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Nooraeen S, Croarkin PE, Geske JR, Shekunov J, Orth SS, Romanowicz M, Frye MA, Vande Voort JL. High Probability of Gene-Drug Interactions Associated with Medication Side Effects in Adolescent Depression: Results from a Randomized Controlled Trial of Pharmacogenetic Testing. J Child Adolesc Psychopharmacol 2024; 34:28-33. [PMID: 38377526 DOI: 10.1089/cap.2023.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Introduction: Combinatorial pharmacogenetic testing panels are widely available in clinical practice and often separate medications into columns/bins associated with low, medium, or high probability of gene-drug interactions. The objective of the Adolescent Management of Depression (AMOD) study was to determine the clinical utility of combinatorial pharmacogenetic testing in a double-blind, randomized, controlled effectiveness study by comparing patients who had genetic testing results at time of medication initiation to those that did not have results until week 8. The objective of this post hoc analysis was to assess and report additional outcomes with respect to significant gene-drug interactions (i.e., a medication in the high probability gene-drug interaction bin as defined by a proprietary algorithm) compared with patients taking a medication with minimal to moderate gene-drug interactions (i.e., a medication from the low or medium probability gene-drug interaction bin, respectively). Methods: Adolescents 13-18 years (N = 170) with moderate to severe major depressive disorder received pharmacogenetic testing. Symptom improvement and side effects were assessed at baseline, week 4, week 8, and 6 months. Patients were grouped into three categories based on whether the medication they were prescribed was associated with low, medium, or high risk for gene-drug interactions. Patients taking a medication from the low/medium gene-drug interaction bin were compared with patients taking a medication from the high gene-drug interaction bin. Results: Patients taking a medication from the high gene-drug interaction bin were more likely to endorse side effects compared with patients taking a medication in the low/medium gene-drug interaction bin at week 8 (p = 0.001) and 6 months (p < 0.0001). Depressive symptom severity scores did not differ significantly across the medication bins. Conclusions: This study demonstrates the utility of gene-drug interaction testing to guide medication decisions to minimize side effect burden rather than solely prioritizing the search for the most efficacious medication. (Clinical Trials Registration Identifier: NCT02286440).
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Affiliation(s)
- Sara Nooraeen
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul E Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer R Geske
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Julia Shekunov
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Mark A Frye
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
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2
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Liu X, Ju G, Yang W, Chen L, Xu N, He Q, Zhu X, Ouyang D. Escitalopram Personalized Dosing: A Population Pharmacokinetics Repository Method. Drug Des Devel Ther 2023; 17:2955-2967. [PMID: 37789969 PMCID: PMC10544162 DOI: 10.2147/dddt.s425654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/20/2023] [Indexed: 10/05/2023] Open
Abstract
Escitalopram (SCIT) represents a first-line antidepressant and antianxiety medication. Pharmacokinetic studies of SCIT have demonstrated considerable interindividual variability, emphasizing the need for personalized dosing. Accordingly, we aimed to create a repository of parametric population pharmacokinetic (PPK) models of SCIT to facilitate model-informed precision dosing. In November 2022, we searched PubMed, Embase, and Web of Science for published PPK models and identified eight models. All the structural models reported in the literature were either one- or two-compartment models. In order to investigate the variances in model performance, the parameters of all PPK models were derived from the literature published. A representative virtual population, characterized by an age of 30, a body weight of 70 kg, and a BMI of 23 kg/m2, was generated for the purpose of replicating these models. To accomplish this, the rxode2 package in the R programming language was employed. Subsequently, we compared simulated concentration-time profiles and evaluated the impact of covariates on clearance. The most significant covariates were CYP2C19 phenotype, weight, and age, indicating that dosing regimens should be tailored accordingly. Additionally, among Chinese psychiatric patients, SCIT showed nearly double the exposure compared to other populations, specifically when considering the same CYP2C19 population restriction, which is a knowledge gap that needs further investigation. Furthermore, this repository of parametric PPK models for SCIT has a wide range of potential applications, like design miss or delay dose remedy strategies and external PPK model validation.
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Affiliation(s)
- Xin Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute of Clinical Pharmacology, Central South University, Changsha, People’s Republic of China
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd, Changsha, People’s Republic of China
| | - Gehang Ju
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute of Clinical Pharmacology, Central South University, Changsha, People’s Republic of China
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd, Changsha, People’s Republic of China
| | - Wenyu Yang
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai, People’s Republic of China
| | - Lulu Chen
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd, Changsha, People’s Republic of China
- Changsha Duxact Biotech Co., Ltd, Changsha, People’s Republic of China
- Department of Pharmacy, Affiliated Hospital of Xiangnan University, Chenzhou, People’s Republic of China
| | - Nuo Xu
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai, People’s Republic of China
| | - Qingfeng He
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai, People’s Republic of China
| | - Xiao Zhu
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai, People’s Republic of China
| | - Dongsheng Ouyang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute of Clinical Pharmacology, Central South University, Changsha, People’s Republic of China
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd, Changsha, People’s Republic of China
- Changsha Duxact Biotech Co., Ltd, Changsha, People’s Republic of China
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Díaz-Tufinio CA, Palma-Aguirre JA, Gonzalez-Covarrubias V. Pharmacogenetic Variants Associated with Fluoxetine Pharmacokinetics from a Bioequivalence Study in Healthy Subjects. J Pers Med 2023; 13:1352. [PMID: 37763120 PMCID: PMC10532907 DOI: 10.3390/jpm13091352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/17/2023] [Accepted: 08/19/2023] [Indexed: 09/29/2023] Open
Abstract
Fluoxetine is one of the most prescribed antidepressants, yet it still faces challenges due to high intersubject variability in patient response. Mainly metabolized by the highly polymorphic gene CYP2D6, important differences in plasma concentrations after the same doses are found among individuals. This study investigated the association of fluoxetine pharmacokinetics (PK) with pharmacogenetic variants. A bioequivalence crossover trial (two sequences, two periods) was conducted with fluoxetine 20 mg capsules, in 24 healthy subjects. Blood samples for fluoxetine determination were collected up to 72 h post-dose. Subjects were genotyped and single nucleotide variants (SNV) were selected using a candidate gene approach, and then associated with the PK parameters. Bioequivalence was confirmed for the test formulation. We found 34 SNV on 10 genes with a quantifiable impact on the PK of fluoxetine in the randomized controlled trial. Out of those, 29 SNVs belong to 7 CYPs (CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP3A4, CYP3A5), and 5 SNVs to 3 genes impacting the pharmacodynamics and efficacy of fluoxetine (SLC6A4, TPH1, ABCB1). Moreover, decreased/no function SNVs of CYP2D6 (rs1065852, rs28371703, rs1135840) and CYP2C19 (rs12769205) were confirmed phenotypically. Our research contributes to deepening the catalog of genotype-phenotype associations in pharmacokinetics, aiming to increase pharmacogenomics knowledge for rational treatment schemes of antidepressants.
