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Poweleit EA, Vaughn SE, Desta Z, Dexheimer JW, Strawn JR, Ramsey LB. Machine Learning-Based Prediction of Escitalopram and Sertraline Side Effects With Pharmacokinetic Data in Children and Adolescents. Clin Pharmacol Ther 2024; 115:860-870. [PMID: 38297828 PMCID: PMC11046530 DOI: 10.1002/cpt.3184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 01/04/2024] [Indexed: 02/02/2024]
Abstract
Selective serotonin reuptake inhibitors (SSRI) are the first-line pharmacologic treatment for anxiety and depressive disorders in children and adolescents. Many patients experience side effects that are difficult to predict, are associated with significant morbidity, and can lead to treatment discontinuation. Variation in SSRI pharmacokinetics could explain differences in treatment outcomes, but this is often overlooked as a contributing factor to SSRI tolerability. This study evaluated data from 288 escitalopram-treated and 255 sertraline-treated patients ≤ 18 years old to develop machine learning models to predict side effects using electronic health record data and Bayesian estimated pharmacokinetic parameters. Trained on a combined cohort of escitalopram- and sertraline-treated patients, a penalized logistic regression model achieved an area under the receiver operating characteristic curve (AUROC) of 0.77 (95% confidence interval (CI): 0.66-0.88), with 0.69 sensitivity (95% CI: 0.54-0.86), and 0.82 specificity (95% CI: 0.72-0.87). Medication exposure, clearance, and time since the last dose increase were among the top features. Individual escitalopram and sertraline models yielded an AUROC of 0.73 (95% CI: 0.65-0.81) and 0.64 (95% CI: 0.55-0.73), respectively. Post hoc analysis showed sertraline-treated patients with activation side effects had slower clearance (P = 0.01), which attenuated after accounting for age (P = 0.055). These findings raise the possibility that a machine learning approach leveraging pharmacokinetic data can predict escitalopram- and sertraline-related side effects. Clinicians may consider differences in medication pharmacokinetics, especially during dose titration and as opposed to relying on dose, when managing side effects. With further validation, application of this model to predict side effects may enhance SSRI precision dosing strategies in youth.
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Affiliation(s)
- Ethan A. Poweleit
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Biomedical Informatics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
- Division of Research in Patient Services, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Samuel E. Vaughn
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH
- Division of Child and Adolescent Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Indiana University, School of Medicine, Indianapolis, IN
| | - Judith W. Dexheimer
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Jeffrey R. Strawn
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH
- Division of Child and Adolescent Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Laura B. Ramsey
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children’s Mercy Kansas City, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
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Zhou Y, Lauschke VM. Next-generation sequencing in pharmacogenomics - fit for clinical decision support? Expert Rev Clin Pharmacol 2024; 17:213-223. [PMID: 38247431 DOI: 10.1080/17512433.2024.2307418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/16/2024] [Indexed: 01/23/2024]
Abstract
INTRODUCTION The technological advances of sequencing methods during the past 20 years have fuelled the generation of large amounts of sequencing data that comprise common variations, as well as millions of rare and personal variants that would not be identified by conventional genotyping. While comprehensive sequencing is technically feasible, its clinical utility for guiding personalized treatment decisions remains controversial. AREAS COVERED We discuss the opportunities and challenges of comprehensive sequencing compared to targeted genotyping for pharmacogenomic applications. Current pharmacogenomic sequencing panels are heterogeneous and clinical actionability of the included genes is not a major focus. We provide a current overview and critical discussion of how current studies utilize sequencing data either retrospectively from biobanks, databases or repurposed diagnostic sequencing, or prospectively using pharmacogenomic sequencing. EXPERT OPINION While sequencing-based pharmacogenomics has provided important insights into genetic variations underlying the safety and efficacy of a multitude pharmacological treatments, important hurdles for the clinical implementation of pharmacogenomic sequencing remain. We identify gaps in the interpretation of pharmacogenetic variants, technical challenges pertaining to complex loci and variant phasing, as well as unclear cost-effectiveness and incomplete reimbursement. It is critical to address these challenges in order to realize the promising prospects of pharmacogenomic sequencing.
