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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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Settanni F, Ponzetto F, Veronesi A, Nonnato A, Martinelli F, Rumbolo F, Fimognari M, Martinasso G, Mengozzi G. Total Value of Ownership and Overall Equipment Effectiveness analysis to evaluate the impact of automation on time and costs of therapeutic drug monitoring. Anal Chim Acta 2021; 1160:338455. [PMID: 33894968 DOI: 10.1016/j.aca.2021.338455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
Total Value of Ownership (TVO) and Overall Equipment Effectiveness (OEE) analysis are novel tools capable of monitoring and analyzing industrial processes by assessing the efficiency of the entire instrumental equipment and calculating instrument capacity utilization. Such integrated analysis, measuring quality indicators of the testing process, could also provide new perspectives and methodologies for the workflow organization of clinical laboratories. In this study, TVO and OEE were employed for the evaluation of two different configurations of a therapeutic drug monitoring sector, comparing the results obtained for immunosuppressant (ISD) and anti-epileptic drugs (AED) analysis as well as checking their quantitative performance in terms of limit of quantification, accuracy and precision. TVO analysis was performed for ISDs, including the Total Direct Labor Time, Total Cycle Time and Turnaround Time as well as cost of testing. Instruments' performance and workload were assessed using OEE indicator, studying Availability, Performance and Quality factors. Total Cycle Time for a batch was 3.55 h, decreasing of 1.5 h in the new setting where personnel are engaged for 0.98 h, 25% of total testing time. The calculated cost per sample was 6.60 euro. Availability values were significantly higher for automated sample-handling system and ISDs analysis by LC-MS. Higher Performance values were obtained for LC-MS system for AED and other TDM. Quality values were >0.94 for all instruments. TVO and OEE proved to be applicable to clinical laboratory environment, quantifying benefits and costs of newly developed semi-automated therapeutic drug monitoring sector. This novel approach based on an integrated analysis may help activity planning and quality improvement and could be used in the future for benchmarking progress as a product/process comparison tool in other laboratory fields.
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Affiliation(s)
- Fabio Settanni
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
| | - Federico Ponzetto
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy.
| | - Agnese Veronesi
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
| | - Antonello Nonnato
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
| | - Francesco Martinelli
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
| | - Francesca Rumbolo
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Maurizio Fimognari
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
| | - Giovanna Martinasso
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
| | - Giulio Mengozzi
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
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De Donatis D, Florio V, Porcelli S, Saria A, Mercolini L, Serretti A, Conca A. Duloxetine plasma level and antidepressant response. Prog Neuropsychopharmacol Biol Psychiatry 2019; 92:127-132. [PMID: 30611837 DOI: 10.1016/j.pnpbp.2019.01.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/11/2018] [Accepted: 01/02/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Major Depressive Disorder (MDD) is associated with a high rate of inadequate treatment response, which is mainly due to the large inter-individual genetic variability in pharmacokinetic and pharmacodynamic targets of antidepressant drugs. Little is still known about the exact association between plasma level of first-line antidepressants and clinical response. This is particularly true for duloxetine, a dual serotonin and norepinephrine reuptake inhibitor recommended as first-line treatment for MDD. The aim of this study was to investigate the association between serum concentration of duloxetine (SCD) and antidepressant response (AR). METHODS 66 MDD patients treated with duloxetine 60 mg/day monotherapy were recruited in an outpatient setting and followed for three months. Hamilton Depression Rating Scale - 21 (HAMD-21) was administrated at baseline, at month 1, and at month 3 to assess AR. SCD was measured at steady state. Linear regression analysis and nonlinear least-squares regression were used to estimate association between SCD and AR. RESULTS SCD showed a high inter-individual variability in our sample, despite the duloxetine fixed oral dosage. We found a strong association between SCD and AR following a bell-shaped function at month 1 and at month 3. Nonetheless, within the recommended SCD range of 30-120 ng/mL a more linear correlation between SCD and AR was observed. DISCUSSION Our results suggest that for duloxetine the association between SCD and AR likely follows a bell-shaped quadratic function with poor AR at subtherapeutic SCD and progressive decrease of AR at higher SCD. The maximum antidepressant efficacy seems to require SCD values next to the highest recommended SCD (30-120 ng/mL), probably because of the optimal saturation of both serotonin and norepinephrine transporters. Thus, taking into account the observed high interindividual variability of SCD, our findings suggest that for MDD patients treated with duloxetine, SCD could be a useful tool to guide the treatment by optimizing the oral dosage in order to increase the AR rate.
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Affiliation(s)
- Domenico De Donatis
- Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy
| | | | - Stefano Porcelli
- Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy
| | - Alois Saria
- Experimental Psychiatry Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Laura Mercolini
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Alessandro Serretti
- Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy.