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Affiliation(s)
- Carlos Alejandro Díaz-Tufinio
- Tecnologico de Monterrey, School of Engineering and Sciences, Mexico City 14380, Mexico;
- Axis Clinicals Latina, Mexico City 07870, Mexico;
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Malekpour M, Shekouh D, Safavinia ME, Shiralipour S, Jalouli M, Mortezanejad S, Azarpira N, Ebrahimi ND. Role of FKBP5 and its genetic mutations in stress-induced psychiatric disorders: an opportunity for drug discovery. Front Psychiatry 2023; 14:1182345. [PMID: 37398599 PMCID: PMC10313426 DOI: 10.3389/fpsyt.2023.1182345] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/24/2023] [Indexed: 07/04/2023] Open
Abstract
Stress-induced mental health disorders are affecting many people around the world. However, effective drug therapy for curing psychiatric diseases does not occur sufficiently. Many neurotransmitters, hormones, and mechanisms are essential in regulating the body's stress response. One of the most critical components of the stress response system is the hypothalamus-pituitary-adrenal (HPA) axis. The FKBP prolyl isomerase 51 (FKBP51) protein is one of the main negative regulators of the HPA axis. FKBP51 negatively regulates the cortisol effects (the end product of the HPA axis) by inhibiting the interaction between glucocorticoid receptors (GRs) and cortisol, causing reduced transcription of downstream cortisol molecules. By regulating cortisol effects, the FKBP51 protein can indirectly regulate the sensitivity of the HPA axis to stressors. Previous studies have indicated the influence of FKBP5 gene mutations and epigenetic changes in different psychiatric diseases and drug responses and recommended the FKBP51 protein as a drug target and a biomarker for psychological disorders. In this review, we attempted to discuss the effects of the FKBP5 gene, its mutations on different psychiatric diseases, and drugs affecting the FKBP5 gene.
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Affiliation(s)
- Mahdi Malekpour
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Dorsa Shekouh
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Shadi Shiralipour
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Jalouli
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sahar Mortezanejad
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Negar Azarpira
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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5
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Malekpour M, Jafari A, Kashkooli M, Salarikia SR, Negahdaripour M. A systems biology approach for discovering the cellular and molecular aspects of psychogenic non-epileptic seizure. Front Psychiatry 2023; 14:1116892. [PMID: 37252132 PMCID: PMC10213457 DOI: 10.3389/fpsyt.2023.1116892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Objectives Psychogenic non-epileptic seizure (PNES) is the most common non-epileptic disorder in patients referring to epilepsy centers. Contrary to common beliefs about the disease's harmlessness, the death rate of PNES patients is similar to drug-resistant epilepsy. Meanwhile, the molecular pathomechanism of PNES is unknown with very limited related research. Thus, the aim of this in silico study was to find different proteins and hormones associated with PNES via a systems biology approach. Methods Different bioinformatics databases and literature review were used to find proteins associated with PNES. The protein-hormone interaction network of PNES was constructed to discover its most influential compartments. The pathways associated with PNES pathomechanism were found by enrichment analysis of the identified proteins. Besides, the relationship between PNES-related molecules and psychiatric diseases was discovered, and the brain regions that could express altered levels of blood proteins were discovered. Results Eight genes and three hormones were found associated with PNES through the review process. Proopiomelanocortin (POMC), neuropeptide Y (NPY), cortisol, norepinephrine, and brain-derived neurotrophic factor (BDNF) were identified to have a high impact on the disease pathogenesis network. Moreover, activation of Janus kinase-signaling transducer and activator of transcription (JAK-STAT) and JAK, as well as signaling of growth hormone receptor, phosphatidylinositol 3-kinase /protein kinase B (PI3K/AKT), and neurotrophin were found associated with PNES molecular mechanism. Several psychiatric diseases such as depression, schizophrenia, and alcohol-related disorders were shown to be associated with PNES predominantly through signaling molecules. Significance This study was the first to gather the biochemicals associated with PNES. Multiple components and pathways and several psychiatric diseases associated with PNES, and some brain regions that could be altered during PNES were suggested, which should be confirmed in further studies. Altogether, these findings could be used in future molecular research on PNES patients.
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Affiliation(s)
- Mahdi Malekpour
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Aida Jafari
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Kashkooli
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Manica Negahdaripour
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Science, Shiraz, Iran
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
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Kalla P, Namerow LB, Walker SA, Ruaño G, Malik S. Contrasting ABCB1 pharmacogenetics and psychotropic responses in child and adolescent psychiatry: a case comparison. Pharmacogenomics 2023; 24:131-139. [PMID: 36727491 DOI: 10.2217/pgs-2022-0120] [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: 02/03/2023] Open
Abstract
This case comparison illustrates pharmacogenetic testing in psychotropic and clinical management in relation to the ABCB1 gene, which encodes the P-glycoprotein transporter affecting blood-brain barrier (BBB) permeability. Two pediatric patients (9 and 11 years old) were selected for similar clinical presentations with opposing ABCB1 genotype, while they were identically matched for key CYP450, dopaminergic and serotonergic genes (CYP2C9, CYP2C19, DRD2, SLC6A4, 5HTR2A). Case A was functional for the ABCB1 gene (G/G rs1045642), suggesting that the BBB had a functional P-glycoprotein transporter. Case B was subfunctional for the ABCB1 gene (A/A rs1045642), suggesting that the patient's BBB may be permeable to psychotropic drugs. Case A had more medication trials and dose adjustments than Case B. Case A had two inpatient admissions and interspersed emergency room visits, while case B had none.
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Affiliation(s)
- Pragya Kalla
- Institute of Living at Hartford Hospital, 200 Retreat Ave., Hartford, CT 06019, USA
| | - Lisa B Namerow
- Institute of Living at Hartford Hospital, 200 Retreat Ave., Hartford, CT 06019, USA.,Department of Psychiatry, University of Connecticut School of Medicine, Farmington, CT 06030, USA
| | - Sophia A Walker
- Department of Psychiatry, University of Connecticut School of Medicine, Farmington, CT 06030, USA
| | - Gualberto Ruaño
- Institute of Living at Hartford Hospital, 200 Retreat Ave., Hartford, CT 06019, USA.,Department of Psychiatry, University of Connecticut School of Medicine, Farmington, CT 06030, USA
| | - Salma Malik
- Institute of Living at Hartford Hospital, 200 Retreat Ave., Hartford, CT 06019, USA.,Department of Psychiatry, University of Connecticut School of Medicine, Farmington, CT 06030, USA
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Ghosh P, Martinez J, Shah N, Kenan W, Fowler A, Limdi N, Burns L, Cogan ES, Gardiner A, Hain D, Johnson H, Lewis D, Shelton R, Liebelt E. Pharmacogenomic Profiling of Pediatric Patients on Psychotropic Medications in an Emergency Department. Pediatr Emerg Care 2023; 39:6-12. [PMID: 36413430 PMCID: PMC9815804 DOI: 10.1097/pec.0000000000002871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the ability of a combinatorial pharmacogenomic test to predict medication blood levels and relative clinical improvements in a selected pediatric population. METHODS This study enrolled patients between ages 3 to 18 years who presented to a pediatric emergency department with acute psychiatric, behavioral, or mental health crisis and/or concerns, and had previously been prescribed psychotropic medications. Patients received combinatorial pharmacogenomic testing with medications categorized according to gene-drug interactions (GDIs); medications with a GDI were considered "incongruent," and medications without a GDI were considered "congruent." Blood levels for escitalopram, fluoxetine, aripiprazole, and clonidine were evaluated according to level of GDI. Relative clinical improvements in response to the prescribed psychotropic medications were measured using a parent-rated Clinical Global Impression of Improvement (CGI-I) assessment, where lower scores corresponded with greater improvement. RESULTS Of the 100 patients enrolled, 73% reported taking ≥1 incongruent medication. There was no significant difference in CGI-I scores between patients prescribed congruent versus incongruent medications (3.37 vs 3.68, P = 0.343). Among patients who presented for depression or suicidal ideation, those prescribed congruent medications had significantly lower CGI-I scores compared with those taking incongruent medications ( P = 0.036 for depression, P = 0.018 for suicidal ideation). There was a significant association between medication GDI and blood levels for aripiprazole (n = 15, P = 0.01) and escitalopram (n = 10, P = 0.01). CONCLUSIONS Our preliminary findings suggest that combinatorial pharmacogenomic testing can predict medication blood levels and relative outcomes based on medication congruency in children presenting to an emergency department with acute psychiatric/behavioral crises. Additional studies will be needed to confirm these findings.