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Affiliation(s)
- Yitian Zhou
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Volker M Lauschke
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University of Tübingen, Tübingen, Germany
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Fu R, Yu Z, Zhou C, Zhang J, Gao F, Wang D, Hao X, Pang X, Yu J. Artificial intelligence-based model for dose prediction of sertraline in adolescents: a real-world study. Expert Rev Clin Pharmacol 2024; 17:177-187. [PMID: 38197873 DOI: 10.1080/17512433.2024.2304009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 01/08/2024] [Indexed: 01/11/2024]
Abstract
BACKGROUND Variability exists in sertraline pharmacokinetic parameters in individuals, especially obvious in adolescents. We aimed to establish an individualized dosing model of sertraline for adolescents with depression based on artificial intelligence (AI) techniques. METHODS Data were collected from 258 adolescent patients treated at the First Hospital of Hebei Medical University between December 2019 to July 2022. Nine different algorithms were used for modeling to compare the prediction abilities on sertraline daily dose, including XGBoost, LGBM, CatBoost, GBDT, SVM, ANN, TabNet, KNN, and DT. Performance of four dose subgroups (50 mg, 100 mg, 150 mg, and 200 mg) were analyzed. RESULTS CatBoost was chosen to establish the individualized medication model with the best performance. Six important variables were found to be correlated with sertraline dose, including plasma concentration, PLT, MPV, GL, A/G, and LDH. The ROC curve and confusion matrix exhibited the good prediction performance of CatBoost model in four dose subgroups (the AUC of 50 mg, 100 mg, 150 mg, and 200 mg were 0.93, 0.81, 0.93, and 0.93, respectively). CONCLUSION The AI-based dose prediction model of sertraline in adolescents with depression had a good prediction ability, which provides guidance for clinicians to propose the optimal medication regimen.
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Affiliation(s)
- Ran Fu
- Department of Clinical Pharmacy, The First Hospital of Hebei Medical University, Shijiazhuang, China
- The Technology Innovation Center for Artificial Intelligence in Clinical Pharmacy of Hebei Province, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ze Yu
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Beijing Medicinovo Technology Co., Ltd, Beijing, China
| | - Chunhua Zhou
- Department of Clinical Pharmacy, The First Hospital of Hebei Medical University, Shijiazhuang, China
- The Technology Innovation Center for Artificial Intelligence in Clinical Pharmacy of Hebei Province, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jinyuan Zhang
- Beijing Medicinovo Technology Co., Ltd, Beijing, China
| | - Fei Gao
- Beijing Medicinovo Technology Co., Ltd, Beijing, China
| | - Donghan Wang
- Department of Clinical Pharmacy, The First Hospital of Hebei Medical University, Shijiazhuang, China
- The Technology Innovation Center for Artificial Intelligence in Clinical Pharmacy of Hebei Province, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xin Hao
- Dalian Medicinovo Technology Co., Ltd, Dalian, China
| | - Xiaolu Pang
- Department of Physical Diagnostics, Hebei Medical University, Shijiazhuang, China
| | - Jing Yu
- Department of Clinical Pharmacy, The First Hospital of Hebei Medical University, Shijiazhuang, China
- The Technology Innovation Center for Artificial Intelligence in Clinical Pharmacy of Hebei Province, The First Hospital of Hebei Medical University, Shijiazhuang, China
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Poweleit EA, Taylor ZL, Mizuno T, Vaughn SE, Desta Z, Strawn JR, Ramsey LB. Escitalopram and Sertraline Population Pharmacokinetic Analysis in Pediatric Patients. Clin Pharmacokinet 2023; 62:1621-1637. [PMID: 37755681 PMCID: PMC11003701 DOI: 10.1007/s40262-023-01294-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND AND OBJECTIVE Escitalopram and sertraline are commonly prescribed for anxiety and depressive disorders in children and adolescents. The pharmacokinetics (PK) of these medications have been evaluated in adults and demonstrate extensive variability, but studies in pediatric patients are limited. Therefore, we performed a population PK analysis for escitalopram and sertraline in children and adolescents to characterize the effects of demographic, clinical, and pharmacogenetic factors on drug exposure. METHODS A PK dataset was generated by extracting data from the electronic health record and opportunistic sampling of escitalopram- and sertraline-treated psychiatrically hospitalized pediatric patients aged 5-18 years. A population PK analysis of escitalopram and sertraline was performed using NONMEM. Concentration-time profiles were simulated using MwPharm++ to evaluate how covariates included in the final models influence medication exposure and compared to adult therapeutic reference ranges. RESULTS The final escitalopram