetics of antipsychotics in pediatric populations. AREAS COVERED A comprehensive literature search was conducted, and the main findings regarding the effects of the covariates on the pharmacokinetics of antipsychotics in children and adolescents are presented. EXPERT OPINION Our study highlights significant covariates, including age, sex, weight, CYP2D6 phenotype, co-medication, and smoking habits, which affect the pharmacokinetics of antipsychotics. However, the findings were generally limited by the small sample sizes of naturalistic, open-label, observational studies, and the homogeneous subgroups. Dosing based on weight and preemptive genotyping could prove beneficial for optimizing the dosing regimen in pediatric populations. Future research is needed to refine dosing recommendations and establish therapeutic reference ranges critical for precision dosing and Therapeutic Drug Monitoring (TDM). The integration of individual patient characteristics with TDM can further optimize the efficacy and safety of antipsychotics for each patient.
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Affiliation(s)
- Jiayi Liang
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Maasstad Hospital, Rotterdam, the Netherlands
| | - Lisa T Ringeling
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Rebecca A Hermans
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Izgi Bayraktar
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tessa M Bosch
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Maasstad Hospital, Rotterdam, the Netherlands
- Department of Clinical Pharmacology & Toxicology, Maasstad Lab, Maasstad Hospital, Rotterdam, the Netherlands
| | - Karin M Egberts
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Würzburg, Würzburg, Germany
| | - Sanne M Kloosterboer
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Brenda de Winter
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bram Dierckx
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Birgit C P Koch
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
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6
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Demirbugen Oz M, Ozdemir F, Tok KC, Dural E, Kir Y, Ulusoy M, Gumustas M, Baskak B, Suzen HS. The potential role of por*28 and cyp1a2*f genetic variations and lifestyle factors on clozapine and n-desmethyl clozapine plasma levels in schizophrenia patients. Expert Opin Drug Metab Toxicol 2023. [PMID: 37269349 DOI: 10.1080/17425255.2023.2221849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/24/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Despite its advantages over other antipsychotics, for treatment-resistant schizophrenia, clinical use of Clozapine (CLZ) is challenging by its narrow therapeutic index and potentially life-threatening dose-related adverse effects. RESEARCH DESIGN AND METHODS As the potential role in CLZ metabolism is assigned to CYP1A2 enzyme and consequently Cytochrome P450 oxidoreductase (POR) their genetic variations might help to determine CLZ levels in schizophrenia patients. For this purpose, 112 schizophrenia patients receiving CLZ were included in the current study. Plasma CLZ and N-desmethylclozapine (DCLZ) levels were analyzed by using HPLC and genetic variations were identified with the PCR-RFLP method. RESULTS The patients' CYP1A2 and POR genotypes seemed to not affect plasma CLZ and DCLZ levels whereas in the subgroup analysis, POR × 28 genotype significantly influenced simple and adjusted plasma CLZ and DLCZ levels concerning smoking habit and caffeine consumption. CONCLUSIONS The findings of the present study highlight the importance of both genetic and non-genetic factors (smoking and caffeine consumption) for the individualization of the CLZ treatment. In addition to that, it suggests that the added utility of not only the CLZ metabolizing enzymes but also POR, which is crucial for proper CYP activity, to guide CLZ dosing might be useful for clinical decision-making.
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Affiliation(s)
- Merve Demirbugen Oz
- Faculty of Pharmacy, Department of Pharmaceutical Toxicology, Ankara University, Ankara, Turkey
| | - Fezile Ozdemir
- Dr Fazil Kucuk Faculty of Medicine, Eastern Mediterranean University, North, Cyprus, Turkey
| | - Kenan Can Tok
- Institute of Forensic Sciences, Department of Forensic Toxicology, Ankara University, Ankara, Turkey
| | - Emrah Dural
- Faculty of Pharmacy, Department of Pharmaceutical Toxicology, Sivas Cumhuriyet University, Sivas, Turkey
| | - Yagmur Kir
- Bursa Acibadem Hospital, Department of Psychiatry, Bursa, Turkey
| | - Muge Ulusoy
- School of Medicine, Department of Psychiatry, Ankara University, Ankara, Turkey
| | - Mehmet Gumustas
- Institute of Forensic Sciences, Department of Forensic Toxicology, Ankara University, Ankara, Turkey
| | - Bora Baskak
- School of Medicine, Department of Psychiatry, Ankara University, Ankara, Turkey
| | - H Sinan Suzen
- Faculty of Pharmacy, Department of Pharmaceutical Toxicology, Ankara University, Ankara, Turkey
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7
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Yan Z, Shi Z, Wu Y, Lv J, Deng P, Liu G, An Z, Che Z, Lu Y, Shan J, Liu Q. Wireless, noninvasive therapeutic drug monitoring system for saliva measurement toward medication management of schizophrenia. Biosens Bioelectron 2023; 234:115363. [PMID: 37146537 DOI: 10.1016/j.bios.2023.115363] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 04/14/2023] [Accepted: 04/28/2023] [Indexed: 05/07/2023]
Abstract
As an efficient patient management tool of precision medicine, decentralized therapeutic drug monitoring (TDM) provides new vision for therapy adherence and health management of schizophrenia in a convenient manner. To dispense with psychologically burdensome blood sampling and to achieve real-time, noninvasive, and continual circulating tracking of drugs with narrow therapeutic window, we study the temporal metabolism of clozapine, an antipsychotic with severe side effect, in rat saliva by a wireless, integrated and patient-friendly smart lollipop sensing system. Highly sensitive and efficient sensing performance with acceptable anti-biofouling property was realized based on the synergistic effect of electrodeposited reduced graphene oxide and ionic liquids in pretreatment-free saliva with low detection limit and good accuracy cross-validated with conventional method. On this basis, continual salivary drug levels with distinctive pharmacokinetics were found in different routes of drug administration. Pilot experiment reveals a strong correlation between blood and saliva clozapine and a positive relationship between drug dosage and salivary drug level, indicating potential applications presented by noninvasive saliva analysis towards patient-centered and personalized pharmacotherapy and adherence management via proposed smart lollipop system.
