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Siwek M, Krupa AJ, Woroń J. Interactions between grapefruit juice and psychotropic medications: an update of the literature and an original case series. Expert Opin Drug Metab Toxicol 2024; 20:333-345. [PMID: 38721667 DOI: 10.1080/17425255.2024.2352468] [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: 02/26/2024] [Accepted: 04/29/2024] [Indexed: 05/28/2024]
Abstract
INTRODUCTION There is a large body of preclinical data implicating that grapefruit juice (GJ) inhibits many CYP 450 isoforms. The potential of GJ-to-drug is of high relevance to clinical psychiatry, because a wide range of psychotropic medicines undergo CYP 450 metabolism and P-gp transport. AREAS COVERED Relevant data were identified by searching the electronic databases up to February 2024. This work constitutes a summary of preclinical and clinical data on GJ impact on CYP 450 metabolism, P-glycoprotein, and organic anion-transporting polypeptides (OATPs), with focus on studies that assessed GJ-to-psychotropic drug interactions. Additionally, an unpublished case series of nine patients is provided. EXPERT OPINION The impact of GJ on CYP 3A4 appears to be the critical mechanism for the majority of GJ-to-psychopharmacotherapy interactions described in human studies or case reports. However, there are studies and cases of patients clearly showing that this is not the only route explaining the GJ effect, and at times, this particular is of no relevance and that other CYP 450 isoforms as well as drug transporting proteins might be involved. The risk of GJ-to-psychotropic drugs needs to be further evaluated in a 'real-world' setting and apply not only measures of pharmacokinetics but also treatment effectiveness and safety.
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Affiliation(s)
- Marcin Siwek
- Department of Affective Disorders, Chair of Psychiatry, Jagiellonian University Medical College, Kraków, Poland
| | - Anna Julia Krupa
- Department of Affective Disorders, Chair of Psychiatry, Jagiellonian University Medical College, Kraków, Poland
| | - Jarosław Woroń
- Department of Clinical Pharmacology, Chair of Pharmacology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
- Department of Anesthesiology and Intensive Care, University Hospital in Krakow, Krakow, Poland
- University Center for Monitoring and Research on Adverse Drug Effects in Krakow, Krakow, Poland
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Mairinger S, Leterrier S, Filip T, Löbsch M, Pahnke J, Hernández-Lozano I, Stanek J, Tournier N, Zeitlinger M, Hacker M, Langer O, Wanek T. [ 11C]metoclopramide is a sensitive radiotracer to measure moderate decreases in P-glycoprotein function at the blood-brain barrier. J Cereb Blood Flow Metab 2024; 44:142-152. [PMID: 37728771 PMCID: PMC10905639 DOI: 10.1177/0271678x231202336] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/23/2023] [Accepted: 08/27/2023] [Indexed: 09/21/2023]
Abstract
The efflux transporter P-glycoprotein (P-gp) at the blood-brain barrier limits the cerebral uptake of various xenobiotics. To assess the sensitivity of [11C]metoclopramide to measure decreased cerebral P-gp function, we performed [11C]metoclopramide PET scans without (baseline) and with partial P-gp inhibition by tariquidar in wild-type, heterozygous Abcb1a/b(+/-) and homozygous Abcb1a/b(-/-) mice as models with controlled levels of cerebral P-gp expression. Brains were collected to quantify P-gp expression with immunohistochemistry. Brain uptake of [11C]metoclopramide was expressed as the area under the brain time-activity curve (AUCbrain) and compared with data previously obtained with (R)-[11C]verapamil and [11C]N-desmethyl-loperamide. Abcb1a/b(+/-) mice had intermediate P-gp expression compared to wild-type and Abcb1a/b(-/-) mice. In baseline scans, all three radiotracers were able to discriminate Abcb1a/b(-/-) from wild-type mice (2.5- to 4.6-fold increased AUCbrain, p ≤ 0.0001). However, only [11C]metoclopramide could discriminate Abcb1a/b(+/-) from wild-type mice (1.46-fold increased AUCbrain, p ≤ 0.001). After partial P-gp inhibition, differences in [11C]metoclopramide AUCbrain between Abcb1a/b(+/-) and wild-type mice (1.39-fold, p ≤ 0.001) remained comparable to baseline. There was a negative correlation between baseline [11C]metoclopramide AUCbrain and ex-vivo-measured P-gp immunofluorescence (r = -0.9875, p ≤ 0.0001). Our data suggest that [11C]metoclopramide is a sensitive radiotracer to measure moderate, but (patho-)physiologically relevant decreases in cerebral P-gp function without the need to co-administer a P-gp inhibitor.
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Affiliation(s)
- Severin Mairinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Sarah Leterrier
- Laboratoire d'Imagerie Biomédicale Multimodale (BIOMAPS), Université Paris-Saclay, CEA, CNRS, Inserm, Service Hospitalier Frédéric Joliot, Orsay, France
| | - Thomas Filip
- Core Facility Laboratory Animal Breeding and Husbandry, Medical University of Vienna, Vienna, Austria
- Institute of Animal Breeding and Genetics & Biomodels Austria, University of Veterinary Medicine, Vienna, Austria
| | - Mathilde Löbsch
- Core Facility Laboratory Animal Breeding and Husbandry, Medical University of Vienna, Vienna, Austria
| | - Jens Pahnke
- Department of Pathology, Section of Neuropathology Research, University of Oslo (UiO) and Oslo University Hospital (OUS), Oslo, Norway
- Drug Development and Chemical Biology Lab, Lübeck Institute of Dermatology (LIED), University of Lübeck, Lübeck, Germany
- Department of Pharmacology, Faculty of Medicine, University of Latvia, Rīga, Latvia
- Department of Neurobiology, The George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | | | - Johann Stanek
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Nicolas Tournier
- Laboratoire d'Imagerie Biomédicale Multimodale (BIOMAPS), Université Paris-Saclay, CEA, CNRS, Inserm, Service Hospitalier Frédéric Joliot, Orsay, France
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Marcus Hacker
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Oliver Langer
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Thomas Wanek
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
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Pavlović N, Milošević Sopta N, Mitrović D, Zaklan D, Tomas Petrović A, Stilinović N, Vukmirović S. Principal Component Analysis (PCA) of Molecular Descriptors for Improving Permeation through the Blood-Brain Barrier of Quercetin Analogues. Int J Mol Sci 2023; 25:192. [PMID: 38203364 PMCID: PMC10778702 DOI: 10.3390/ijms25010192] [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: 11/23/2023] [Revised: 12/13/2023] [Accepted: 12/17/2023] [Indexed: 01/12/2024] Open
Abstract
Despite its beneficial pharmacological effects in the brain, partly by modulating inositol phosphate multikinase (IPMK) activity, the therapeutic use of quercetin is limited due to its poor solubility, low oral bioavailability, and low permeability through the blood-brain barrier (BBB). We aimed to identify quercetin analogues with improved BBB permeability and preserved binding affinities towards IPMK and to identify the molecular characteristics required for them to permeate the BBB. Binding affinities of quercetin analogues towards IPMK were determined by molecular docking. Principal component analysis (PCA) was applied to identify the molecular descriptors contributing to efficient permeation through the BBB. Among 34 quercetin analogues, 19 compounds were found to form more stable complexes with IPMK, and the vast majority were found to be more lipophilic than quercetin. Using two distinct in silico techniques, insufficient BBB permeation was determined for all quercetin analogues. However, using the PCA method, the descriptors related to intrinsic solubility and lipophilicity (logP) were identified as mainly responsible for clustering four quercetin analogues (trihydroxyflavones) with the highest BBB permeability. The application of PCA revealed that quercetin analogues could be classified with respect to their structural characteristics, which may be utilized in further analogue syntheses and lead optimization of BBB-penetrating IPMK modulators as neuroprotective agents.
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Affiliation(s)
- Nebojša Pavlović
- Department of Pharmacy, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (D.M.); (D.Z.)
| | | | - Darko Mitrović
- Department of Pharmacy, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (D.M.); (D.Z.)