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Affiliation(s)
- Pallavi Ghosh
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, The University of Alabama at Birmingham Heersink School of Medicine
| | - Jesse Martinez
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Neurobiology, The University of Alabama at Birmingham Heersink School of Medicine
| | - Nipam Shah
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, The University of Alabama at Birmingham Heersink School of Medicine
| | - Will Kenan
- Department of Biomedical and Health Sciences, The University of Alabama at Birmingham, School of Health Processions, Birmingham, AL
| | - Andrew Fowler
- Pediatric Residency Program at Arkansas Children's Hospital, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, AR
| | - Nita Limdi
- Department of Neurology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL
| | | | | | | | | | | | | | - Richard Shelton
- Department of Psychiatry, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL
| | - Erica Liebelt
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, The University of Alabama at Birmingham Heersink School of Medicine
- Department of Pediatrics, Section of Pediatric Emergency Medicine and Pharmacology and Medical Toxicology, University of Arkansas for Medical Sciences, Little Rock, AR
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Alvarado AT, Saravia M, Losno R, Pariona R, Muñoz AM, Ybañez-Julca RO, Loja B, Bendezú MR, García JA, Surco-Laos F, Laos-Anchante D, Chávez H, Aguilar P, Pineda M. CYP2D6 and CYP2C19 Genes Associated with Tricontinental and Latin American Ancestry of Pe-ruvians. DRUG METABOLISM AND BIOANALYSIS LETTERS 2022; 16:DMBL-EPUB-128245. [PMID: 36518034 PMCID: PMC10436705 DOI: 10.2174/1872312815666221213151140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/30/2022] [Accepted: 10/14/2022] [Indexed: 06/17/2023]
Abstract
Precision medicine seeks to individualize the dose from the beginning of phar-macological therapy based on the characteristics of each patient, genes involved in the metabolic phenotype, ethnicity or miscegenation, with the purpose to minimize adverse effects and optimize drug efficacy. The objective was to re-view studies that describe the association of the CYP2D6 and CYP2C19 genes with the tricontinental and Latin American ancestry of Peruvians. A biblio-graphic search was carried out in PubMed/Medline and SciELO, with various descriptors in Spanish and English. The results of this review confirm that the ethnic origin of Peruvians is triconti-nental due to European (mainly Spanish), African and Asian migration, in addi-tion to Latin American migration, being 60.2% mixed, 25.8% Amerindian, 5.9% white, 3.6% African descent, 1.2% Chinese and Japanese descent, and 3.3% unspecified. Studies on CYP2C19*3, CYP2D6*2, *3 and *6 have been reported in Peruvians, and the frequency is similar to that studied in Ecuadori-ans and Colombians. The CYP2C19*3, CYP2D6*3, and CYP2D6*6 alleles found in Peruvians are common in Europeans, Africans, and Asians; while CYP2D6*4 in Africans and CYP2D6*2 related to Asians. In some studies, the ethnic/gene association has not been demonstrated; while others have shown a significant association, which is why further investigation is warranted. It is concluded that the studies on CYP2D6 and CYP2C19 genes associated with the tricontinental and Latin American ancestry of Peruvians are little, and ac-cording to what has been investigated, the CYP2C19*3, CYP2D6*2, *3, *4 and *6 alleles have more related to their ancestry.
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Affiliation(s)
- Angel T. Alvarado
- International Research Network in Pharmacology and Precision Medicine, Human Medicine School, San Ignacio de Loyola University, USIL, Lima, 15024, Peru
- Latin American Network for the Implementation and Validation of Clinical Pharmacogenomics Guidelines (RELIVAF-CYTED), Madrid, 28001, Spain
| | - María Saravia
- International Research Network in Pharmacology and Precision Medicine, Human Medicine School, San Ignacio de Loyola University, USIL, Lima, 15024, Peru
| | - Ricardo Losno
- International Research Network in Pharmacology and Precision Medicine, Human Medicine School, San Ignacio de Loyola University, USIL, Lima, 15024, Peru
| | - Ricardo Pariona
- International Research Network in Pharmacology and Precision Medicine, Human Medicine School, San Ignacio de Loyola University, USIL, Lima, 15024, Peru
| | - Ana María Muñoz
- Institute of Food Science and Nutrition, ICAN, San Ignacio de Loyola University, USIL, Lima, 15024, Peru
| | - Roberto O. Ybañez-Julca
- Faculty of Pharmacy and Biochemistry, National University of Trujillo, Trujillo, 13001, Peru
| | - Berta Loja
- International Research Network in Pharmacology and Precision Medicine, Human Medicine School, San Ignacio de Loyola University, USIL, Lima, 15024, Peru
| | - María R. Bendezú
- Faculty of Pharmacy and Biochemistry, San Luis Gonzaga National University of Ica, Ica, 11001, Peru
| | - Jorge A. García
- Faculty of Pharmacy and Biochemistry, San Luis Gonzaga National University of Ica, Ica, 11001, Peru
| | - Felipe Surco-Laos
- Faculty of Pharmacy and Biochemistry, San Luis Gonzaga National University of Ica, Ica, 11001, Peru
| | - Doris Laos-Anchante
- Faculty of Pharmacy and Biochemistry, San Luis Gonzaga National University of Ica, Ica, 11001, Peru
| | - Haydee Chávez
- Faculty of Pharmacy and Biochemistry, San Luis Gonzaga National University of Ica, Ica, 11001, Peru
| | | | - Mario Pineda
- Pharmacy and Biochemistry, FCS, Scientific of the South University, UCSUR, Lima, 15067, Peru
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Cutuli D, Sampedro-Piquero P. BDNF and its Role in the Alcohol Abuse Initiated During Early Adolescence: Evidence from Preclinical and Clinical Studies. Curr Neuropharmacol 2022; 20:2202-2220. [PMID: 35748555 PMCID: PMC9886842 DOI: 10.2174/1570159x20666220624111855] [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: 12/19/2021] [Revised: 02/23/2022] [Accepted: 04/19/2022] [Indexed: 11/22/2022] Open
Abstract
Brain-derived neurotrophic factor (BDNF) is a crucial brain signaling protein that is integral to many signaling pathways. This neurotrophin has shown to be highly involved in brain plastic processes such as neurogenesis, synaptic plasticity, axonal growth, and neurotransmission, among others. In the first part of this review, we revise the role of BDNF in different neuroplastic processes within the central nervous system. On the other hand, its deficiency in key neural circuits is associated with the development of psychiatric disorders, including alcohol abuse disorder. Many people begin to drink alcohol during adolescence, and it seems that changes in BDNF are evident after the adolescent regularly consumes alcohol. Therefore, the second part of this manuscript addresses the involvement of BDNF during adolescent brain maturation and how this process can be negatively affected by alcohol abuse. Finally, we propose different BNDF enhancers, both behavioral and pharmacological, which should be considered in the treatment of problematic alcohol consumption initiated during the adolescence.