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Affiliation(s)
- Zupeng Yan
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, PR China; Biosensor National Special Laboratory, Key Laboratory for Biomedical Engineering of Education Ministry, Department of Biomedical Engineering, Zhejiang University, Hangzhou, 310027, PR China
| | - Zhenghan Shi
- Biosensor National Special Laboratory, Key Laboratory for Biomedical Engineering of Education Ministry, Department of Biomedical Engineering, Zhejiang University, Hangzhou, 310027, PR China
| | - Yue Wu
- Biosensor National Special Laboratory, Key Laboratory for Biomedical Engineering of Education Ministry, Department of Biomedical Engineering, Zhejiang University, Hangzhou, 310027, PR China
| | - Jingjiang Lv
- Biosensor National Special Laboratory, Key Laboratory for Biomedical Engineering of Education Ministry, Department of Biomedical Engineering, Zhejiang University, Hangzhou, 310027, PR China
| | - Peixue Deng
- Life Sciences Institute, Guangxi Key Laboratory of AIDS Prevention and Treatment, Guangxi Medical University, Nanning, Guangxi, 530021, PR China
| | - Guang Liu
- Biosensor National Special Laboratory, Key Laboratory for Biomedical Engineering of Education Ministry, Department of Biomedical Engineering, Zhejiang University, Hangzhou, 310027, PR China
| | - Zijian An
- Biosensor National Special Laboratory, Key Laboratory for Biomedical Engineering of Education Ministry, Department of Biomedical Engineering, Zhejiang University, Hangzhou, 310027, PR China
| | - Ziyuan Che
- Biosensor National Special Laboratory, Key Laboratory for Biomedical Engineering of Education Ministry, Department of Biomedical Engineering, Zhejiang University, Hangzhou, 310027, PR China
| | - Yanli Lu
- Biosensor National Special Laboratory, Key Laboratory for Biomedical Engineering of Education Ministry, Department of Biomedical Engineering, Zhejiang University, Hangzhou, 310027, PR China; Intelligent Perception Research Institute, Zhejiang Lab, Hangzhou, 311100, PR China.
| | - Jianzhen Shan
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, PR China; Cancer Center, Zhejiang University, Hangzhou, 310058, PR China.
| | - Qingjun Liu
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, PR China; Biosensor National Special Laboratory, Key Laboratory for Biomedical Engineering of Education Ministry, Department of Biomedical Engineering, Zhejiang University, Hangzhou, 310027, PR China.
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8
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Rizvi A, Reyazuddin M, Shaan F. Low Dose Clozapine in Early Onset Resistant Schizophrenia: Case Report and Two Year Follow-up. J Am Acad Child Adolesc Psychiatry 2023:S0890-8567(23)00181-8. [PMID: 37075891 DOI: 10.1016/j.jaac.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/04/2023] [Accepted: 04/10/2023] [Indexed: 04/21/2023]
Abstract
Childhood-onset schizophrenia (COS) is considered a rare and severe form of schizophrenia, with onset before age 13 and only half of affected patients responding to nonclozapine antipsychotics.1 These patients with resistant COS show favorable responses to clozapine, but with higher adverse effects than seen in adults. Some resistant cases respond at a lower dose with minimal adverse effects.2 However, it is unclear which patients will respond to a low dose and how long one should wait before increasing the dose of clozapine. We report a patient with resistant COS who showed a favorable but delayed-onset response to low-dose clozapine.
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Affiliation(s)
- Abid Rizvi
- West Virginia University, Morgantown, West Virginia.
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9
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Fekete S, Güntzel T, Egberts K, Geissler J, Neubert A, Gerlach M, Romanos M, Taurines R. Serious Adverse Drug Reactions to Antipsychotics in Minors with Multiple Disabilities: Preventability and Potential Cost Savings by Therapeutic Drug Monitoring. PHARMACOPSYCHIATRY 2022; 56:32-39. [PMID: 36332618 PMCID: PMC9811527 DOI: 10.1055/a-1963-7631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Children and adolescents with multiple disabilities and mental disorders (CAMD) are frequently treated with antipsychotic drugs. However, CAMD are particularly susceptible to serious adverse drug reactions (sADRs). This retrospective study examined the frequency of sADRs to antipsychotics in CAMD. Further, the potential preventability of these sADRs through therapeutic drug monitoring (TDM) and the potential socio-economic benefits of TDM were explored. METHODS Routine clinical data of all patients treated at a specialized psychiatric clinic for CAMD between January 2017 and December 2018 were retrospectively examined. Data on the occurrence of sADRs (definition according to the European Medicines Agency), their causality with antipsychotics, as well as their preventability (Schumock criteria) were extracted from patient files. The prolongation of the hospital stay due to sADRs was calculated, and the cost savings were estimated if TDM had been applied. The data were based on a subsample of the KiDSafe project, supported by the Innovation Fund of the Joint Federal Committee, grant number 01NVF16021. RESULTS One hundred two CAMD who were administered at least one antipsychotic drug during inpatient treatment were identified. Of these patients, 22 (21.6%) sADRs with a possible causal relationship with the antipsychotic treatment were documented. Eleven sADRs (50%) could potentially have been prevented through TDM. Mitigating sADRs through TDM likely would have prevented prolonged hospital stays and thus conferred considerable savings for health insurance companies. DISCUSSION The routine implementation of TDM is urgently recommended for antipsychotic treatment in CAMD to increase drug therapy safety.