- Accelsiors CRO, Háros Street 103, 1222 Budapest, Hungary;
| | - Dragana Zaklan
- Department of Pharmacy, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (D.M.); (D.Z.)
| | - Ana Tomas Petrović
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (A.T.P.); (N.S.); (S.V.)
| | - Nebojša Stilinović
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (A.T.P.); (N.S.); (S.V.)
| | - Saša Vukmirović
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (A.T.P.); (N.S.); (S.V.)
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Bathgate CJ, Muther E, Georgiopoulos AM, Smith B, Tillman L, Graziano S, Verkleij M, Lomas P, Quittner A. Positive and negative impacts of elexacaftor/tezacaftor/ivacaftor: Healthcare providers' observations across US centers. Pediatr Pulmonol 2023; 58:2469-2477. [PMID: 37265418 DOI: 10.1002/ppul.26527] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/20/2023] [Accepted: 05/21/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Elexacaftor/tezacaftor/ivacaftor (ETI) has been associated with unprecedented clinical improvements, transforming the management of cystic fibrosis (CF). However, side effects with implications for safety and well-being have been reported, including neuropsychiatric changes. This study aimed to better characterize the emerging positive and negative impacts of ETI. METHODS The Cystic Fibrosis Foundation's Mental Health Advisory Committee distributed a 26-item survey to US CF care teams to assess clinician observations of patient-reported experiences with ETI. Survey responses measured the prevalence of these effects in five domains: (1) positive physical and psychological effects, (2) sleep difficulties, (3) cognitive difficulties, (4) worsening mental health, and (5) concerns about the future and finances. RESULTS Seventy-five healthcare providers responded from a pediatric, adult, and combined centers. Positive physical effects of ETI and increased optimism were reported in the upper quartiles (50%-100%) and rated as having a significant impact on daily functioning. Sleep and cognitive difficulties were reported in 1%-24%, with slight impacts on functioning, and psychological symptoms (e.g., increased stress, depression, anxiety) and new psychiatric medications were reported in 1%-24%, with moderate impacts. Concerns about the future were reported in 1%-24%, with minimal impacts. CONCLUSION Across US centers, providers most often observed positive physical effects of ETI. However, a variety of negative side effects were also reported, including sleep disruptions and worsening psychological functioning, which should be systematically monitored by CF teams. These national-level data are a first step in evaluating the prevalence and consequences of these side effects and can directly inform future studies.
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Affiliation(s)
| | - Emily Muther
- Department of Psychiatry and Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anna M Georgiopoulos
- Department of Child and Adolescent Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Beth Smith
- Departments of Psychiatry and Pediatrics, University at Buffalo-Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | | | - Sonia Graziano
- Department of Pediatrics, Unit of Cystic Fibrosis, Bambino Gesù Children's Hospital, Rome, Italy
| | - Marieke Verkleij
- Department of Pediatric Psychology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paula Lomas
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | - Alexandra Quittner
- Joe DiMaggio Cystic Fibrosis Pulmonary and Sleep Center, Hollywood, Florida, USA
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Zaccara G, Franco V. Pharmacokinetic Interactions Between Antiseizure and Psychiatric Medications. Curr Neuropharmacol 2023; 21:1666-1690. [PMID: 35611779 PMCID: PMC10514545 DOI: 10.2174/1570159x20666220524121645] [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: 02/15/2022] [Revised: 03/27/2022] [Accepted: 05/03/2022] [Indexed: 11/22/2022] Open
Abstract
Antiseizure medications and drugs for psychiatric diseases are frequently used in combination. In this context, pharmacokinetic interactions between these drugs may occur. The vast majority of these interactions are primarily observed at a metabolic level and result from changes in the activity of the cytochrome P450 (CYP). Carbamazepine, phenytoin, and barbiturates induce the oxidative biotransformation and can consequently reduce the plasma concentrations of tricyclic antidepressants, many typical and atypical antipsychotics and some benzodiazepines. Newer antiseizure medications show a lower potential for clinically relevant interactions with drugs for psychiatric disease. The pharmacokinetics of many antiseizure medications is not influenced by antipsychotics and anxiolytics, while some newer antidepressants, namely fluoxetine, fluvoxamine and viloxazine, may inhibit CYP enzymes leading to increased serum concentrations of some antiseizure medications, including phenytoin and carbamazepine. Clinically relevant pharmacokinetic interactions may be anticipated by knowledge of CYP enzymes involved in the biotransformation of individual medications and of the influence of the specific comedication on the activity of these CYP enzymes. As a general rule, these interactions can be managed by careful evaluation of clinical response and, when indicated, individualized dosage adjustments guided by measurement of drugs serum concentrations, especially if pharmacokinetic interactions may cause any change in seizure control or signs of toxicity. Further studies are required to improve predictions of pharmacokinetic interactions between antiseizure medications and drugs for psychiatric diseases providing practical helps for clinicians in the clinical setting.
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Affiliation(s)
| | - Valentina Franco
- Department of Internal Medicine and Therapeutics, Clinical and Experimental Pharmacology Unit, University of Pavia, Pavia, Italy
- IRCCS Mondino Foundation, Pavia, Italy
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Impact of Cytochrome Induction or Inhibition on the Plasma and Brain Kinetics of [ 11C]metoclopramide, a PET Probe for P-Glycoprotein Function at the Blood-Brain Barrier. Pharmaceutics 2022; 14:pharmaceutics14122650. [PMID: 36559144 PMCID: PMC9785688 DOI: 10.3390/pharmaceutics14122650] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 11/23/2022] [Accepted: 11/26/2022] [Indexed: 12/03/2022] Open
Abstract
[11C]metoclopramide PET imaging provides a sensitive and translational tool to explore P-glycoprotein (P-gp) function at the blood-brain barrier (BBB). Patients with neurological diseases are often treated with cytochrome (CYP) modulators which may impact the plasma and brain kinetics of [11C]metoclopramide. The impact of the CYP inducer carbamazepine or the CYP inhibitor ritonavir on the brain and plasma kinetics of [11C]metoclopramide was investigated in rats. Data obtained in a control group were compared with groups that were either orally pretreated with carbamazepine (45 mg/kg twice a day for 7 days before PET) or ritonavir (20 mg/kg, 3 h before PET) (n = 4 per condition). Kinetic modelling was performed to estimate the brain penetration (VT) of [11C]metoclopramide. CYP induction or inhibition had negligible impact on the plasma kinetics and metabolism of [11C]metoclopramide. Moreover, carbamazepine neither impacted the brain kinetics nor VT of [11C]metoclopramide (p > 0.05). However, ritonavir significantly increased VT (p < 0.001), apparently behaving as an inhibitor of P-gp at the BBB. Our data suggest that treatment with potent CYP inducers such as carbamazepine does not bias the estimation of P-gp function at the BBB with [11C]metoclopramide PET. This supports further use of [11C]metoclopramide for studies in animals and patients treated with CYP inducers.
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Zaccara G, Lattanzi S, Russo E. Pharmacokinetic drug interactions between antiseizure medications and drugs for comorbid diseases in children with epilepsy. Expert Opin Drug Metab Toxicol 2021; 17:595-610. [PMID: 33709868 DOI: 10.1080/17425255.2021.1903429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Nearly 80% of children with epilepsy have one or more chronic comorbidities that require specific drug treatments in several cases. Drug-drug interactions (DDIs) between antiseizure medications (ASMs) and all other drugs (NON-ASMs) used to treat comorbid diseases may have serious consequences.Areas covered: All potential DDIs between 27 ASMs and all NON-ASMs used for oral chronic treatment of those disorders most often comorbid with epilepsy in children were searched for drug compendia. Clinical evidence of the identified DDIs was also searched in the literature. Forty-eight drugs have been identified as potential DDIs with at least one ASM. Most important DDIs are between some ASMs and omeprazole and pantoprazole (drugs for gastrointestinal disorders), ibuprofen and cyclobenzaprine (drugs for musculoskeletal disorders), loratidine, lumacaftor/ivacaftor, montelukast, and theophylline (drugs for respiratory system), levothyroxine, liothyronine and several corticosteroids (systemic hormonal preparations), almotriptan, dihydroergotamine, ergotamine, and several antipsychotics, antidepressants and anxiolytics (drugs for nervous diseases). Clinical evidence of the predicted DDIs was found in a minority of cases.Expert opinion: Treatment of children with epilepsy should be decided considering treatment of both seizures and comorbid diseases and aimed at minimizing the risk of DDIs between ASMs and NON-ASMs.