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Affiliation(s)
- Debora Cutuli
- Department of Psychology, Medicine and Psychology Faculty, University Sapienza of Rome, Rome, Italy; ,I.R.C.C.S. Fondazione Santa Lucia, Laboratorio di Neurofisiologia Sperimentale e del Comportamento, Via del Fosso di Fiorano 64, 00143 Roma, Italy; ,Address correspondence to these authors at the Department of Biological and Health Psychology, Psychology Faculty, Autonomous University of Madrid, Madrid, Spain, Spain and Cutuli, D. at Fondazione Santa Lucia. Laboratorio di Neurofisiologia Sperimentale e del Comportamento. Via del Fosso di Fiorano 64, 00143 Roma, Italy; E-mails: ;
| | - Piquero Sampedro-Piquero
- Department of Biological and Health Psychology, Psychology Faculty, Autonomous University of Madrid, Madrid, Spain,Address correspondence to these authors at the Department of Biological and Health Psychology, Psychology Faculty, Autonomous University of Madrid, Madrid, Spain, Spain and Cutuli, D. at Fondazione Santa Lucia. Laboratorio di Neurofisiologia Sperimentale e del Comportamento. Via del Fosso di Fiorano 64, 00143 Roma, Italy; E-mails: ;
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A Double-Blind Randomized Trial to Investigate Mechanisms of Antidepressant-Related Dysfunctional Arousal in Depressed or Anxious Youth at Familial Risk for Bipolar Disorder. J Pers Med 2022; 12:jpm12061006. [PMID: 35743790 PMCID: PMC9225632 DOI: 10.3390/jpm12061006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/11/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022] Open
Abstract
Antidepressants are standardly used to treat moderate to severe symptoms of depression and/or anxiety in youth but may also be associated with rare but serious psychiatric adverse events such as irritability, agitation, aggression, or suicidal ideation. Adverse events are especially common in youth with a family history of bipolar disorder (BD) who are at heightened risk for dysfunction in neurobiological systems that regulate emotion and arousal. To further understand this phenomenon, this study will examine (a) baseline risk factors associated with dysfunctional arousal in a sample of youth at high-risk for BD treated with or without an antidepressant, (b) whether antidepressant-related changes in arousal are mediated by changes in prefrontal-limbic circuitry, and (c) whether pharmacogenetic factors influence antidepressant-related changes in arousal. High-risk youth (aged 12-17 years with moderate to severe depressive and/or anxiety symptoms and at least one first-degree relative with bipolar I disorder) will be randomized to receive psychotherapy plus escitalopram or psychotherapy plus placebo. Neuroimaging and behavioral measures of arousal will be collected prior to randomization and at 4 weeks. Samples for pharmacogenetic analysis (serum escitalopram concentration, CYP2C19 metabolizer phenotype, and HTR2A and SLC6A4 genotypes) will be collected at 8 weeks. Youth will be followed for up to 16 weeks to assess change in arousal measures.
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Vande Voort JL, Orth SS, Shekunov J, Romanowicz M, Geske JR, Ward JA, Leibman NI, Frye MA, Croarkin PE. A Randomized Controlled Trial of Combinatorial Pharmacogenetics Testing in Adolescent Depression. J Am Acad Child Adolesc Psychiatry 2022; 61:46-55. [PMID: 34099307 PMCID: PMC9118122 DOI: 10.1016/j.jaac.2021.03.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 03/04/2021] [Accepted: 03/19/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Numerous commercial pharmacogenetics panels are now widely available for clinical use in psychiatric practice. However, there is a paucity of literature evaluating the use of combinatorial pharmacogenetics panels to enhance outcomes in the treatment of adolescents with depression. This study sought to prospectively evaluate the clinical impact of combinatorial pharmacogenetics testing in a double-blind, randomized, controlled effectiveness study for the pharmacologic treatment of adolescents with depression. METHOD Adolescents aged 13 to 18 years (N = 176) with moderate to severe major depressive disorder (MDD) were randomized to treatment arm guided by testing in which pharmacogenetic testing results were available at the baseline visit (GENE arm, n = 84) or a treatment-as-usual arm (TAU arm, n = 92) in which testing results were not available until an 8-week visit. Raters, participants, and families were blinded to group allocation. Symptom improvement, side effects, and satisfaction were assessed throughout the study at 4 weeks, 8 weeks, and 6 months. RESULTS There were no differences between the GENE and TAU arms at 8 weeks or 6 months for symptom improvement, side effect burden, or satisfaction. Selective serotonin reuptake inhibitors were prescribed at higher rates in the TAU arm compared to the GENE arm (p = .024). CONCLUSION Combinatorial pharmacogenetics-guided treatment did not demonstrate improved outcomes compared to TAU in adolescents with MDD. Future research should examine how specific medication-gene pairs may affect clinical outcomes in the treatment of adolescents with depression and how best to integrate pharmacogenetics into clinical practice. CLINICAL TRIAL REGISTRATION INFORMATION A PK/PD Genetic Variation Treatment Algorithm Versus Treatment As Usual for Adolescent Management Of Depression; https://www.clinicaltrials.gov; NCT02286440.