cohort consisted of 315 samples from 288 patients, and the sertraline cohort consisted of 265 samples from 255 patients. A one-compartment model with a proportional residual error model best described the data for both medications. For escitalopram, CYP2C19 phenotype and concomitant CYP2C19 inhibitors affected apparent clearance (CL/F), and normalizing CL/F and apparent volume of distribution (V/F) to body surface area (BSA) improved estimations. The final escitalopram model estimated CL/F and V/F at 14.2 L/h/1.73 m2 and 428 L/1.73 m2, respectively. For sertraline, CYP2C19 phenotype and concomitant CYP2C19 inhibitors influenced CL/F, and empirical allometric scaling of patient body weight on CL/F and V/F was significant. The final sertraline model estimated CL/F and V/F at 124 L/h/70 kg and 4320 L/70 kg, respectively. Normalized trough concentrations (Ctrough) for CYP2C19 poor metabolizers taking escitalopram were 3.98-fold higher compared to normal metabolizers (151.1 ng/mL vs 38.0 ng/mL, p < 0.0001), and normalized Ctrough for CYP2C19 poor metabolizers taking sertraline were 3.23-fold higher compared to normal, rapid, and ultrarapid metabolizers combined (121.7 ng/mL vs 37.68 ng/mL, p < 0.0001). Escitalopram- and sertraline-treated poor metabolizers may benefit from a dose reduction of 50-75% and 25-50%, respectively, to normalize exposure to other phenotypes. CONCLUSION To our knowledge, this is the largest population PK analysis of escitalopram and sertraline in pediatric patients. Significant PK variability for both medications was observed and was largely explained by CYP2C19 phenotype. Slower CYP2C19 metabolizers taking escitalopram or sertraline may benefit from dose reductions given increased exposure.
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Affiliation(s)
- Ethan A Poweleit
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Biomedical Informatics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Research in Patient Services, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH, 45229, USA
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Zachary L Taylor
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Samuel E Vaughn
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Jeffrey R Strawn
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Clinical Pharmacology, School of Medicine, Indiana University, Indianapolis, IN, USA
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Laura B Ramsey
- Division of Research in Patient Services, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH, 45229, USA.
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.
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Wong WLE, Fabbri C, Laplace B, Li D, van Westrhenen R, Lewis CM, Dawe GS, Young AH. The Effects of CYP2C19 Genotype on Proxies of SSRI Antidepressant Response in the UK Biobank. Pharmaceuticals (Basel) 2023; 16:1277. [PMID: 37765085 PMCID: PMC10535191 DOI: 10.3390/ph16091277] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/03/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Selective serotonin reuptake inhibitors (SSRIs) are the most commonly used psychopharmaceutical treatment for major depressive disorder (MDD), but individual responses to SSRIs vary greatly. CYP2C19 is a key enzyme involved in the metabolism of several drugs, including SSRIs. Variations in the CYP2C19 gene are associated with differential metabolic activity, and thus differential SSRI exposure; accordingly, the CYP2C19 genotype may affect the therapeutic response and clinical outcomes, though existing evidence of this link is not entirely consistent. Therefore, we analysed data from the UK Biobank, a large, deeply phenotyped prospective study, to investigate the effects of CYP2C19 metaboliser phenotypes on several clinical outcomes derived from primary care records, including multiple measures of antidepressant switching, discontinuation, duration, and side effects. In this dataset, 24,729 individuals were prescribed citalopram, 3012 individuals were prescribed escitalopram, and 12,544 individuals were prescribed sertraline. Consistent with pharmacological expectations, CYP2C19 poor metabolisers on escitalopram were more likely to switch antidepressants, have side effects following first prescription, and be on escitalopram for a shorter duration compared to normal metabolisers. CYP2C19 poor and intermediate metabolisers on citalopram also exhibited increased odds of discontinuation and shorter durations relative to normal metabolisers. Generally, no associations were found between metabolic phenotypes and proxies of response to sertraline. Sensitivity analyses in a depression subgroup and metabolic activity scores corroborated results from the primary analysis. In summary, our findings suggest that CYP2C19 genotypes, and thus metabolic phenotypes, may have utility in determining clinical responses to SSRIs, particularly escitalopram and citalopram, though further investigation of such a relationship is warranted.