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Affiliation(s)
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
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Islam F, Gorbovskaya I, Müller DJ. Pharmacogenetic/Pharmacogenomic Tests for Treatment Prediction in Depression. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1305:231-255. [PMID: 33834403 DOI: 10.1007/978-981-33-6044-0_13] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Genetic factors play a significant but complex role in antidepressant (AD) response and tolerability. During recent years, there is growing enthusiasm in the promise of pharmacogenetic/pharmacogenomic (PGx) tools for optimizing and personalizing treatment outcomes for patients with major depressive disorder (MDD). The influence of pharmacokinetic and pharmacodynamic genes on response and tolerability has been investigated, including those encoding the cytochrome P450 superfamily, P-glycoprotein, monoaminergic transporters and receptors, intracellular signal transduction pathways, and the stress hormone system. Genome-wide association studies are also identifying new genetic variants associated with AD response phenotypes, which, combined with methods such as polygenic risk scores (PRS), is opening up new avenues for novel personalized treatment approaches for MDD. This chapter describes the basic concepts in PGx of AD response, reviews the major pharmacokinetic and pharmacodynamic genes involved in AD outcome, discusses PRS as a promising approach for predicting AD efficacy and tolerability, and addresses key challenges to the development and application of PGx tests.
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Affiliation(s)
- Farhana Islam
- Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Pharmacology & Toxicology, University of Toronto, Toronto, ON, Canada
| | - Ilona Gorbovskaya
- Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
| | - Daniel J Müller
- Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.
- Department of Pharmacology & Toxicology, University of Toronto, Toronto, ON, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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Clinically Significant Drug Interactions Between Psychotropic Agents and Repurposed COVID-19 Therapies. CNS Drugs 2021; 35:345-384. [PMID: 33866523 PMCID: PMC8053373 DOI: 10.1007/s40263-021-00811-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 02/07/2023]
Abstract
As many patients with underlying psychiatric disorders may be infected with COVID-19, and COVID-19-affected subjects may frequently experience a new onset of psychiatric manifestations, concomitant use of psychotropic medications and COVID-19 therapies is expected to be highly likely and raises concerns of clinically relevant drug interactions. In this setting, four major mechanisms responsible for drug interactions involving psychotropic agents and COVID-19 therapies may be identified: (1) pharmacokinetic drug-drug interactions mainly acting on cytochrome P450; (2) pharmacodynamic drug-drug interactions resulting in additive or synergistic toxicity; (3) drug-disease interactions according to stage and severity of the disease; and (4) pharmacogenetic issues associated with polymorphisms of cytochrome P450 isoenzymes. In this review, we summarise the available literature on relevant drug interactions between psychotropic agents and COVID-19 therapies, providing practical clinical recommendations and potential management strategies according to severity of illness and clinical scenario.
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Ibrahim H, El Kerdawy AM, Abdo A, Sharaf Eldin A. Similarity-based machine learning framework for predicting safety signals of adverse drug–drug interactions. INFORMATICS IN MEDICINE UNLOCKED 2021. [DOI: 10.1016/j.imu.2021.100699] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Clinically Relevant Interactions between Atypical Antipsychotics and Anti-Infective Agents. Pharmaceuticals (Basel) 2020; 13:ph13120439. [PMID: 33276675 PMCID: PMC7761579 DOI: 10.3390/ph13120439] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/23/2020] [Accepted: 11/30/2020] [Indexed: 12/11/2022] Open
Abstract
This is a comprehensive review of the literature on drug interactions (DIs) between atypical antipsychotics and anti-infective agents that focuses on those DIs with the potential to be clinically relevant and classifies them as pharmacokinetic (PK) or pharmacodynamic (PD) DIs. PubMed searches were conducted for each of the atypical antipsychotics and most commonly used anti-infective agents (13 atypical antipsychotics by 61 anti-infective agents/classes leading to 793 individual searches). Additional relevant articles were obtained from citations and from prior review articles written by the authors. Based on prior DI articles and our current understanding of PK and PD mechanism, we developed tables with practical recommendations for clinicians for: antibiotic DIs, antitubercular DIs, antifungal DIs, antiviral DIs, and other anti-infective DIs. Another table reflects that in clinical practice, DIs between atypical antipsychotics and anti-infective agents occur in patients also suffering an infection that may also influence the PK and PD mechanisms of both drugs (the atypical antipsychotic and the anti-infective agent(s)). These tables reflect the currently available literature and our current knowledge of the field and will need to be updated as new DI information becomes available.
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Spina E, Barbieri MA, Cicala G, Bruno A, de Leon J. Clinically relevant drug interactions between newer antidepressants and oral anticoagulants. Expert Opin Drug Metab Toxicol 2019; 16:31-44. [PMID: 31795773 DOI: 10.1080/17425255.2020.1700952] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction: This is a review of the drug interactions (DIs) between newer antidepressants and oral anticoagulants (OACs): vitamin K antagonists (VKAs) and direct-acting OACs (DOACs).Areas covered: Articles were obtained from PubMed searches performed for each of the newer antidepressants and oral anticoagulants. The basic pharmacokinetic and pharmacodynamic mechanisms for DIs with these drugs were summarized. Some newer antidepressants are inhibitors of a number of cytochrome P450 (CYP) isoforms and many antidepressants appear to have potential to impair serotonin platelet function and increase bleeding risk.Expert opinion: Clinicians should not forget that the DIs between newer antidepressants and VKAs can be potentially lethal. Among SSRIs, fluoxetine and fluvoxamine appear to be associated with the highest DI risk with warfarin, the most commonly prescribed VKA worldwide. Case reports featuring duloxetine, mirtazapine and trazadone suggested potential for interaction with warfarin. As CYP3A4 is an important metabolic pathway for all DOACs except dabigatran, it appears reasonable to recommend avoiding the co-prescription of fluoxetine and fluvoxamine (weak to moderate CYP3A4 inhibitors) and St John's wort (CYP3A4 inducer). Many package inserts for the newer antidepressants include a warning regarding an increased risk of bleeding events with concomitant use of these agents with OACs.