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12
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Strawn JR, Poweleit EA, Mills JA, Schroeder HK, Neptune ZA, Specht AM, Farrow JE, Zhang X, Martin LJ, Ramsey LB. Pharmacogenetically Guided Escitalopram Treatment for Pediatric Anxiety Disorders: Protocol for a Double-Blind Randomized Trial. J Pers Med 2021; 11:1188. [PMID: 34834540 PMCID: PMC8621124 DOI: 10.3390/jpm11111188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/26/2021] [Accepted: 11/02/2021] [Indexed: 12/23/2022] Open
Abstract
Current pharmacologic treatments for pediatric anxiety disorders (e.g., selective serotonin reuptake inhibitors (SSRIs)) frequently use "one size fits all" dosing strategies based on average responses in clinical trials. However, for some SSRIs, including escitalopram, variation in CYP2C19 activity produces substantial variation in medication exposure (i.e., blood medication concentrations). This raises an important question: would refining current SSRI dosing strategies based on CYP2C19 phenotypes increase response and reduce side effect burden? To answer this question, we designed a randomized, double-blind trial of adolescents 12-17 years of age with generalized, separation, and/or social anxiety disorders (N = 132). Patients are randomized (1:1) to standard escitalopram dosing or dosing based on validated CYP2C19 phenotypes for escitalopram metabolism. Using this approach, we will determine whether pharmacogenetically-guided treatment-compared to standard dosing-produces faster and greater reduction in anxiety symptoms (i.e., response) and improves tolerability (e.g., decreased risk of treatment-related activation and weight gain). Secondarily, we will examine pharmacodynamic variants associated with treatment outcomes, thus enhancing clinicians' ability to predict response and tolerability. Ultimately, developing a strategy to optimize dosing for individual patients could accelerate response while decreasing side effects-an immediate benefit to patients and their families. ClinicalTrials.gov Identifier: NCT04623099.
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Affiliation(s)
- Jeffrey R. Strawn
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Clinical Pharmacology, Cincinnati, OH 45219, USA;
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Child & Adolescent Psychiatry, Cincinnati, OH 45219, USA
| | - Ethan A. Poweleit
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Clinical Pharmacology, Cincinnati, OH 45219, USA;
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Child & Adolescent Psychiatry, Cincinnati, OH 45219, USA
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Biomedical Informatics, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
- Department of Biomedical Informatics, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Jeffrey A. Mills
- Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, OH 45219, USA;
| | - Heidi K. Schroeder
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
| | - Zoe A. Neptune
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
| | - Ashley M. Specht
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
| | - Jenni E. Farrow
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
| | - Xue Zhang
- Cincinnati Children’s Hospital Medical Center, Division of Human Genetics, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (X.Z.); (L.J.M.)
| | - Lisa J. Martin
- Cincinnati Children’s Hospital Medical Center, Division of Human Genetics, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (X.Z.); (L.J.M.)
| | - Laura B. Ramsey
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Clinical Pharmacology, Cincinnati, OH 45219, USA;
- Cincinnati Children’s Hospital Medical Center, Division of Research in Patient Services, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
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13
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Bis-Humbert C, García-Cabrerizo R, García-Fuster MJ. Dose-dependent opposite effects of nortriptyline on affective-like behavior in adolescent rats: Comparison with adult rats. Eur J Pharmacol 2021; 910:174465. [PMID: 34464602 DOI: 10.1016/j.ejphar.2021.174465] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/27/2021] [Accepted: 08/27/2021] [Indexed: 11/19/2022]
Abstract
Antidepressant drugs elicit different behavioral and neurochemical responses with age. In fact, the use of antidepressants during adolescence is associated with an increased risk of suicidal thinking, being the best pharmacological treatment during this critical period a matter of constant debate in terms of its risk-benefit outcome. In this regard, the present study compared the effects of nortriptyline (3-10 mg/kg, 7 days) on regulating different aspects of affective-like behavior by screening adolescent and adult Sprague-Dawley rats through several consecutive tests (forced-swim, open field, sucrose preference). Brains were later collected to evaluate hippocampal neurogenesis and mBDNF protein content as potential molecular correlates of the observed behavioral responses. The main results in adolescent rats showed that nortriptyline induced dose-dependent opposite effects: while 3 mg/kg decreased immobility and increased mBDNF (indicative of an antidepressant-like response), 10 mg/kg decreased exploratory time in the open field and mBDNF (suggestive of an anxiogenic-like response). These effects were not associated with changes in neurogenesis regulation. In adult rats, nortriptyline failed to modulate affective-like behavior or the neuroplasticity markers evaluated at the doses tested. In conclusion, clear behavioral and neurochemical differences were observed between adolescent and adult rats in response to nortriptyline treatment. Interestingly, while nortriptyline displayed an antidepressant-like potential at the lowest dose examined in adolescence, a higher dose shifted these results towards a negative outcome, thus reinforcing the need to extreme caution when considering this treatment for our younger population.
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Affiliation(s)
- Cristian Bis-Humbert
- IUNICS, University of the Balearic Islands, Palma, Spain; Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
| | - Rubén García-Cabrerizo
- IUNICS, University of the Balearic Islands, Palma, Spain; Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
| | - M Julia García-Fuster
- IUNICS, University of the Balearic Islands, Palma, Spain; Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain.
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Gårdvik KS, Rygg M, Torgersen T, Wallander JL, Lydersen S, Indredavik MS. Association of treatment procedures and resilience to symptom load three-years later in a clinical sample of adolescent psychiatric patients. BMC Psychiatry 2021; 21:411. [PMID: 34412609 PMCID: PMC8377856 DOI: 10.1186/s12888-021-03417-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to examine symptom load in a clinical adolescent population at three-year follow-up and explore associations with standard care treatment procedures and resilience factors upon first presenting at Child and Adolescent Mental Health Services. METHODS This study is part of a prospective longitudinal cohort study: The Health Survey in Department of Children and Youth, St. Olavs hospital, Norway. A clinical population of 717 (43.5% of eligible) adolescents aged 13-18 years participated in the first study visit (T1, 2009-2011). Of these, 447 adolescents with psychiatric disorders, with treatment history from medical records and self-reported resilience factors (Resilience Scale for Adolescents; READ) at T1, reported symptom load (Achenbach System of Empirically Based Assessment - Youth Self Report; YSR) three years later aged 16-21 years (T2). RESULT At T1, 93.0% received individual treatment. The frequency of psychotherapy and medication varied by disorder group and between genders. Overall, psychotherapy was more frequent among girls, whereas medication was more common among boys. Total READ mean value (overall 3.5, SD 0.8), ranged from patients with mood disorders (3.0, SD 0.7) to patients with Attention Deficit Hyperactivity disorder (3.7, SD 0.7), and was lower for girls than boys in all diagnostic groups. At T2, the YSR Total Problem mean T-score ranged across the diagnostic groups (48.7, SD 24.0 to 62.7, SD 30.2), with highest symptom scores for those with mood disorders at T1, of whom 48.6% had T-scores in the borderline/clinical range (≥60) three years later. Number of psychotherapy sessions was positively associated and Total READ score was negatively associated with the YSR Total Problems T-score (regression coefficient β = 0.5, CI (0.3 to 0.7), p < 0.001 and β = - 15.7, CI (- 19.2 to - 12.1), p < 0.001, respectively). The subscale Personal Competence was associated with the lowest Total Problem score for both genders. CONCLUSIONS Self-reported symptom load was substantial after three years, despite comprehensive treatment procedures. Higher self-reported resilience characteristics were associated with lower symptom load after three years. These results highlight the burden of adolescent psychiatric disorders, the need for extensive interventions and the importance of resilience factors for a positive outcome.