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Affiliation(s)
- Stefanie Fekete
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group ‘Child and Adolescent
Psychopharmacology’,Correspondence Dr. Stefanie
Fekete University hospital of
WürzburgDepartment of Child and Adolescent
Psychiatry, Psychosomatics and Psychotherapy, Margarete-Höppel-Platz
197080
WurzburgGermany
| | - Tim Güntzel
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany
| | - Karin Egberts
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group ‘Child and Adolescent
Psychopharmacology’,AGNP-Work group Therapeutic Drug Monitoring,Competence network for Therapeutic Drug Monitoring in child and
adolescent psychiatry
| | - Julia Geissler
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany
| | - Antje Neubert
- Department of Paediatrics and Adolescent Medicine, University Hospital
Erlangen, Erlangen, Germany
| | - Manfred Gerlach
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group ‘Child and Adolescent
Psychopharmacology’,AGNP-Work group Therapeutic Drug Monitoring,Competence network for Therapeutic Drug Monitoring in child and
adolescent psychiatry
| | - Marcel Romanos
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group ‘Child and Adolescent
Psychopharmacology’,AGNP-Work group Therapeutic Drug Monitoring
| | - Regina Taurines
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group Therapeutic Drug Monitoring
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10
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Therapeutic drug monitoring of sertraline in children and adolescents: A naturalistic study with insights into the clinical response and treatment of obsessive-compulsive disorder. Compr Psychiatry 2022; 115:152301. [PMID: 35248877 DOI: 10.1016/j.comppsych.2022.152301] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 02/07/2022] [Accepted: 02/18/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Sertraline is a selective serotonin reuptake inhibitor with specific indications in child and adolescent psychiatry. Notwithstanding its frequent use and clinical benefits, the relationship between pharmacokinetics, pharmacodynamics, efficacy, and tolerability of sertraline across indications, particularly in non-adult patients, is not fully understood. METHOD This naturalistic therapeutic drug monitoring (TDM) study was conducted in a transdiagnostic sample of children and adolescents treated with sertraline (n = 78; mean age, 14.22 ± 2.39; range, 7-18 years) within the prospective multicenter "TDM-VIGIL" project. Associations between dose, serum concentration, and medication-specific therapeutic and side effects based on the Clinical Global Impression scale were examined. Tolerability was measured qualitatively with the 56-item Pediatric Adverse Event Rating Scale. RESULTS A strong linear positive dose-serum concentration relationship (with dose explaining 45% of the variance in concentration) and significant effects of weight and co-medication were found. Neither dose nor serum concentration were associated with side effects. An overall mild-to-moderate tolerability profile of sertraline was observed. In contrast with the transdiagnostic analysis that did not indicate an effect of concentration, when split into depression (MDD) and obsessive-compulsive disorder (OCD) diagnoses, the probability of clinical improvement significantly increased as both dose and concentration increased for OCD, but not for MDD. CONCLUSIONS This TDM-flexible-dose study revealed a significant diagnosis-specific effect between sertraline serum concentration and clinical efficacy for pediatric OCD. While TDM already guides clinical decision-making regarding compliance, dose calibration, and drug-drug interactions, combining TDM with other methods, such as pharmacogenetics, may facilitate a personalized medicine approach in psychiatry.
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11
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Hassab Errasoul A, Alarabi MA. Factors predicting serum clozapine levels in Middle Eastern patients: an observational study. BMC Psychiatry 2022; 22:269. [PMID: 35428222 PMCID: PMC9011948 DOI: 10.1186/s12888-022-03910-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/01/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Despite its superiority over other drugs for psychosis, clozapine remains underused and is associated with many clinical challenges, including difficulties in predicting therapeutic serum levels (350-600 ng/mL). We found no large or recent study that investigated the determinants of serum clozapine levels in Middle Eastern patients. Therefore, we investigated the association between clozapine dose and serum level, and the clinical predictors of the clozapine serum level, in Middle Eastern patients. METHODS This cross-sectional study included 94 patients of Middle Eastern ethnicity who attended the Clozapine Clinic in King Saud University Medical City in Riyadh, Saudi Arabia. We used a single measure of the serum clozapine level, which was collected 12 h after the last oral dose of clozapine under steady-state conditions. RESULTS The average clozapine dose and serum level were 400 mg/daily and 705 ng/mL, respectively. The majority of patients (59.8%) had serum levels higher than 600 ng/mL. Clozapine dose and serum level were positively correlated (rs [94] = 0.32, p = 0.002). We generated a predictive model of the serum clozapine level, which revealed that the daily dose, smoking status, use of fluvoxamine or lamotrigine, and body mass index (BMI) predicted 43.6% of the variance in the serum level (p < 0.001). Using this model, we calculated that patients with a BMI of 25 kg/m2 would require a clozapine dose between 50 to 275 mg/daily if they were non-smokers, and a dose of 200 to 450 mg/daily if they were smokers, in order to reach a serum clozapine level between 350 to 600 ng/mL. Patients with higher BMI and those receiving fluvoxamine would require lower doses. CONCLUSIONS This was a naturalistic study of the clozapine dose-level relationship and the clinical predictors of the serum clozapine level in a sample of Middle Eastern patients. The ratios of clozapine level to dose in our patients more closely resembled those reported in Asian samples than in European samples. These findings do not reduce the value of individualised therapeutic drug monitoring, but may assist clinicians when prescribing clozapine to Middle Eastern patients. Further psychopharmacological studies are needed on this demographic population.