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Affiliation(s)
- Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Giuseppe Cicala
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonio Bruno
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Jose de Leon
- University of Kentucky Mental Health Research Center at Eastern State Hospital, Lexington, KY, 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 Apostol Hospital, University of the Basque Country, Vitoria, Spain
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Palleria C, Roberti R, Iannone LF, Tallarico M, Barbieri MA, Vero A, Manti A, De Sarro G, Spina E, Russo E. Clinically relevant drug interactions between statins and antidepressants. J Clin Pharm Ther 2019; 45:227-239. [PMID: 31587356 DOI: 10.1111/jcpt.13058] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/05/2019] [Accepted: 09/09/2019] [Indexed: 12/24/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Statins, also known as 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors, and antidepressant drugs are frequently used in combination due to the high and growing incidence of cardiovascular diseases and psychiatric disorders worldwide. Several aspects on management, the risk of adverse events (AEs) occurrence and the potential clinically relevant pharmacokinetic (PK) and pharmacodynamic (PD) drug-drug interactions (DDIs) between these two classes have not been well investigated. The aim of the present review was to describe the PK and PD interactions, of clinical relevance, between statins and antidepressant drugs and provide a comprehensive overview of their pharmacological features for appropriate multiple drug regimens. METHODS Relevant studies were identified through a literature search of PubMed and the Cochrane databases focusing on clinically relevant DDIs between statins and antidepressants. Only papers in English were included in the search. RESULTS AND DISCUSSION Pharmacodynamic (PD) drug-drug interactions (DDIs) are unlikely to occur as statins are highly selective inhibitors of HMG-CoA reductase with no relevant effect on other enzymes or receptor systems. Despite the numerous PK studies on individual drugs belonging to statins and antidepressant agents, only a few case reports regarding specific DDIs are present in the literature and no clinical studies have been performed. PK data allow to speculate on potential DDIs, comparing the metabolic pathways, intestinal and liver transporters and elimination routes. Overall, second-generation antidepressants, in particular citalopram, escitalopram, mirtazapine, reboxetine and venlafaxine, have weak inhibitory effects on various cytochrome (CYP) isozymes and seem to have a more advantageous DDIs profile in vivo. Conversely, nefazodone, fluoxetine, paroxetine and fluvoxamine influence considerably CYPs activity with potential effects on statins plasma levels, although pravastatin, pitavastatin and rosuvastatin are not susceptible to inhibition by any CYP. Albeit no studies have been performed on P-glycoprotein (P-gp), interactions of clinical relevance are unlikely. WHAT IS NEW AND CONCLUSION Although DDIs with antidepressants are potentially, but rarely clinically significant, the use of antidepressants with a more favourable drug interaction profile is advisable. An evaluation on DDIs between these drugs can be useful for future PK/PD studies on drug-drug interaction to provide clinicians with more data for appropriate multiple drug regimens.
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Affiliation(s)
- Caterina Palleria
- Science of Health Department, School of Medicine, University of Catanzaro, Catanzaro, Italy
| | - Roberta Roberti
- Science of Health Department, School of Medicine, University of Catanzaro, Catanzaro, Italy
| | | | - Martina Tallarico
- Science of Health Department, School of Medicine, University of Catanzaro, Catanzaro, Italy
| | | | - Ada Vero
- Science of Health Department, School of Medicine, University of Catanzaro, Catanzaro, Italy
| | - Antonia Manti
- Science of Health Department, School of Medicine, University of Catanzaro, Catanzaro, Italy
| | | | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, University of Catanzaro, Catanzaro, Italy
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Akamine Y, Yasui-Furukori N, Uno T. Drug-Drug Interactions of P-gp Substrates Unrelated to CYP Metabolism. Curr Drug Metab 2019; 20:124-129. [PMID: 30280663 DOI: 10.2174/1389200219666181003142036] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 08/31/2018] [Accepted: 09/04/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Recent US Food and Drug Administration (FDA) draft guidance on pharmacokinetic drugdrug interactions (DDIs) has highlighted the clinical importance of ABC transporters B1 or P-glycoprotein (P-gp), hepatic organic anion-transporting polypeptide transporters and breast cancer resistant protein because of their broad substrate specificity and the potential to be involved in DDIs. This guidance has indicated that digoxin, dabigatran etexilate and fexofenadine are P-gp substrate drugs and has defined P-gp inhibitors as those that increase the AUC of digoxin by ≧1.25-fold in clinical DDI studies. However, when substrate drugs of both CYPs and P-gp are involved in DDIs, it remains that the mechanisms of DDIs will be quite ambiguous in assessing how much the CYPs and/or drug transporters partially contribute to DDIs. OBJECTIVE Since there are no detailed manuscripts that summarizes P-gp interactions unrelated to CYP metabolism, this article reviews the effects of potent P-gp inhibitors and P-gp inducers on the pharmacokinetics of P-gp substrate drugs, including digoxin, talinolol, dabigatran etexilate, and fexofenadine in human studies. In addition, the present outcome were to determine the PK changes caused by DDIs among P-gp substrate drugs without CYP metabolism in human DDI studies. CONCLUSION Our manuscript concludes that the PK changes of the DDIs among P-gp drugs unrelated to CYP metabolism are less likely to be serious, and it appears to be convincing that the absences of clinical effects caused to the PK changes by the P-gp inducers is predominant compared with the excessive effects caused to those by the P-gp inhibitors.
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Affiliation(s)
- Yumiko Akamine
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Norio Yasui-Furukori
- Department of Neuropsychiatry, Hirosaki University School of Medicine, Hirosaki, Japan
| | - Tsukasa Uno
- Department of Hospital Pharmacy, Zikeikai-Aoimori Hospital, Aomori, Japan
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Galgani A, Palleria C, Iannone LF, De Sarro G, Giorgi FS, Maschio M, Russo E. Pharmacokinetic Interactions of Clinical Interest Between Direct Oral Anticoagulants and Antiepileptic Drugs. Front Neurol 2018; 9:1067. [PMID: 30581412 PMCID: PMC6292857 DOI: 10.3389/fneur.2018.01067] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 11/23/2018] [Indexed: 01/08/2023] Open
Abstract
Direct oral anticoagulants (DOACs), namely apixaban, dabigatran, edoxaban, and rivaroxaban are being increasingly prescribed among the general population, as they are considered to be associated to lower bleeding risk than classical anticoagulants, and do not require coagulation monitoring. Likewise, DOACs are increasingly concomitantly prescribed in patients with epilepsy taking, therefore, antiepileptic drugs (AEDs), above all among the elderly. As a result, potential interactions may cause an increased risk of DOAC-related bleeding or a reduced antithrombotic efficacy. The objective of the present review is to describe the pharmacokinetic interactions between AEDs and DOACs of clinical relevance. We observed that there are only few clinical reports in which such interactions have been described in patients. More data are available on the pharmacokinetics of both drugs classes which allow speculating on their potential interactions. Older AEDs, acting on cytochrome P450 isoenzymes, and especially on CYP3A4, such as phenobarbital, phenytoin, and carbamazepine are more likely to significantly reduce the anticoagulant effect of DOACs (especially rivaroxaban, apixaban, and edoxaban). Newer AEDs not affecting significantly CYP or P-gp, such as lamotrigine, or pregabalin are not likely to affect DOACs efficacy. Zonisamide and lacosamide, which do not affect significantly CYP activity in vitro, might have a quite safe profile, even though their effects on P-gp are not well-known, yet. Levetiracetam exerts only a potential effect on P-gp activity, and thus it might be safe, as well. In conclusion, there are only few case reports and limited evidence on interactions between DOACs and AEDs in patients. However, the overall evidence suggests that the interaction between these drug classes might be of high clinical relevance and therefore further studies in larger patients' cohorts are warranted for the future in order to better clarify their pharmacokinetic and define the most appropriate clinical behavior.
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Affiliation(s)
| | - Caterina Palleria
- Department of Science of Health, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | | | | | | | - Marta Maschio
- UOSD Neurology, Center for Tumor-related Epilepsy, Regina Elena National Cancer Institute, Rome, Italy
| | - Emilio Russo
- Department of Science of Health, University Magna Graecia of Catanzaro, Catanzaro, Italy
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Akamine Y, Miura M. An update on the clinical pharmacokinetics of fexofenadine enantiomers. Expert Opin Drug Metab Toxicol 2018; 14:429-434. [DOI: 10.1080/17425255.2018.1459565] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Yumiko Akamine
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Masatomo Miura
- Department of Pharmacy, Akita University Hospital, Akita, Japan
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Abstract
The newer atypical antipsychotic agents (AAPs) represent an attractive therapeutic option for a wide range of psychotic disorders, including schizophrenia and bipolar mania, because of the reduced risk of disabling extrapyramidal symptoms. However, their growing use has raised questions about their tolerability over the endocrine, metabolic, and cardiovascular axes. Indeed, atypical antipsychotic drugs are associated, to differing extents, with mild elevation of aminotransferases related to weight gain, AAP-induced metabolic syndrome, and nonalcoholic fatty liver disease. Although the hepatic safety of new AAPs seems improved over that of chlorpromazine, they can occasionally cause idiosyncratic liver injury with varying phenotypes and, rarely, lead to acute liver failure. However, AAPs are a group of heterogeneous, chemically unrelated compounds with distinct pharmacological and pharmacokinetic properties and substantially different safety profiles, which precludes the notion of a class effect for hepatotoxicity risk and highlights the need for an individualized therapeutic approach. We discuss the current evidence on the hepatotoxicity potential of AAPs, the emerging underlying mechanisms, and the limitations inherent to this group of drugs for both establishing a proper causality assessment and developing strategies for risk management.