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Affiliation(s)
- Kari Skulstad Gårdvik
- Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway. .,Department of Children and Youth, Clinic of Mental Health Care, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Marite Rygg
- grid.5947.f0000 0001 1516 2393Department of Clinical and Molecular Medicine (IKOM), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway ,grid.52522.320000 0004 0627 3560Department of Pediatrics, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Terje Torgersen
- grid.52522.320000 0004 0627 3560Orkdal District Psychiatric Centre, Clinic of Mental Health Care, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway ,grid.5947.f0000 0001 1516 2393Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jan Lance Wallander
- grid.5947.f0000 0001 1516 2393Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway ,grid.266096.d0000 0001 0049 1282Psychological Sciences and Health Sciences Research Institute, University of California, Merced, USA
| | - Stian Lydersen
- grid.5947.f0000 0001 1516 2393Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Marit Sæbø Indredavik
- grid.5947.f0000 0001 1516 2393Department of Clinical and Molecular Medicine (IKOM), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
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15
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Affiliation(s)
- Leslie Miller
- From the Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine (L.M., J.V.C.), and the Kennedy Krieger Institute (J.V.C.) - both in Baltimore
| | - John V Campo
- From the Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine (L.M., J.V.C.), and the Kennedy Krieger Institute (J.V.C.) - both in Baltimore
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16
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The Utility of Pharmacogenetic-Guided Psychotropic Medication Selection for Pediatric Patients: A Retrospective Study. Pediatr Rep 2021; 13:421-433. [PMID: 34449718 PMCID: PMC8396342 DOI: 10.3390/pediatric13030049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/12/2021] [Accepted: 07/20/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND To describe trends and clinical experiences in applying commercial pharmacogenetic testing among pediatric patients with neuropsychiatric disorders. METHODS Demographic and clinical data of patients receiving GeneSight® testing from January 2015 to November 2016 at an urban pediatric hospital were retrospectively extracted from medical charts. Outcome data included pharmacogenetic test results and medication prescriptions before and after the test. RESULTS A total of 450 patients (12.1 ± 4.3 years) diagnosed with anxiety disorder, attention deficit hyperactivity disorder, developmental disorders including autism, and/or a mood disorder received testing, and 435 of them were prescribed medications. Comparing data before and after testing, the total number of psychotropic prescriptions were reduced by 27.2% and the number of prescribed medications with severe gene-drug interactions decreased from 165 to 95 (11.4% to 8.9% of total medications prescribed). Approximately 40% of actionable genetic annotation were related to CYP2CD6 and CYP2C19. Patients of Asian descent had significantly higher likelihood than other races of being classified as poor to intermediate metabolizers of antidepressants, mood stabilizers, and antipsychotics (p = 0.008, 0.007, and 0.001, respectively). Diagnoses, including autism spectrum disorder, were not associated with increased risks of severe gene-drug interactions. CONCLUSIONS Pharmacogenetic testing in child and adolescent psychiatry is currently based on few clinically actionable genes validated by CPIC and/or FDA. Although this approach can be moderately utilized to guide psychotropic medication prescribing for pediatric patients with psychiatric disorders, clinicians should cautiously interpret test results while still relying on clinical experience and judgment to direct the final selection of medication.
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17
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Vaughn SE, Strawn JR, Poweleit EA, Sarangdhar M, Ramsey LB. The Impact of Marijuana on Antidepressant Treatment in Adolescents: Clinical and Pharmacologic Considerations. J Pers Med 2021; 11:jpm11070615. [PMID: 34209709 PMCID: PMC8307883 DOI: 10.3390/jpm11070615] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 12/12/2022] Open
Abstract
The neuropharmacology of marijuana, including its effects on selective serotonin reuptake inhibitor (SSRI)/antidepressant metabolism and the subsequent response and tolerability in youth, has received limited attention. We sought to (1) review clinically relevant pharmacokinetic (PK) and pharmacodynamic (PD) interactions between cannabinoids and selected SSRIs, (2) use PK models to examine the impact of cannabinoids on SSRI exposure (area under curve (AUC)) and maximum concentration (CMAX) in adolescents, and (3) examine the frequency of adverse events reported when SSRIs and cannabinoids are used concomitantly. Cannabinoid metabolism, interactions with SSRIs, impact on relevant PK/PD pathways and known drug–drug interactions were reviewed. Then, the impact of tetrahydrocannabinol (THC) and cannabidiol (CBD) on exposure (AUC24) and CMAX for escitalopram and sertraline was modeled using pediatric PK data. Using data from the Food and Drug Administration Adverse Events Reporting System (FAERS), the relationship between CBD and CYP2C19-metabolized SSRIs and side effects was examined. Cannabis and CBD inhibit cytochrome activity, alter serotonergic transmission, and modulate SSRI response. In PK models, CBD and/or THC increases sertraline and es/citalopram concentrations in adolescents, and coadministration of CBD and CYP2C19-metabolized SSRIs increases the risk of cough, diarrhea, dizziness, and fatigue. Given the significant SSRI–cannabinoid interactions, clinicians should discuss THC and CBD use in youth prescribed SSRIs and be aware of the impact of initiating, stopping, or decreasing cannabinoid use as this may significantly affect es/citalopram and sertraline exposure.
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Affiliation(s)
- Samuel E. Vaughn
- Division of Child and Adolescent Psychiatry, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA;
- Correspondence: ; Tel.: +1-513-636-4788
| | - Jeffrey R. Strawn
- Division of Child and Adolescent Psychiatry, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA;
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA;
| | - Ethan A. Poweleit
- Division of Biomedical Informatics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (E.A.P.); (M.S.)
- Division of Research in Patient Services, Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Mayur Sarangdhar
- Division of Biomedical Informatics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (E.A.P.); (M.S.)
- Department of Biomedical Informatics, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Laura B. Ramsey
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA;
- Division of Research in Patient Services, Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA
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18
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Zanardi R, Manfredi E, Montrasio C, Colombo C, Serretti A, Fabbri C. Pharmacogenetic-Guided Treatment of Depression: Real-World Clinical Applications, Challenges, and Perspectives. Clin Pharmacol Ther 2021; 110:573-581. [PMID: 34047355 DOI: 10.1002/cpt.2315] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 05/20/2021] [Indexed: 12/12/2022]
Abstract
Depression is a leading cause of disability worldwide and, despite the availability of numerous antidepressants, the lack of standardized criteria to apply personalized prescription is still a major issue. Pharmacogenetic (PGx) markers in cytochrome P450 (CYP450) genes are already usable to guide antidepressant choice/titration according to clinical guidelines; they are an important step toward personalized psychiatry as they can reduce the time to identify an effective and tolerated treatment. Clinical application is still limited due to the financial and organizational challenges, but the number of services providing genotyping of pharmacogenes is increasing, with encouraging projections of cost-effectiveness. Critical aspects that emerged from the available studies are the importance of integration of genotyping results in electronic medical records, standardization, and regular updates of decision support systems, training and collaboration of different professionals, need of longer follow-ups to estimate cost-effectiveness, and importance of avoiding inequalities in access to genotyping. Diversities exist among the groups of patients to whom genotyping is offered (pre-emptive or reactive testing) and the type of clinical services (e.g., hospitals and primary care), currently without a consensus on which is the best approach. Future studies should aim to clarify these issues, as well as consider and compare PGx applications among different countries and healthcare systems. Finally, the extension of genotyping outside pharmacokinetic genes should be considered as a key step to improve the clinical impact of PGx, as this could significantly increase the variance explained in treatment outcomes.