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Affiliation(s)
- Ahmed Hassab Errasoul
- Department of Psychiatry, College of Medicine, King Saud University, PO Box 7805, Riyadh, 11472, Kingdom of Saudi Arabia
| | - Mohammed A Alarabi
- Department of Psychiatry, College of Medicine, King Saud University, PO Box 7805, Riyadh, 11472, Kingdom of Saudi Arabia.
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12
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Ruppert K, Geffert C, Clement HW, Bachmann C, Haberhausen M, Schulz E, Fleischhaker C, Biscaldi-Schäfer M. Therapeutic drug monitoring of atomoxetine in children and adolescents with attention-deficit/ hyperactivity disorder: a naturalistic study. J Neural Transm (Vienna) 2022; 129:945-959. [PMID: 35391568 PMCID: PMC9217867 DOI: 10.1007/s00702-022-02483-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/22/2022] [Indexed: 12/02/2022]
Abstract
The selective norepinephrine reuptake inhibitor atomoxetine is potentially among the first-line pharmacotherapy options for ADHD. Therapeutic drug monitoring (TDM) with the quantification and interpretation of atomoxetine serum concentrations is used to determine an individual dose followed by an optimal effectiveness and minimal side effects. The aim of this retrospective pharmacokinetic–pharmacodynamic analysis was to derive age-appropriate recommendations for the implementation of TDM to improve the efficacy and tolerability of atomoxetine in children and adolescents. Using the analytical method of high-performance liquid chromatography with UV detection, 94 serum concentrations of 74 patients between 6 and 21 years of age were determined. Therapeutic effectiveness and side effects were evaluated according to the categories “low”, “moderate”, and “significant”. As part of TDM, a time interval with maximum concentrations of 1–3 h after the administration of atomoxetine was determined for blood sampling. In this time interval, a significant correlation between the weight-normalized dose and the serum concentrations was found. The efficacy as well as the tolerability proved to be mainly moderate or significant. A preliminary therapeutic reference range was between 100 and 400 ng/ml. Naturalistic studies have limitations. Therefore, and due to a limited study population, the results have to be regarded as preliminary observations that must be confirmed in further studies. The preliminary therapeutic reference range for children and adolescents proved to be narrower than the reference range for adult patients. However, due to good efficacy and tolerability an exact reference range remained difficult to determine.
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Affiliation(s)
- Katrin Ruppert
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Hans-Willi Clement
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Bachmann
- Department of Child and Adolescent Psychiatry, University Hospital Marburg, Philipps-University Marburg, Marburg, Germany
- Department of Child and Adolescent Psychiatry and Psychotherapy, University of Ulm, Ulm, Germany
| | - Michael Haberhausen
- Department of Child and Adolescent Psychiatry, University Hospital Marburg, Philipps-University Marburg, Marburg, Germany
| | - Eberhard Schulz
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Fleischhaker
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.
| | - Monica Biscaldi-Schäfer
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
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13
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Egberts K, Fekete S, Häge A, Hiemke C, Scherf-Clavel M, Taurines R, Unterecker S, Gerlach M, Romanos M. [Therapeutic drug monitoring to optimize psychopharmacotherapy in children and adolescents - Update and guidelines for practice]. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2022; 50:133-152. [PMID: 35274573 DOI: 10.1024/1422-4917/a000845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Therapeutic drug monitoring to optimize psychopharmacotherapy in children and adolescents - Update and guidelines for practice Abstract. Despite the improved evidence base, many uncertainties remain in child and adolescent psychiatric pharmacotherapy about the efficacy and tolerability of drugs, which are often prescribed off-label or in combination therapy in this age group. Because medium- to long-term use is unavoidable in many cases, clinicians should minimize adverse drug reactions as far as possible and tailor an effective dosage to the individual characteristics of the patient. Not only are children and adolescents particularly vulnerable to certain adverse drug effects, they are also exposed to iatrogenic risks from dosing or application errors, which can lead to under- or overdosing with correspondingly negative effects on the success of the therapy. In addition to determining a strict indication, it is therefore essential to establish precise dosage and systematic monitoring of the safety of the psychopharmacotherapy. This article introduces therapeutic drug monitoring as a useful clinical tool and describes how its correct application in practice can improve the efficacy as well as the safety and tolerability of psychotropic therapy in children and adolescents for the immediate benefit of patients. Keywords: Psychopharmacotherapy, adverse drug reactions, pharmacovigilance, therapeutic drug monitoring, quality assurance.