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Concordance between actual and pharmacogenetic predicted desvenlafaxine dose needed to achieve remission in major depressive disorder: a 10-week open-label study. Pharmacogenet Genomics 2017; 27:1-6. [PMID: 27779571 PMCID: PMC5152629 DOI: 10.1097/fpc.0000000000000253] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background Pharmacogenetic-based dosing support tools have been developed to personalize antidepressant-prescribing practice. However, the clinical validity of these tools has not been adequately tested, particularly for specific antidepressants. Objective To examine the concordance between the actual dose and a polygene pharmacogenetic predicted dose of desvenlafaxine needed to achieve symptom remission. Materials and methods A 10-week, open-label, prospective trial of desvenlafaxine among Caucasian adults with major depressive disorder (n=119) was conducted. Dose was clinically adjusted and at the completion of the trial, the clinical dose needed to achieve remission was compared with the predicted dose needed to achieve remission. Results Among remitters (n=95), there was a strong concordance (Kendall’s τ-b=0.84, P=0.0001; Cohen’s κ=0.82, P=0.0001) between the actual and the predicted dose need to achieve symptom remission, showing high sensitivity (≥85%), specificity (≥86%), and accuracy (≥89%) of the tool. Conclusion Findings provide initial evidence for the clinical validity of a polygene pharmacogenetic-based tool for desvenlafaxine dosing.
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Pravastatin-Induced Eczematous Eruption Mimicking Psoriasis. Case Rep Dermatol Med 2017; 2017:3418204. [PMID: 28831316 PMCID: PMC5555012 DOI: 10.1155/2017/3418204] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 07/03/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Statins, an example of the most commonly prescribed medications to the elderly, are not without side effects. Dermatologic events are often overlooked as arising from medications, particularly those which are taken chronically. Moreover, elderly patients are prone to pharmacologic interactions due to multiple medications. In this report, we describe a case of a statin-induced eczematous dermatitis with a psoriasis-like clinical presentation and review the skin manifestations that may arise from statin therapy. CASE PRESENTATION An 82-year-old man with gout and hypercholesterolemia presented to dermatology clinic with new onset of pruritic, scaly erythematous plaques bilaterally on the extensor surfaces of his arms. He had never had similar lesions before. Despite various topical and systemic treatments over several months, the rash continued to evolve. The patient was then advised to discontinue his long-term statin, which led to gradual resolution of his symptoms. He was subsequently diagnosed with statin-induced eczematous dermatitis. CONCLUSIONS This case report describes an adverse cutaneous reaction to statins that is rarely reported in the literature. Medications, including longstanding therapies, should be suspected in cases of refractory dermatologic lesions.
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Abstract
Polypharmacy is common in psychiatry. Usage of cognitive enhancers is increasing in the psychiatric population. Many clinicians are not familiar with these new psychoactive compounds. This paper reviews the potential drug-drug interactions when these cognitive enhancers are used together with psychotropic drugs and their confounding effects on diagnosis and clinical management.
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Daud ANA, Bergman JEH, Kerstjens-Frederikse WS, van der Vlies P, Hak E, Berger RMF, Groen H, Wilffert B. Prenatal exposure to serotonin reuptake inhibitors and congenital heart anomalies: an exploratory pharmacogenetics study. Pharmacogenomics 2017. [PMID: 28639488 DOI: 10.2217/pgs-2017-0036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
AIM To explore the role of pharmacogenetics in determining the risk of congenital heart anomalies (CHA) with prenatal use of serotonin reuptake inhibitors. METHODS We included 33 case-mother dyads and 2 mother-only (child deceased) cases of CHA in a case-only study. Ten genes important in determining fetal exposure to serotonin reuptake inhibitors were examined: CYP1A2, CYP2C9, CYP2C19, CYP2D6, ABCB1, SLC6A4, HTR1A, HTR1B, HTR2A and HTR3B. RESULTS Among the exposed cases, polymorphisms that tended to be associated with an increased risk of CHA were SLC6A4 5-HTTLPR and 5-HTTVNTR, HTR1A rs1364043, HTR1B rs6296 and rs6298 and HTR3B rs1176744, but none reached statistical significance due to our limited sample sizes. CONCLUSION We identified several polymorphisms that might potentially affect the risk of CHA among exposed fetuses, which warrants further investigation.
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Affiliation(s)
- Aizati N A Daud
- Unit of PharmacoTherapy, -Epidemiology & -Economics, Department of Pharmacy, University of Groningen, Groningen Research Institute of Pharmacy, Groningen, The Netherlands.,School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Jorieke E H Bergman
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Pieter van der Vlies
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eelko Hak
- Unit of PharmacoTherapy, -Epidemiology & -Economics, Department of Pharmacy, University of Groningen, Groningen Research Institute of Pharmacy, Groningen, The Netherlands
| | - Rolf M F Berger
- Department of Pediatric Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Bob Wilffert
- Unit of PharmacoTherapy, -Epidemiology & -Economics, Department of Pharmacy, University of Groningen, Groningen Research Institute of Pharmacy, Groningen, The Netherlands.,Department of Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Day RO, Snowden L, McLachlan AJ. Life‐threatening drug interactions: what the physician needs to know. Intern Med J 2017; 47:501-512. [DOI: 10.1111/imj.13404] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 11/11/2016] [Accepted: 11/11/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Richard O. Day
- Department of Clinical Pharmacology and Toxicology St Vincent's Hospital Sydney New South Wales Australia
- School of Medical Sciences, Medicine University of New South Wales Sydney New South Wales Australia
- St Vincent's Clinical School, Medicine University of New South Wales Sydney New South Wales Australia
| | - Leone Snowden
- New South Wales Medicines Information Centre Sydney New South Wales Australia
| | - Andrew J. McLachlan
- Faculty of Pharmacy University of Sydney and Centre for Education and Research on Ageing, Concord Hospital Sydney New South Wales Australia
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Loperamide-Related Deaths in North Carolina. J Anal Toxicol 2016; 40:677-686. [DOI: 10.1093/jat/bkw069] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 05/05/2016] [Indexed: 01/16/2023] Open
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Spina E, Pisani F, de Leon J. Clinically significant pharmacokinetic drug interactions of antiepileptic drugs with new antidepressants and new antipsychotics. Pharmacol Res 2016; 106:72-86. [DOI: 10.1016/j.phrs.2016.02.014] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 02/08/2016] [Accepted: 02/11/2016] [Indexed: 12/14/2022]