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Affiliation(s)
- Raffaella Zanardi
- Department of Clinical Neurosciences, Mood Disorder Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Department of Clinical Neurosciences, University Vita-Salute San Raffaele, Milan, Italy
| | - Elena Manfredi
- Department of Clinical Neurosciences, University Vita-Salute San Raffaele, Milan, Italy
| | - Cristina Montrasio
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Cristina Colombo
- Department of Clinical Neurosciences, Mood Disorder Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Department of Clinical Neurosciences, University Vita-Salute San Raffaele, Milan, Italy
| | - Alessandro Serretti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Chiara Fabbri
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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19
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Lara DVD, Melo DOD, Silva RAM, Santos PCJLD. Pharmacogenetic testing in psychiatry and neurology: an overview of reviews. Pharmacogenomics 2021; 22:505-513. [PMID: 33973477 DOI: 10.2217/pgs-2020-0187] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Pharmacogenetic testing is available to healthcare professionals to guide drug selection and prevent adverse events. However, its implementation in the clinical practice of psychiatry/neurology still has barriers, mainly due to a lack of evidence. We conducted a literature search on Cochrane Library, Embase and Pubmed, from their inception to 18 June 2020. We included 16 published systematic reviews. The most studied drug categories were anticonvulsants and selective serotonin reuptake inhibitors associated with human leukocyte antigen and cytochrome P450 genes (HLA-A, HLA-B, CYP2C9, CYP2D6, CYP2C19), classified as critically low quality/low quality. There is a need for more robust studies with adequate design to assess the potential benefits of adopting pharmacogenetics in health systems and services.
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Affiliation(s)
- Danilo Vieira de Lara
- Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Daniela Oliveira de Melo
- Department of Pharmaceutical Sciences, Institute of Environmental Sciences, Chemistry and Pharmaceuticals, Universidade Federal de São Paulo, Diadema, São Paulo, Brazil
| | - Rafael Augusto Mantovani Silva
- Department of Pharmaceutical Sciences, Institute of Environmental Sciences, Chemistry and Pharmaceuticals, Universidade Federal de São Paulo, Diadema, São Paulo, Brazil
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20
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Claudio-Campos K, Padrón A, Jerkins G, Nainaparampil J, Nelson R, Martin A, Wiisanen K, Smith DM, Strekalova Y, Marsiske M, Cicali EJ, Cavallari LH, Mathews CA. Acceptability, Feasibility, and Utility of Integrating Pharmacogenetic Testing into a Child Psychiatry Clinic. Clin Transl Sci 2020; 14:589-598. [PMID: 33166056 PMCID: PMC7993320 DOI: 10.1111/cts.12914] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/06/2020] [Indexed: 12/16/2022] Open
Abstract
Pharmacogenetic (PGx) testing is a tool to identify patients at a higher risk of adverse events or treatment failure. The concern for unwanted side effects can limit medication adherence, particularly in children and adolescents. We conducted a pragmatic study to evaluate the acceptability and feasibility and gather pilot data on the utility of PGx testing in a child and adolescent psychiatry clinic. Both physicians and families participated in the study and answered pre‐survey and post‐survey questionnaires to examine their attitudes toward PGx testing. Patients were randomized into implementation (N = 25) and control groups (N = 24) and underwent PGx testing at the beginning or end of the study, respectively. Clinical consult notes with genotype‐guided recommendations were provided to physicians for their consideration in clinical decisions. Patient‐reported symptom severity and antidepressant‐related side effects were assessed at baseline and for 12 weeks. Both participating physicians and families agreed that PGx testing is a useful tool to improve medication selection. The time from sample collection to having PGx test results was ~ 10 days and 15 days to having consult notes available, which may have impaired test utility in clinical decision making. There were no differences in any clinical end point between the implementation and control arms; however, there were higher antidepressant side effect scores for CYP2D6 poor and intermediate metabolizers after the eighth week of treatment. Our findings revealed benefits and pitfalls with the use of PGx testing in the real‐world clinical setting, which may inform the methodology of a larger trial focused on outcomes.
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Affiliation(s)
- Karla Claudio-Campos
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Adaixa Padrón
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
| | - Gabriel Jerkins
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jaison Nainaparampil
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Department of Psychiatry, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Robyn Nelson
- Department of Psychiatry, College of Medicine, Center for OCD, Anxiety, and Related Disorders, University of Florida, Gainesville, Florida, USA
| | - Anna Martin
- Department of Psychiatry, College of Medicine, Center for OCD, Anxiety, and Related Disorders, University of Florida, Gainesville, Florida, USA
| | - Kristin Wiisanen
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | | | - Yulia Strekalova
- College of Journalism and Communications, University of Florida, Gainesville, Florida, USA
| | - Michael Marsiske
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
| | - Emily J Cicali
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Carol A Mathews
- Department of Psychiatry, College of Medicine, Center for OCD, Anxiety, and Related Disorders, University of Florida, Gainesville, Florida, USA
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21
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Du D, Tang Q, Han Q, Zhang J, Liang X, Tan Y, Liu K, Xiang B. Association between genetic polymorphism and antidepressants in major depression: a network meta-analysis. Pharmacogenomics 2020; 21:963-974. [PMID: 32819202 DOI: 10.2217/pgs-2020-0037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This network meta-analysis was conducted to compare the predictive value of eight SNPs on the efficacy of antidepressants in major depressive disorder (MDD), including 5-HTTLPR, 5HTR2A (rs6311, rs6314, rs7997012 and rs6313), 5HTR2A (rs6295), BDNF (rs6265) and 5HTTSTin2. Databases were searched for related studies published up to December 2019. A total of 16 studies were included in this study. The predictive value were evaluated by the use of the odd ratios (OR) and drawing surface under the cumulative ranking curves (SUCRA). The pairwise meta-analysis indicated that in terms of overall response ratio, the SNPs were not associated with the efficacy of antidepressants in MDD. The result of this network meta-analysis suggested that there was no significant difference in predictive value of eight SNPs on the efficacy of antidepressants in MDD. More research is needed to explore the relationship between SNPs and antidepressant response.