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Affiliation(s)
- Karin Egberts
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Stefanie Fekete
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V
| | - Alexander Häge
- Klinik für Psychiatrie und Psychotherapie des Kindes- und Jugendalters, Zentralinstitut für Seelische Gesundheit, Medizinische Fakultät Mannheim, Universität Heidelberg.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Christoph Hiemke
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Mainz.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V
| | - Maike Scherf-Clavel
- Speziallabor für Therapeutisches Drug Monitoring, Klinik und Poliklinik für Psychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V
| | - Regina Taurines
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Stefan Unterecker
- Speziallabor für Therapeutisches Drug Monitoring, Klinik und Poliklinik für Psychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V
| | - Manfred Gerlach
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Marcel Romanos
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
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14
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Bez Y, Kompella S, Gallucci F, Awerbuch A, Coffey BJ. Clinical Use of Clozapine Serum Level and Management of Adverse Effects in an Adolescent with Difficult to Treat Schizophrenia. J Child Adolesc Psychopharmacol 2021; 31:699-703. [PMID: 34958240 DOI: 10.1089/cap.2021.29213.bjc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Yasin Bez
- Department of Psychiatry, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Psychiatry, Jackson Behavioral Health Hospital, Miami, Florida, USA
| | - Sindhura Kompella
- Department of Psychiatry, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Psychiatry, Jackson Behavioral Health Hospital, Miami, Florida, USA
| | - Felicia Gallucci
- Department of Psychiatry, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Psychiatry, Jackson Behavioral Health Hospital, Miami, Florida, USA
| | - Adam Awerbuch
- Department of Psychiatry, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Psychiatry, Jackson Behavioral Health Hospital, Miami, Florida, USA
| | - Barbara J Coffey
- Department of Psychiatry, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Psychiatry, Jackson Behavioral Health Hospital, Miami, Florida, USA
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15
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Yada Y, Kitagawa K, Sakamoto S, Ozawa A, Nakada A, Kashiwagi H, Okahisa Y, Takao S, Takaki M, Kishi Y, Yamada N. The relationship between plasma clozapine concentration and clinical outcome: a cross-sectional study. Acta Psychiatr Scand 2021; 143:227-237. [PMID: 33274435 DOI: 10.1111/acps.13264] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/24/2020] [Accepted: 11/29/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE There is no report that statistically evaluates the therapeutic reference (350-600 ng/ml) and adverse drug reaction (ADR) range (>1000 ng/ml) of clozapine (CLZ) recommended by the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) consensus guidelines in an isolated and large sampling study. METHODS We administered CLZ to 131 Japanese patients with treatment-resistant schizophrenia in a multicenter cross-sectional study. Plasma CLZ concentrations were assayed by high-performance liquid chromatography using trough sampling. The Brief Psychiatric Rating Scale (BPRS) and severe dose-dependent ADR (sedation, myoclonus, and seizures) were analyzed statistically after adjusting for possible confounders. RESULTS The daily CLZ dosage showed a moderately positive relationship with the plasma concentration (r = 0.49, p < 0.001). Every 100 ng/ml increase in plasma CLZ concentration improved the total BPRS score 1.95% (95% CI: 0.89-3.01, p < 0.001) and the odds ratio (OR) 1.38 (95% CI: 1.14-1.66, p = 0.001) for BPRS response. Compared with concentrations below 350 ng/ml CLZ, 350-600 ng/ml (11.12%; 95% CI: 2.52-19.72, p = 0.012) and 600-1000 ng/ml (11.05%; 95% CI: 2.40-19.71, p = 0.013) showed significant improvement in the total BPRS score. Dosages above 1000 ng/ml showed greater improvement (25.36%; 95% CI: 13.08-37.64, p < 0.001) of the total BPRS score but more severe ADRs than dosages below 1000 ng/ml (OR: 31.72; 95% CI: 1.04-968.81, p = 0.048). CONCLUSION The AGNP therapeutic reference range (350-600 ng/ml) is useful, and a dose above 1000 ng/ml is potentially more effective but carries the risk of severe ADRs in the central nervous system.
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Affiliation(s)
- Yuji Yada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.,Okayama Psychiatric Medical Center, Okayama, Japan
| | | | - Shinji Sakamoto
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | | | - Hiroko Kashiwagi
- Department of Forensic Psychiatry, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yuko Okahisa
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Soshi Takao
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Manabu Takaki
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | - Norihito Yamada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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16
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Ishikawa S, Kobayashi M, Hashimoto N, Mikami H, Tanimura A, Narumi K, Furugen A, Kusumi I, Iseki K. Association Between N-Desmethylclozapine and Clozapine-Induced Sialorrhea: Involvement of Increased Nocturnal Salivary Secretion via Muscarinic Receptors by N-Desmethylclozapine. J Pharmacol Exp Ther 2020; 375:376-384. [PMID: 32862145 DOI: 10.1124/jpet.120.000164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/12/2020] [Indexed: 11/22/2022] Open
Abstract
Clozapine-induced sialorrhea (CIS) is a common side effect of clozapine. There is no established standard treatment of CIS since the underlying mechanism remains unknown. This study aimed to elucidate the mechanisms involved in CIS. In our clinical study, a prospective observational study evaluated the association between serum and saliva concentrations of clozapine or its metabolites and Drooling Severity and Frequency Scale (DSFS) score. In our in vivo study, we first developed a new CIS animal model; subsequently, we measured salivary secretion and concentrations of clozapine or its metabolites in the animal model. In our in vitro study, we measured the calcium ion (Ca2+) response to evaluate the effect of clozapine or its metabolites on human salivary gland cell line (HSY cells) and then examined whether their effect was inhibited by atropine. In our clinical study, serum and saliva N-desmethylclozapine concentrations were significantly correlated with nocturnal DSFS score. In our in vivo study, daily single oral administration of 100 mg/kg clozapine for 7 days significantly increased salivary secretion in rats. Furthermore, N-desmethylclozapine concentrations in serum and submandibular glands of the rats were higher than clozapine concentrations. In our in vitro study, N-desmethylclozapine only elicited an increase in the intracellular Ca2+ in HSY cells. N-desmethylclozapine-induced Ca2+ responses were inhibited by atropine. These results suggest that N-desmethylclozapine is implicated in CIS by increasing nocturnal salivation via the muscarinic receptors. Moreover, our developed animal model that reflects CIS in clinical condition plays a key role as a bridge between basic and clinical research. SIGNIFICANCE STATEMENT: Clozapine-induced sialorrhea (CIS) is a severe and frequent adverse reaction, but the mechanism underlying CIS is less well understood. This paper reports that N-desmethylclozapine, a metabolite of clozapine, is implicated in CIS by increasing nocturnal salivation via the muscarinic receptors and that oral administration of clozapine at 100 mg/kg once daily for 7 days to rat is the optimum method for establishing the new animal model reflecting the clinical scenario of CIS.