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Daud ANA, Bergman JEH, Bakker MK, Wang H, Kerstjens-Frederikse WS, de Walle HEK, Groen H, Bos JHJ, Hak E, Wilffert B. P-Glycoprotein-Mediated Drug Interactions in Pregnancy and Changes in the Risk of Congenital Anomalies: A Case-Reference Study. Drug Saf 2016; 38:651-9. [PMID: 26017034 PMCID: PMC4486783 DOI: 10.1007/s40264-015-0299-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Introduction Drug use in pregnancy is very common but may cause harm to the fetus. The teratogenic effect of a drug is partly dependent on the drug level in the fetal circulation, which is associated with the transport across the placenta. Many drugs are substrates of P-glycoprotein (P-gp), an efflux transporter that acts as a protective barrier for the fetus. We aim to identify whether drug interactions associated with P-gp promote any changes in fetal drug exposure, as measured by the risk of having children with congenital anomalies. Methods In this study, cases (N = 4634) were mothers of children with congenital anomalies registered in the EUROCAT Northern Netherlands registry, and the reference population were mothers of children (N = 25,126) from a drug prescription database (IADB.nl). Results Drugs that are associated with P-gp transport were commonly used in pregnancy in cases (10 %) and population (12 %). Several drug classes, which are substrates for P-gp, were shown to have a higher user rate in mothers of cases with specific anomalies. The use of this subset of drugs in combination with other P-gp substrates increased the risk for specific anomalies (odds ratio [OR] 4.17, 95 % CI 1.75–9.91), and the addition of inhibitors further increased the risk (OR 13.03, 95 % CI 3.37–50.42). The same pattern of risk increment was observed when the drugs were analyzed separately according to substrate specificity. Conclusions The use of drugs associated with P-gp transport was common during pregnancy. For several drug classes associated with specific anomalies, P-gp-mediated drug interactions are associated with an increased risk for those specific anomalies. Electronic supplementary material The online version of this article (doi:10.1007/s40264-015-0299-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aizati N A Daud
- Unit of Pharmacotherapy and Pharmaceutical Care, Department of Pharmacy, University of Groningen, Groningen, The Netherlands,
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Pottier G, Marie S, Goutal S, Auvity S, Peyronneau MA, Stute S, Boisgard R, Dollé F, Buvat I, Caillé F, Tournier N. Imaging the Impact of the P-Glycoprotein (ABCB1) Function on the Brain Kinetics of Metoclopramide. J Nucl Med 2015; 57:309-14. [PMID: 26585058 DOI: 10.2967/jnumed.115.164350] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 11/02/2015] [Indexed: 12/25/2022] Open
Abstract
UNLABELLED The effects of metoclopramide on the central nervous system (CNS) in patients suggest substantial brain distribution. Previous data suggest that metoclopramide brain kinetics may nonetheless be controlled by ATP-binding cassette (ABC) transporters expressed at the blood-brain barrier. We used (11)C-metoclopramide PET imaging to elucidate the kinetic impact of transporter function on metoclopramide exposure to the brain. METHODS (11)C-metoclopramide transport by P-glycoprotein (P-gp; ABCB1) and the breast cancer resistance protein (BCRP; ABCG2) was tested using uptake assays in cells overexpressing P-gp and BCRP. (11)C-metoclopramide brain kinetics were compared using PET in rats (n = 4-5) in the absence and presence of a pharmacologic dose of metoclopramide (3 mg/kg), with or without P-gp inhibition using intravenous tariquidar (8 mg/kg). The (11)C-metoclopramide brain distribution (VT based on Logan plot analysis) and brain kinetics (2-tissue-compartment model) were characterized with either a measured or an imaged-derived input function. Plasma and brain radiometabolites were studied using radio-high-performance liquid chromatography analysis. RESULTS (11)C-metoclopramide transport was selective for P-gp over BCRP. Pharmacologic dose did not affect baseline (11)C-metoclopramide brain kinetics (VT = 2.28 ± 0.32 and 2.04 ± 0.19 mL⋅cm(-3) using microdose and pharmacologic dose, respectively). Tariquidar significantly enhanced microdose (11)C-metoclopramide VT (7.80 ± 1.43 mL⋅cm(-3)) with a 4.4-fold increase in K1 (influx rate constant) and a 2.3-fold increase in binding potential (k3/k4) in the 2-tissue-compartment model. In the pharmacologic situation, P-gp inhibition significantly increased metoclopramide brain distribution (VT = 6.28 ± 0.48 mL⋅cm(-3)) with a 2.0-fold increase in K1 and a 2.2-fold decrease in k2 (efflux rate), with no significant impact on binding potential. In this situation, only parent (11)C-metoclopramide could be detected in the brains of P-gp-inhibited rats. CONCLUSION (11)C-metoclopramide benefits from favorable pharmacokinetic properties that offer reliable quantification of P-gp function at the blood-brain barrier in a pharmacologic situation. Using metoclopramide as a model of CNS drug, we demonstrated that P-gp function not only reduces influx but also mediates the efflux from the brain back to the blood compartment, with additional impact on brain distribution. This PET-based strategy of P-gp function investigation may provide new insight on the contribution of P-gp to the variability of response to CNS drugs between patients.
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Affiliation(s)
- Géraldine Pottier
- Inserm/CEA/Université Paris Sud, UMR 1023 - ERL 9218 CNRS, IMIV, Orsay, France; and CEA, DSV, I2BM, Service Hospitalier Frédéric Joliot, Orsay, France
| | - Solène Marie
- Inserm/CEA/Université Paris Sud, UMR 1023 - ERL 9218 CNRS, IMIV, Orsay, France; and CEA, DSV, I2BM, Service Hospitalier Frédéric Joliot, Orsay, France
| | - Sébastien Goutal
- Inserm/CEA/Université Paris Sud, UMR 1023 - ERL 9218 CNRS, IMIV, Orsay, France; and CEA, DSV, I2BM, Service Hospitalier Frédéric Joliot, Orsay, France
| | - Sylvain Auvity
- Inserm/CEA/Université Paris Sud, UMR 1023 - ERL 9218 CNRS, IMIV, Orsay, France; and CEA, DSV, I2BM, Service Hospitalier Frédéric Joliot, Orsay, France
| | - Marie-Anne Peyronneau
- Inserm/CEA/Université Paris Sud, UMR 1023 - ERL 9218 CNRS, IMIV, Orsay, France; and CEA, DSV, I2BM, Service Hospitalier Frédéric Joliot, Orsay, France
| | - Simon Stute
- Inserm/CEA/Université Paris Sud, UMR 1023 - ERL 9218 CNRS, IMIV, Orsay, France; and CEA, DSV, I2BM, Service Hospitalier Frédéric Joliot, Orsay, France
| | - Raphaël Boisgard
- Inserm/CEA/Université Paris Sud, UMR 1023 - ERL 9218 CNRS, IMIV, Orsay, France; and CEA, DSV, I2BM, Service Hospitalier Frédéric Joliot, Orsay, France
| | - Frédéric Dollé
- Inserm/CEA/Université Paris Sud, UMR 1023 - ERL 9218 CNRS, IMIV, Orsay, France; and CEA, DSV, I2BM, Service Hospitalier Frédéric Joliot, Orsay, France
| | - Irène Buvat
- Inserm/CEA/Université Paris Sud, UMR 1023 - ERL 9218 CNRS, IMIV, Orsay, France; and CEA, DSV, I2BM, Service Hospitalier Frédéric Joliot, Orsay, France
| | - Fabien Caillé
- Inserm/CEA/Université Paris Sud, UMR 1023 - ERL 9218 CNRS, IMIV, Orsay, France; and CEA, DSV, I2BM, Service Hospitalier Frédéric Joliot, Orsay, France
| | - Nicolas Tournier
- Inserm/CEA/Université Paris Sud, UMR 1023 - ERL 9218 CNRS, IMIV, Orsay, France; and CEA, DSV, I2BM, Service Hospitalier Frédéric Joliot, Orsay, France
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Singh AB. Improved Antidepressant Remission in Major Depression via a Pharmacokinetic Pathway Polygene Pharmacogenetic Report. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2015; 13:150-6. [PMID: 26243841 PMCID: PMC4540033 DOI: 10.9758/cpn.2015.13.2.150] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 01/04/2015] [Accepted: 01/07/2015] [Indexed: 12/26/2022]
Abstract
Objective Major depressive disorder (MDD) is projected to be a leading cause of disability globally by 2030. Only a minority of patients remit with antidepressants. If assay of polymorphisms influencing central nervous system (CNS) bioavailability could guide prescribers to more effectively dose patients, remission rates may improve and the burden of disease from MDD reduce. Hepatic and blood brain barrier (BBB) polymorphisms appear to influence antidepressant CNS bioavailability. Methods A 12-week prospective double blind randomized genetically guided versus unguided trial of antidepressant dosing in Caucasian adults with MDD (n=148) was conducted. Results Subjects receiving genetically guided prescribing had a 2.52-fold greater chance of remission (95% confidence interval [CI]=1.71–3.73, z=4.66, p<0.0001). The number needed to genotype (NNG)=3 (95% CI=1.7–3.5) to produce an additional remission. Conclusion These data suggest that a pharmacogenetic dosing report (CNSDose®) improves antidepressant efficacy. The effect size was sufficient that translation to clinical care may arise if results are independently replicated.