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Affiliation(s)
- Dan Du
- Department of Psychiatry, Laboratory of Neurological Diseases & Brain Function, Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan Province, China
| | - Qiong Tang
- Department of Psychiatry, Laboratory of Neurological Diseases & Brain Function, Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan Province, China
| | - Qiong Han
- Department of Breast Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan Province, China
| | - Jin Zhang
- Department of Psychiatry, Laboratory of Neurological Diseases & Brain Function, Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan Province, China.,Zigong Mental Health Research Center & Institute on Aging at Zigong, Zigong, 643020, Sichuan Province, China
| | - Xuemei Liang
- Geriatrics Department, Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan Province, China
| | - Youguo Tan
- Zigong Mental Health Center, Zigong, 643020, Sichuan Province, China.,Zigong Mental Health Research Center & Institute on Aging at Zigong, Zigong, 643020, Sichuan Province, China
| | - Kezhi Liu
- Department of Psychiatry, Laboratory of Neurological Diseases & Brain Function, Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan Province, China
| | - Bo Xiang
- Department of Psychiatry, Laboratory of Neurological Diseases & Brain Function, Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan Province, China.,Zigong Mental Health Research Center & Institute on Aging at Zigong, Zigong, 643020, Sichuan Province, China
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22
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Fortinguerra S, Sorrenti V, Giusti P, Zusso M, Buriani A. Pharmacogenomic Characterization in Bipolar Spectrum Disorders. Pharmaceutics 2019; 12:E13. [PMID: 31877761 PMCID: PMC7022469 DOI: 10.3390/pharmaceutics12010013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/14/2019] [Accepted: 12/19/2019] [Indexed: 12/15/2022] Open
Abstract
The holistic approach of personalized medicine, merging clinical and molecular characteristics to tailor the diagnostic and therapeutic path to each individual, is steadily spreading in clinical practice. Psychiatric disorders represent one of the most difficult diagnostic challenges, given their frequent mixed nature and intrinsic variability, as in bipolar disorders and depression. Patients misdiagnosed as depressed are often initially prescribed serotonergic antidepressants, a treatment that can exacerbate a previously unrecognized bipolar condition. Thanks to the use of the patient's genomic profile, it is possible to recognize such risk and at the same time characterize specific genetic assets specifically associated with bipolar spectrum disorder, as well as with the individual response to the various therapeutic options. This provides the basis for molecular diagnosis and the definition of pharmacogenomic profiles, thus guiding therapeutic choices and allowing a safer and more effective use of psychotropic drugs. Here, we report the pharmacogenomics state of the art in bipolar disorders and suggest an algorithm for therapeutic regimen choice.
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Affiliation(s)
- Stefano Fortinguerra
- Maria Paola Belloni Center for Personalized Medicine, Data Medica Group (Synlab Limited), 35131 Padova, Italy; (S.F.); (V.S.)
- Department of Pharmaceutical & Pharmacological Sciences, University of Padova, 35131 Padova, Italy; (P.G.); (M.Z.)
| | - Vincenzo Sorrenti
- Maria Paola Belloni Center for Personalized Medicine, Data Medica Group (Synlab Limited), 35131 Padova, Italy; (S.F.); (V.S.)
- Department of Pharmaceutical & Pharmacological Sciences, University of Padova, 35131 Padova, Italy; (P.G.); (M.Z.)
- Bendessere™ Study Center, Solgar Italia Multinutrient S.p.A., 35131 Padova, Italy
| | - Pietro Giusti
- Department of Pharmaceutical & Pharmacological Sciences, University of Padova, 35131 Padova, Italy; (P.G.); (M.Z.)
| | - Morena Zusso
- Department of Pharmaceutical & Pharmacological Sciences, University of Padova, 35131 Padova, Italy; (P.G.); (M.Z.)
| | - Alessandro Buriani
- Maria Paola Belloni Center for Personalized Medicine, Data Medica Group (Synlab Limited), 35131 Padova, Italy; (S.F.); (V.S.)
- Department of Pharmaceutical & Pharmacological Sciences, University of Padova, 35131 Padova, Italy; (P.G.); (M.Z.)
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23
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Haga SB. Pharmacogenomic Testing In Pediatrics: Navigating The Ethical, Social, And Legal Challenges. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2019; 12:273-285. [PMID: 31686893 PMCID: PMC6800463 DOI: 10.2147/pgpm.s179172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 09/12/2019] [Indexed: 12/17/2022]
Abstract
For the past several years, the implementation of pharmacogenetic (PGx) testing has become widespread in several centers and clinical practice settings. PGx testing may be ordered at the point-of-care when treatment is needed or in advance of treatment for future use. The potential benefits of PGx testing are not limited to adult patients, as children are increasingly using medications more often and at earlier ages. This review provides some background on the use of PGx testing in children as well as mothers (prenatally and post-natally) and discusses the challenges, benefits, and the ethical, legal, and social implications of providing PGx testing to children.
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Affiliation(s)
- Susanne B Haga
- Department of Medicine, Division of General Internal Medicine, Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, 27708, USA
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24
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Moretti M, Freni F, Valentini B, Vignali C, Groppi A, Visonà SD, Osculati AMM, Morini L. Determination of Antidepressants and Antipsychotics in Dried Blood Spots (DBSs) Collected from Post-Mortem Samples and Evaluation of the Stability over a Three-Month Period. Molecules 2019; 24:molecules24203636. [PMID: 31600953 PMCID: PMC6832719 DOI: 10.3390/molecules24203636] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 10/04/2019] [Accepted: 10/06/2019] [Indexed: 01/17/2023] Open
Abstract
An LC-MS/MS method for the identification and quantification of antidepressants and antipsychotics was developed on dried blood spots (DBSs). Moreover, analyte stability on DBSs within a 3-month period was monitored. Aliquots of 85 µL of blood from autopsy cases were pipetted onto DBS cards, which were dried and stored at room temperature. DBSs were analyzed in triplicate immediately, within the following 3 weeks, and after 3 months. For each analysis, a whole blood stain was extracted in phosphate buffer and purified using Solid Phase Extraction (SPE) cartridges in order to avoid matrix effects and injected in the LC-MS/MS system. Thirty-nine molecules were screened. Limits of detection (LODs) ranged between 0.1 and 3.2 ng/mL (g) and 0.1 and 5.2 ng/mL (g) for antidepressants and antipsychotics, respectively. Limits of quantification (LOQs) varied from 5 to 10.0 ng/mL for both. Sixteen cases among the 60 analyzed resulted positive for 17 different analytes; for 14 of these the method was fully validated. A general good agreement between the concentrations on DBSs and those measured in conventional blood samples (collected concurrently and stored at -20 °C) was observed. The degradation/enhancement percentage for most of the substances was lower than 20% within the 3-month period. Our results, obtained from real post-mortem cases, suggest that DBSs can be used for routine sample storage.
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Affiliation(s)
- Matteo Moretti
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, via Forlanini 12, 27100 Pavia, Italy.
| | - Francesca Freni
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, via Forlanini 12, 27100 Pavia, Italy.
| | - Beatrice Valentini
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, via Forlanini 12, 27100 Pavia, Italy.
| | - Claudia Vignali
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, via Forlanini 12, 27100 Pavia, Italy.
| | - Angelo Groppi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, via Forlanini 12, 27100 Pavia, Italy.
| | - Silvia Damiana Visonà
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, via Forlanini 12, 27100 Pavia, Italy.
| | - Antonio Marco Maria Osculati
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, via Forlanini 12, 27100 Pavia, Italy.
| | - Luca Morini
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, via Forlanini 12, 27100 Pavia, Italy.
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25
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Ramsey LB, Bishop JR, Strawn JR. Pharmacogenetics of treating pediatric anxiety and depression. Pharmacogenomics 2019; 20:867-870. [DOI: 10.2217/pgs-2019-0088] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Laura B Ramsey
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
- Divisions of Research in Patient Services & Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Jeffrey R Bishop
- Department of Experimental & Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN 55455, USA
- Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Jeffrey R Strawn
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH 452196, USA
- Department of Pediatrics, Division of Child & Adolescent Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45219, USA
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