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Affiliation(s)
- Shuhei Ishikawa
- Laboratory of Clinical Pharmaceutics and Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences (S.I., M.K., H.M., K.N., A.F., K.I.) and Education Research Center for Clinical Pharmacy, Faculty of Pharmaceutical Sciences (M.K.), Hokkaido University, Sapporo, Japan; Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan (S.I.); Department of Psychiatry, Hokkaido University Graduate School of Medicine, Sapporo, Japan (N.H., I.K.); and Department of Pharmacology, School of Dentistry, Health Sciences University of Hokkaido, Sapporo, Japan (A.T.)
| | - Masaki Kobayashi
- Laboratory of Clinical Pharmaceutics and Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences (S.I., M.K., H.M., K.N., A.F., K.I.) and Education Research Center for Clinical Pharmacy, Faculty of Pharmaceutical Sciences (M.K.), Hokkaido University, Sapporo, Japan; Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan (S.I.); Department of Psychiatry, Hokkaido University Graduate School of Medicine, Sapporo, Japan (N.H., I.K.); and Department of Pharmacology, School of Dentistry, Health Sciences University of Hokkaido, Sapporo, Japan (A.T.)
| | - Naoki Hashimoto
- Laboratory of Clinical Pharmaceutics and Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences (S.I., M.K., H.M., K.N., A.F., K.I.) and Education Research Center for Clinical Pharmacy, Faculty of Pharmaceutical Sciences (M.K.), Hokkaido University, Sapporo, Japan; Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan (S.I.); Department of Psychiatry, Hokkaido University Graduate School of Medicine, Sapporo, Japan (N.H., I.K.); and Department of Pharmacology, School of Dentistry, Health Sciences University of Hokkaido, Sapporo, Japan (A.T.)
| | - Hideaki Mikami
- Laboratory of Clinical Pharmaceutics and Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences (S.I., M.K., H.M., K.N., A.F., K.I.) and Education Research Center for Clinical Pharmacy, Faculty of Pharmaceutical Sciences (M.K.), Hokkaido University, Sapporo, Japan; Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan (S.I.); Department of Psychiatry, Hokkaido University Graduate School of Medicine, Sapporo, Japan (N.H., I.K.); and Department of Pharmacology, School of Dentistry, Health Sciences University of Hokkaido, Sapporo, Japan (A.T.)
| | - Akihiko Tanimura
- Laboratory of Clinical Pharmaceutics and Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences (S.I., M.K., H.M., K.N., A.F., K.I.) and Education Research Center for Clinical Pharmacy, Faculty of Pharmaceutical Sciences (M.K.), Hokkaido University, Sapporo, Japan; Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan (S.I.); Department of Psychiatry, Hokkaido University Graduate School of Medicine, Sapporo, Japan (N.H., I.K.); and Department of Pharmacology, School of Dentistry, Health Sciences University of Hokkaido, Sapporo, Japan (A.T.)
| | - Katsuya Narumi
- Laboratory of Clinical Pharmaceutics and Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences (S.I., M.K., H.M., K.N., A.F., K.I.) and Education Research Center for Clinical Pharmacy, Faculty of Pharmaceutical Sciences (M.K.), Hokkaido University, Sapporo, Japan; Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan (S.I.); Department of Psychiatry, Hokkaido University Graduate School of Medicine, Sapporo, Japan (N.H., I.K.); and Department of Pharmacology, School of Dentistry, Health Sciences University of Hokkaido, Sapporo, Japan (A.T.)
| | - Ayako Furugen
- Laboratory of Clinical Pharmaceutics and Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences (S.I., M.K., H.M., K.N., A.F., K.I.) and Education Research Center for Clinical Pharmacy, Faculty of Pharmaceutical Sciences (M.K.), Hokkaido University, Sapporo, Japan; Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan (S.I.); Department of Psychiatry, Hokkaido University Graduate School of Medicine, Sapporo, Japan (N.H., I.K.); and Department of Pharmacology, School of Dentistry, Health Sciences University of Hokkaido, Sapporo, Japan (A.T.)