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Efectos de los inductores antiepilépticos en la neuropsicofarmacología: una cuestión ignorada. Parte II: cuestiones farmacológicas y comprensión adicional. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2015; 8:167-88. [DOI: 10.1016/j.rpsm.2014.10.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 10/23/2014] [Indexed: 12/19/2022]
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Macaluso M, Nichols AI, Preskorn SH. How the Probability and Potential Clinical Significance of Pharmacokinetically Mediated Drug-Drug Interactions Are Assessed in Drug Development: Desvenlafaxine as an Example. Prim Care Companion CNS Disord 2015; 17:14r01710. [PMID: 26445693 DOI: 10.4088/pcc.14r01710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 10/29/2014] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The avoidance of adverse drug-drug interactions (DDIs) is a high priority in terms of both the US Food and Drug Administration (FDA) and the individual prescriber. With this perspective in mind, this article illustrates the process for assessing the risk of a drug (example here being desvenlafaxine) causing or being the victim of DDIs, in accordance with FDA guidance. DATA SOURCES/STUDY SELECTION DDI studies for the serotonin-norepinephrine reuptake inhibitor desvenlafaxine conducted by the sponsor and published since 2009 are used as examples of the systematic way that the FDA requires drug developers to assess whether their new drug is either capable of causing clinically meaningful DDIs or being the victim of such DDIs. In total, 8 open-label studies tested the effects of steady-state treatment with desvenlafaxine (50-400 mg/d) on the pharmacokinetics of cytochrome (CYP) 2D6 and/or CYP 3A4 substrate drugs, or the effect of CYP 3A4 inhibition on desvenlafaxine pharmacokinetics. The potential for DDIs mediated by the P-glycoprotein (P-gp) transporter was assessed in in vitro studies using Caco-2 monolayers. DATA EXTRACTION Changes in area under the plasma concentration-time curve (AUC; CYP studies) and efflux (P-gp studies) were reviewed for potential DDIs in accordance with FDA criteria. RESULTS Desvenlafaxine coadministration had minimal effect on CYP 2D6 and/or 3A4 substrates per FDA criteria. Changes in AUC indicated either no interaction (90% confidence intervals for the ratio of AUC geometric least-squares means [GM] within 80%-125%) or weak inhibition (AUC GM ratio 125% to < 200%). Coadministration with ketoconazole resulted in a weak interaction with desvenlafaxine (AUC GM ratio of 143%). Desvenlafaxine was not a substrate (efflux ratio < 2) or inhibitor (50% inhibitory drug concentration values > 250 μM) of P-gp. CONCLUSIONS A 2-step process based on FDA guidance can be used first to determine whether a pharmacokinetically mediated interaction occurs and then to assess the potential clinical significance of the DDI. In the case of the drug tested in this series of studies, the potential for clinically meaningful DDIs mediated by CYP 2D6, CYP 3A4, or P-gp was found to be low.
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Affiliation(s)
- Matthew Macaluso
- University of Kansas School of Medicine, Wichita, Kansas (Drs Macaluso and Preskorn); Pfizer Inc, Collegeville, Pennsylvania (Dr Nichols); and Laureate Institute for Brain Research, Tulsa, Oklahoma (Dr Preskorn)
| | - Alice I Nichols
- University of Kansas School of Medicine, Wichita, Kansas (Drs Macaluso and Preskorn); Pfizer Inc, Collegeville, Pennsylvania (Dr Nichols); and Laureate Institute for Brain Research, Tulsa, Oklahoma (Dr Preskorn)
| | - Sheldon H Preskorn
- University of Kansas School of Medicine, Wichita, Kansas (Drs Macaluso and Preskorn); Pfizer Inc, Collegeville, Pennsylvania (Dr Nichols); and Laureate Institute for Brain Research, Tulsa, Oklahoma (Dr Preskorn)
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Akamine Y. Determinants of the Stereoselective Pharmacokinetics of Fexofenadine. YAKUGAKU ZASSHI 2015; 135:473-81. [DOI: 10.1248/yakushi.14-00218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Yumiko Akamine
- Department of Hospital Pharmacy, Faculty of Medicine, University of the Ryukyus
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University
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Italiano D, Spina E, de Leon J. Pharmacokinetic and pharmacodynamic interactions between antiepileptics and antidepressants. Expert Opin Drug Metab Toxicol 2014; 10:1457-89. [PMID: 25196459 DOI: 10.1517/17425255.2014.956081] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Antiepileptic-antidepressant combinations are frequently used by clinicians; their pharmacokinetic (PK) and pharmacodynamic (PD) drug interactions (DIs) have not been well studied but are frequently likely to be clinically relevant. AREAS COVERED This article provides a comprehensive review of PK DIs between antiepileptics and antidepressants. In the absence of PD DI studies, PD information on pharmacological mechanisms and studies on efficacy and safety of individual drugs are reviewed. EXPERT OPINION The clinical relevance of the inductive properties of carbamazepine, phenytoin, phenobarbital and primidone and the inhibitory properties of valproic acid and some antidepressants are well understood; correction factors are provided if appropriate DI studies have been completed. More PK studies are needed for: i) antiepileptics with potent inductive effects for all recently approved antidepressants; ii) high doses of mild CYP3A4 inducers, such as clobazam, eslicarbazepine, oxcarbazepine, rufinamide and topiramate for reboxetine and vilazodone; iii) valproate as a possible inhibitor, mild inducer or both a mild inducer and competitive inhibitor of some antidepressants; and iv) inhibitory effects of long-term fluoxetine use on clobazam, lacosamide, phenobarbital, primidone, carbamazepine, felbamate, tiagabine and zonisamide. Possible synergistic or additive beneficial PD DIs in generalized anxiety disorder, chronic pain, migraine prophylaxis, weight control and menopausal symptoms need study.
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Affiliation(s)
- Domenico Italiano
- University of Messina, Department of Clinical and Experimental Medicine , Messina , Italy
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Franzellitti S, Buratti S, Capolupo M, Du B, Haddad SP, Chambliss CK, Brooks BW, Fabbri E. An exploratory investigation of various modes of action and potential adverse outcomes of fluoxetine in marine mussels. AQUATIC TOXICOLOGY (AMSTERDAM, NETHERLANDS) 2014; 151:14-26. [PMID: 24361074 DOI: 10.1016/j.aquatox.2013.11.016] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 11/18/2013] [Accepted: 11/25/2013] [Indexed: 05/27/2023]
Abstract
The present study investigated possible adverse outcome pathways (AOPs) of the antidepressant fluoxetine (FX) in the marine mussel Mytilus galloprovincialis. An evaluation of molecular endpoints involved in modes of action (MOAs) of FX and biomarkers for sub-lethal toxicity were explored in mussels after a 7-day administration of nominal FX concentrations encompassing a range of environmentally relevant values (0.03-300ng/L). FX bioaccumulated in mussel tissues after treatment with 30 and 300ng/L FX, resulting in bioconcentration factor (BCF) values ranging from 200 to 800, which were higher than expected based solely on hydrophobic partitioning models. Because FX acts as a selective serotonin (5-HT) re-uptake inhibitor increasing serotonergic neurotransmission at mammalian synapses, cell signaling alterations triggered by 5-HT receptor occupations were assessed. cAMP levels and PKA activities were decreased in digestive gland and mantle/gonads of FX-treated mussels, consistent with an increased occupation of 5-HT1 receptors negatively coupled to the cAMP/PKA pathway. mRNA levels of a ABCB gene encoding the P-glycoprotein were also significantly down-regulated. This membrane transporter acts in detoxification towards xenobiotics and in altering pharmacokinetics of antidepressants; moreover, it is under a cAMP/PKA transcriptional regulation in mussels. Potential stress effects of FX were investigated using a battery of biomarkers for mussel health status that included lysosomal parameters, antioxidant enzyme activities, lipid peroxidation, and acetylcholinesterase activity. FX reduced the health status of mussels and induced lysosomal alterations, as suggested by reduction of lysosomal membrane stability in haemocytes and by lysosomal accumulation of neutral lipids in digestive gland. No clear antioxidant responses to FX were detected in digestive gland, while gills displayed significant increases of catalase and glutathione-s-transferase activities and a significant decrease of acetylcholinesterase activity. Though AOPs associated with mammalian therapeutic MOAs remain important during assessments of pharmaceutical hazards in the environment, this study highlights the importance of considering additional MOAs and AOPs for FX, particularly in marine mussels.