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Schoretsanitis G, Paulzen M, Unterecker S, Schwarz M, Conca A, Zernig G, Gründer G, Haen E, Baumann P, Bergemann N, Clement HW, Domschke K, Eckermann G, Egberts K, Gerlach M, Greiner C, Havemann-Reinecke U, Hefner G, Helmer R, Janssen G, Jaquenoud-Sirot E, Laux G, Messer T, Mössner R, Müller MJ, Pfuhlmann B, Riederer P, Saria A, Schoppek B, Silva Gracia M, Stegmann B, Steimer W, Stingl JC, Uhr M, Ulrich S, Waschgler R, Zurek G, Hiemke C. TDM in psychiatry and neurology: A comprehensive summary of the consensus guidelines for therapeutic drug monitoring in neuropsychopharmacology, update 2017; a tool for clinicians<sup/>. World J Biol Psychiatry 2018; 19:162-174. [PMID: 29493375 DOI: 10.1080/15622975.2018.1439595] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Therapeutic drug monitoring (TDM) combines the quantification of drug concentrations in blood, pharmacological interpretation and treatment guidance. TDM introduces a precision medicine tool in times of increasing awareness of the need for personalized treatment. In neurology and psychiatry, TDM can guide pharmacotherapy for patient subgroups such as children, adolescents, pregnant women, elderly patients, patients with intellectual disabilities, patients with substance use disorders, individuals with pharmacokinetic peculiarities and forensic patients. Clear indications for TDM include lack of clinical response in the therapeutic dose range, assessment of drug adherence, tolerability issues and drug-drug interactions. METHODS Based upon existing literature, recommended therapeutic reference ranges, laboratory alert levels, and levels of recommendation to use TDM for dosage optimization without specific indications, conversion factors, factors for calculation of dose-related drug concentrations and metabolite-to-parent ratios were calculated. RESULTS This summary of the updated consensus guidelines by the TDM task force of the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie offers the practical and theoretical knowledge for the integration of TDM as part of pharmacotherapy with neuropsychiatric agents into clinical routine. CONCLUSIONS The present guidelines for TDM application for neuropsychiatric agents aim to assist clinicians in enhancing safety and efficacy of treatment.
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Affiliation(s)
- Georgios Schoretsanitis
- a Department of Psychiatry , University of Bern , Bern , Switzerland.,b Department of Psychiatry, Psychotherapy and Psychosomatics , RWTH Aachen University, JARA - Translational Brain Medicine , Aachen , Germany
| | - Michael Paulzen
- b Department of Psychiatry, Psychotherapy and Psychosomatics , RWTH Aachen University, JARA - Translational Brain Medicine , Aachen , Germany.,c Alexianer Hospital Aachen , Aachen , Germany
| | - Stefan Unterecker
- d Department of Psychiatry, Psychosomatics and Psychotherapy , University Hospital of Würzburg , Germany
| | - Markus Schwarz
- e Department of Laboratory Medicine , Ludwig Maximilian University , Munich , Germany
| | - Andreas Conca
- f Servizio Psichiatrico del Comprensorio Sanitario di Bolzano , Bolzano , Italy
| | - Gerald Zernig
- g Experimental Psychiatry Unit, Department of Psychiatry and Psychotherapy , Medical University of Innsbruck , Innsbruck , Austria.,h Private Practice for Psychotherapy and Court-Certified Witness , Hall in Tirol , Austria
| | - Gerhard Gründer
- i Department of Molecular Neuroimaging , Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg , Mannheim , Germany
| | - Ekkerhard Haen
- j Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology , University of Regensburg , Regensburg , Germany
| | - Pierre Baumann
- k Department of Psychiatry , University of Lausanne , Lausanne , Switzerland
| | - Niels Bergemann
- l Kitzberg Hospitals, Center for Psychosomatic Medicine and Psychotherapy , Bad Mergentheim , Germany
| | - Hans Willi Clement
- m Department of Child and Adolescent Psychiatry , University of Freiburg , Freiburg , Germany
| | - Katharina Domschke
- n Department of Psychiatry and Psychotherapy , Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg , Freiburg , Germany
| | | | - Karin Egberts
- p Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy , Center of Mental Health, University Hospital of Würzburg , Germany
| | - Manfred Gerlach
- p Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy , Center of Mental Health, University Hospital of Würzburg , Germany
| | - Christine Greiner
- q Federal Institute for Drugs and Medical Devices (BfArM) , Bonn , Germany
| | | | - Gudrun Hefner
- s Psychiatric Hospital, Vitos Klinik Hochtaunus , Friedrichsdorf , Germany
| | | | - Ger Janssen
- u Medical Laboratory Stein , Limbach Group , Mönchengladbach , Germany
| | | | - Gerd Laux
- w Institute of Psychological Medicine , Haag in Oberbayern , Germany
| | - Thomas Messer
- x Danuviuskliniken, Psychiatric Hospital , Pfaffenhofen , Germany
| | - Rainald Mössner
- y Department of Psychiatry and Psychotherapy , University of Tübingen , Tübingen , Germany
| | | | | | - Peter Riederer
- d Department of Psychiatry, Psychosomatics and Psychotherapy , University Hospital of Würzburg , Germany
| | - Alois Saria
- g Experimental Psychiatry Unit, Department of Psychiatry and Psychotherapy , Medical University of Innsbruck , Innsbruck , Austria
| | - Bernd Schoppek
- ab kbo-Isar-Amper Klinikum München-Ost, Psychiatric Hospital , Munich , Germany
| | - Margarete Silva Gracia
- j Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology , University of Regensburg , Regensburg , Germany
| | - Benedikt Stegmann
- j Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology , University of Regensburg , Regensburg , Germany
| | - Werner Steimer
- ac Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich , Munich , Germany
| | - Julia C Stingl
- q Federal Institute for Drugs and Medical Devices (BfArM) , Bonn , Germany
| | - Manfred Uhr
- ad Max Planck Institute of Psychiatry , Munich , Germany
| | | | | | | | - Christoph Hiemke
- ah Department of Psychiatry and Psychotherapy , University Medical Center of Mainz , Mainz , Germany.,ai Institute of Clinical Chemistry and Laboratory Medicine , University Medical Center of Mainz , Mainz , Germany
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