| | - Ichiro Kusumi
- Laboratory of Clinical Pharmaceutics and Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences (S.I., M.K., H.M., K.N., A.F., K.I.) and Education Research Center for Clinical Pharmacy, Faculty of Pharmaceutical Sciences (M.K.), Hokkaido University, Sapporo, Japan; Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan (S.I.); Department of Psychiatry, Hokkaido University Graduate School of Medicine, Sapporo, Japan (N.H., I.K.); and Department of Pharmacology, School of Dentistry, Health Sciences University of Hokkaido, Sapporo, Japan (A.T.)
| | - Ken Iseki
- Laboratory of Clinical Pharmaceutics and Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences (S.I., M.K., H.M., K.N., A.F., K.I.) and Education Research Center for Clinical Pharmacy, Faculty of Pharmaceutical Sciences (M.K.), Hokkaido University, Sapporo, Japan; Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan (S.I.); Department of Psychiatry, Hokkaido University Graduate School of Medicine, Sapporo, Japan (N.H., I.K.); and Department of Pharmacology, School of Dentistry, Health Sciences University of Hokkaido, Sapporo, Japan (A.T.)
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17
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Kloosterboer SM, Vierhout D, Stojanova J, Egberts KM, Gerlach M, Dieleman GC, Hillegers MHJ, Passe KM, Gelder TV, Dierckx B, Koch BCP. Psychotropic drug concentrations and clinical outcomes in children and adolescents: a systematic review. Expert Opin Drug Saf 2020; 19:873-890. [PMID: 32421365 DOI: 10.1080/14740338.2020.1770224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The use of psychotropic drugs in children and adolescents is widespread but associated with suboptimal treatment effects. Therapeutic drug monitoring (TDM) can improve safety of psychotropic drugs in children and adolescents but is not routinely performed. A major reason is that the relationship between drug concentrations and effects is not well known. AREAS COVERED This systematic review evaluated studies assessing the relationship between psychotropic drug concentrations and clinical outcomes in children and adolescents, including antipsychotics, psychostimulants, alpha-agonists, antidepressants, and mood-stabilizers. PRISMA guidelines were used and a quality assessment of the retrieved studies was performed. Sixty-seven eligible studies involving 24 psychotropic drugs were identified from 9,298 records. The findings were generally heterogeneous and the majority of all retrieved studies were not of sufficient quality. For 11 psychotropic drugs, a relationship between drug concentrations and side-effects and/or effectiveness was evidenced in reasonably reported and executed studies, but these findings were barely replicated. EXPERT OPINION In order to better support routine TDM in child- and adolescent psychiatry, future work must improve in aspects of study design, execution and reporting to demonstrate drug concentration-effect relationships. The quality criteria proposed in this work can guide future TDM research. Systematic review protocol and registration PROSPERO CRD42018084159.
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Affiliation(s)
- Sanne M Kloosterboer
- Department of Hospital Pharmacy, Erasmus Medical Center , Rotterdam, The Netherlands.,Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Denise Vierhout
- Department of Hospital Pharmacy, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Jana Stojanova
- Interdisciplinary Center for Health Studies (CIESAL), Universidad de Valparaíso , Valparaíso, Chile
| | - Karin M Egberts
- Department for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Würzburg , Würzburg, Germany
| | - Manfred Gerlach
- Department for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Würzburg , Würzburg, Germany
| | - Gwen C Dieleman
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Manon H J Hillegers
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Kimberly M Passe
- Department of Psychiatry, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Bram Dierckx
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus Medical Center , Rotterdam, The Netherlands
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18
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de Leon J, Ruan CJ, Schoretsanitis G, De las Cuevas C. A Rational Use of Clozapine Based on Adverse Drug Reactions, Pharmacokinetics, and Clinical Pharmacopsychology. PSYCHOTHERAPY AND PSYCHOSOMATICS 2020; 89:200-214. [PMID: 32289791 PMCID: PMC7206357 DOI: 10.1159/000507638] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022]
Abstract
Using Richardson and Davidson's model and the sciences of pharmacokinetics and clinical pharmacopsychology, this article reviewed the: (1) poor life expectancy associated with treatment-resistant schizophrenia (TRS), which may be improved in patients who adhere to clozapine; (2) findings that clozapine is the best treatment for TRS (according to efficacy, effectiveness and well-being); and (3) potential for clozapine to cause vulnerabilities, including potentially lethal adverse drug reactions such as agranulocytosis, pneumonia, and myocarditis. Rational use requires: (1) modification of the clozapine package insert worldwide to include lower doses for Asians and to avoid the lethality associated with pneumonia, (2) the use of clozapine levels for personalizing dosing, and (3) the use of slow and personalized titration. This may make clozapine as safe as possible and contribute to increased life expectancy and well-being. In the absence of data on COVID-19 in clozapine patients, clozapine possibly impairs immunological mechanisms and may increase pneumonia risk in infected patients. Psychiatrists should call their clozapine patients and families and explain to them that if the patient develops fever or flu-like symptoms, the psychiatrist should be called and should consider halving the clozapine dose. If the patient is hospitalized with pneumonia, the treating physician needs to assess for symptoms of clozapine intoxication since halving the dose may not be enough for all patients; consider decreasing it to one-third or even stopping it. Once the signs of inflammation and fever have disappeared, the clozapine dose can be slowly increased to the prior dosage level.