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Affiliation(s)
- Silvia Franzellitti
- University of Bologna, Interdepartment Centre for Environmental Science Research, via S. Alberto 163, 48123 Ravenna, Italy; University of Bologna, Department of Biological, Geological, and Environmental Sciences, via Selmi 3, 40100 Bologna, Italy.
| | - Sara Buratti
- University of Bologna, Interdepartment Centre for Environmental Science Research, via S. Alberto 163, 48123 Ravenna, Italy
| | - Marco Capolupo
- University of Bologna, Interdepartment Centre for Environmental Science Research, via S. Alberto 163, 48123 Ravenna, Italy
| | - Bowen Du
- Department of Environmental Science, Baylor University, Waco, TX 76798, USA
| | - Samuel P Haddad
- Department of Environmental Science, Baylor University, Waco, TX 76798, USA
| | - C Kevin Chambliss
- Department of Chemistry and Biochemistry, Baylor University, Waco, TX 76798, USA
| | - Bryan W Brooks
- Department of Environmental Science, Baylor University, Waco, TX 76798, USA
| | - Elena Fabbri
- University of Bologna, Interdepartment Centre for Environmental Science Research, via S. Alberto 163, 48123 Ravenna, Italy; University of Bologna, Department of Biological, Geological, and Environmental Sciences, via Selmi 3, 40100 Bologna, Italy
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Schrickx JA, Fink-Gremmels J. Inhibition of P-glycoprotein by psychotherapeutic drugs in a canine cell model. J Vet Pharmacol Ther 2014; 37:515-7. [DOI: 10.1111/jvp.12111] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 01/14/2014] [Indexed: 01/16/2023]
Affiliation(s)
- J. A. Schrickx
- Faculty of Veterinary Medicine; Institute for Risk Assessment Sciences; Utrecht University; Utrecht The Netherlands
| | - J. Fink-Gremmels
- Faculty of Veterinary Medicine; Institute for Risk Assessment Sciences; Utrecht University; Utrecht The Netherlands
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Spina E, de Leon J. Clinically relevant interactions between newer antidepressants and second-generation antipsychotics. Expert Opin Drug Metab Toxicol 2014; 10:721-46. [PMID: 24494611 DOI: 10.1517/17425255.2014.885504] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Combinations of newer antidepressants and second-generation antipsychotics (SGAs) are frequently used by clinicians. Pharmacokinetic drug interaction (PK DI) and poorly understood pharmacodynamic (PD) drug interaction (PD DI) can occur between them. AREAS COVERED This paper comprehensively reviews PD DI and PK DI studies. EXPERT OPINION More PK DI studies are needed to better establish dose correction factors after adding fluoxetine and paroxetine to aripiprazole, iloperidone and risperidone. Further PK DI studies and case reports are also needed to better establish the need for dose correction factors after adding i) fluoxetine to clozapine, lurasidone, quetiapine and olanzapine; ii) paroxetine to olanzapine; iii) fluvoxamine to asenapine, aripiprazole, iloperidone, lurasidone, olanzapine, quetiapine and risperidone; iv) high sertraline doses to aripiprazole, clozapine, iloperidone and risperidone: v) bupropion and duloxetine to aripiprazole, clozapine, iloperidone and risperidone; and vi) asenapine to paroxetine and venlafaxine. Possible beneficial PD DI effects occur after adding SGAs to newer antidepressants for treatment-resistant major depressive and obsessive-compulsive disorders. The lack of studies combining newer antidepressants and SGAs in psychotic depression is worrisome. PD DIs between newer antidepressants and SGAs may be more likely for mirtazapine and bupropion. Adding selective serotonin reuptake inhibitors and SGAs may increase QTc interval and may very rarely contribute to torsades de pointes.
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Affiliation(s)
- Edoardo Spina
- University of Messina, Policlinico Universitario, Department of Clinical and Experimental Medicine , Via Consolare Valeria, 98125 Messina , Italy +39 090 2213647 ; +39 090 2213300 ;
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Ginanneschi F, Volpi N, Giannini F, Rocchi R, Donati D, Aglianò M, Lorenzoni P, Rossi A. Rhabdomyolysis in an elderly multitreated patient: multiple drug interactions after statin withdrawal. J Neurol Sci 2013; 336:284-7. [PMID: 24252882 DOI: 10.1016/j.jns.2013.10.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 10/24/2013] [Accepted: 10/28/2013] [Indexed: 01/16/2023]
Abstract
Rhabdomyolysis precipitated by multitherapy is most frequently described during statin treatment, due to impairment of statin clearance by drugs sharing cytochrome P450 biotransformation pathway. Modulation of membrane transporters for drug efflux, operated by substrates, can also affect drugs' tissue levels. We report rhabdomyolysis in an elderly patient, in multitreatment with different potentially myotoxic medications, taking place seven months after atorvastatin discontinuation. Affected by ischaemic heart disease, arterial hypertension and dementia-related behaviour disturbances, the patient was receiving angiotensin 2-receptor inhibitors, beta-blockers, vasodilators, diuretics, salycilates, allopurinol, proton pump inhibitors, antipsychotics and antidepressants. He had taken atorvastatin for 14 years, with constantly normal creatine-kinase plasma levels. Two months after addition of the antianginal drug ranolazine, creatine-kinase mildly increased and atorvastatin was withdrawn. Nonetheless, creatine-kinase progressively rose, with severe weakness and rhabdomyolysis developing seven months later. Muscle biopsy showed a necrotizing myopathy with no inflammation or autoimmune changes. After ranolazine withdrawal, creatine-kinase and myoglobin returned to normal levels and strength was restored. Several psychotropic and cardiovascular medications prescribed to the patient share either cytochrome P450 biotransformation and permeability-glycoprotein efflux transport. In the event of cardiovascular/neuropsychiatric polypharmacy in geriatric patients, the risk of muscle severe adverse effects from pharmacokinetic drug-drug interaction should be considered beyond the direct myotoxicity of statins.
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Affiliation(s)
- Federica Ginanneschi
- Department of Medical Sciences, Surgical Sciences and Neurosciences, Siena University, 53100 Siena, Italy
| | - Nila Volpi
- Department of Medical Sciences, Surgical Sciences and Neurosciences, Siena University, 53100 Siena, Italy.
| | - Fabio Giannini
- Department of Medical Sciences, Surgical Sciences and Neurosciences, Siena University, 53100 Siena, Italy
| | - Raffaele Rocchi
- Department of Medical Sciences, Surgical Sciences and Neurosciences, Siena University, 53100 Siena, Italy
| | - Donatella Donati
- Department of Medical Sciences, Surgical Sciences and Neurosciences, Siena University, 53100 Siena, Italy
| | - Margherita Aglianò
- Department of Medical Sciences, Surgical Sciences and Neurosciences, Siena University, 53100 Siena, Italy
| | - Paola Lorenzoni
- Department of Medical Sciences, Surgical Sciences and Neurosciences, Siena University, 53100 Siena, Italy
| | - Alessandro Rossi
- Department of Medical Sciences, Surgical Sciences and Neurosciences, Siena University, 53100 Siena, Italy
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