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Affiliation(s)
- Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, Kentucky, USA, .,Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain, .,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain,
| | - Can-Jun Ruan
- The National Clinical Research Centre for Mental Disorders, Beijing Key Laboratory of Mental Disorders, and Laboratory of Clinical Psychopharmacology, Beijing Anding Hospital, Capital Medical University, Beijing, China,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Georgios Schoretsanitis
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York, USA
| | - Carlos De las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, University of La Laguna, San Cristóbal de La Laguna, Spain
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19
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Vloet TD, Egberts K, Taurines R, Wewetzer C, Mehler-Wex C, Plener PL, Romanos M, Gerlach M. [Polypharmacy of psychotropic drugs in child and adolescent psychiatry in Germany - rather the rule than the exception]. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2018; 47:193-202. [PMID: 30422047 DOI: 10.1024/1422-4917/a000632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Polypharmacy of psychotropic drugs in child and adolescent psychiatry in Germany - rather the rule than the exception Abstract. Background: Polypharmacy increases the risk of interactions and enhances the chance of adverse drug reactions (ADRs). Hence, child and adolescent psychiatrists generally try to avoid polypharmacy with psychotropic drugs. However, only little data regarding the frequency of polypharmacy in child and adolescent psychiatry are available. This study analyzes clinical data on polypharmacy and the possible association with a higher risk of ADRs in Germany, with a focus on antidepressants and antipsychotics. Methods: We investigated a total of 940 datasets from descriptive studies on therapeutic drug monitoring (TDM) of pediatric patients treated with different psychotropic drugs. Results: The frequency of polypharmacy ranged up to 45.6 % (escitalopram) and 72.1 % (olanzapine). In 17.4 % of the cases, polypharmacy consisted of four or more psycho-/neuropharmacological substances. No increased incidence of ADRs was reported with polypharmacy of antipsychotics compared to monotherapy. Polypharmacy with sertraline was associated with a higher number of ADRs. Discussion and Conclusion: There is a high prevalence of polypharmacy with psychotropic drugs in child and adolescent psychiatry in Germany. Conclusions concerning individual drugs should be drawn with care since the subsample sizes were relatively small. However, our results do provide an indication of the prevalence of polypharmacy, although the validity of the data is limited. There is an urgent need to analyze data from larger and more homogeneous groups under more controlled conditions.
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Affiliation(s)
- Timo D Vloet
- a geteilte Erstautorenschaft.,1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
| | - Karin Egberts
- a geteilte Erstautorenschaft.,1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
| | - Regina Taurines
- 1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
| | - Christoph Wewetzer
- 2 Abteilung für Kinder- und Jugendpsychiatrie und Psychotherapie, Kliniken der Stadt Köln gGmbH, Köln
| | - Claudia Mehler-Wex
- 3 Privatklinik für Seelische Gesundheit, Jugendliche und junge Erwachsene, HEMERA Klinik, Bad Kissingen
| | - Paul L Plener
- 4 Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universitätsklinik Ulm, Ulm
| | - Marcel Romanos
- 1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
| | - Manfred Gerlach
- 1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
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Mauri MC, Paletta S, Di Pace C, Reggiori A, Cirnigliaro G, Valli I, Altamura AC. Clinical Pharmacokinetics of Atypical Antipsychotics: An Update. Clin Pharmacokinet 2018; 57:1493-1528. [DOI: 10.1007/s40262-018-0664-3] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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21
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Therapeutic Drug Monitoring in Children and Adolescents Under Pharmacotherapy With Olanzapine in Daily Clinical Practice. Ther Drug Monit 2017; 39:273-281. [DOI: 10.1097/ftd.0000000000000398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Gerlach M, Egberts K, Dang SY, Plener P, Taurines R, Mehler-Wex C, Romanos M. Therapeutic drug monitoring as a measure of proactive pharmacovigilance in child and adolescent psychiatry. Expert Opin Drug Saf 2016; 15:1477-1482. [PMID: 27551945 DOI: 10.1080/14740338.2016.1225721] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Off-label or unlicensed use of psychotropic drugs is common rather than the exception in child and adolescent psychiatry. This use exposes patients to an unknown additional risk of ineffective or even harmful treatment. In addition, treatment with psychotropic drugs during a period of life when the patient undergoes marked developmental hormonal and neurobiological changes often requires different dosing regimes in later life and may result in adverse drug reactions, which are either not seen in adults at all or not in the same frequency. Areas covered: Given these critical safety issues, efficient pharmacovigilance methods as part of routine practice are essential for the improvement of patient care. The purpose of this article is to introduce methods to increase the safety of psychotropic drug use in youngsters. In particular, therapeutic drug monitoring (TDM) as a routine measure of proactive pharmacovigilance is discussed. Expert opinion: Given the special features of psychopharmacological therapy in children and adolescents in day-to-day clinical practise, proactive surveillance by using a close standardized 'patient monitoring' and long-term follow-up with TDM is very important. This approach could minimize the risk of exposing paediatric patients to ineffective treatments of uncertain or unknown risks.
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Affiliation(s)
- Manfred Gerlach
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
| | - Karin Egberts
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
| | - Su-Yin Dang
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
| | - Paul Plener
- b Department of Child and Adolescent Psychiatry and Psychotherapy , Central Institute of Mental Health , Mannheim , Germany
| | - Regina Taurines
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
| | - Claudia Mehler-Wex
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany.,c HEMERA Private Hospital for Mental Health, Adolescents and Young Adults , Bad Kissingen , Germany
| | - Marcel Romanos
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
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