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Affiliation(s)
- Win Lee Edwin Wong
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117600, Singapore
- Healthy Longevity Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AG, UK; (R.v.W.)
| | - Chiara Fabbri
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40127 Bologna, Italy
| | - Benjamin Laplace
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
- Psychiatry Department of Research and Innovation, Esquirol Hospital Center, 87000 Limoges, France
| | - Danyang Li
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | - Roos van Westrhenen
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AG, UK; (R.v.W.)
- Parnassia Psychiatric Institute/PsyQ, 1062 HN Amsterdam, The Netherlands
- Department of Psychiatry & Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Cathryn M. Lewis
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | - Gavin Stewart Dawe
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117600, Singapore
- Healthy Longevity Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Neurobiology Programme, Life Sciences Institute, National University of Singapore, Singapore 119077, Singapore
| | - Allan H. Young
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AG, UK; (R.v.W.)
- Department of Medical and Molecular Genetics, Faculty of Life Sciences and Medicine, King’s College London, London WC2R 2LS, UK
- South London & Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, London BR3 3BX, UK
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Pjevac M, Redenšek Trampuž S, Blagus T, Dolžan V, Bon J. Case report: application of pharmacogenetics in the personalized treatment of an elderly patient with a major depressive episode. Front Psychiatry 2023; 14:1250253. [PMID: 37608991 PMCID: PMC10440381 DOI: 10.3389/fpsyt.2023.1250253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/24/2023] [Indexed: 08/24/2023] Open
Abstract
Background Pharmacogenetic analyses can predict interpersonal differences in response to psychopharmacotherapy, which greatly facilitates the selection of the most effective medication at optimal doses. By personalizing therapy in this way, we can minimize adverse drug reactions (ADR) and prevent polypharmacy. Most psychotropic medications are metabolized by the cytochrome P450 enzymes CYP2D6, CYP2C19, and CYPA3A4, which influence drug metabolism and concentration, affecting both efficacy and the occurrence of ADR. The relationships between genetic variations and enzymatic activity allow pharmacogenetic analysis to provide important data for optimal drug selection. The following case report illustrates the impact of pharmacogenetic analysis on the course of pharmacologic treatment in an elderly patient with a major depressive episode. Methods We present a case of a 79-year-old patient treated for severe depression with psychotic symptoms. We collected data on treatment selection and response to treatment before and after pharmacogenetic analysis. For pharmacogenetic analysis, common functional variants in CYP1A2, CYP3A4, CYP2B6, CYP2C19, and CYP2D6 were genotyped, and corresponding evidence-based treatment recommendations were prepared. Results The patient suffered from lack of efficacy and serious ADR of several medications, resulting in worsening depression and treatment resistance over the course of several months of treatment. Pharmacogenetic analysis provided important insights into the patient's pharmacokinetic phenotype and allowed us to personalize treatment and achieve remission of the depressive episode. Conclusion In the case presented, we have shown how consideration of pharmacogenetic characteristics in an individual patient can improve treatment outcome and patient well-being. Knowledge of the patient's pharmacogenetic characteristics helped us to personalize treatment, resulting in complete remission of psychopathology. Due to the complexity of psychiatric disorders, the efficacy of combinations of different medications, which are often required in individual patients, cannot be clearly explained. Therefore, it is of great importance to conduct further pharmacokinetic and pharmacogenetic studies to better assess gene-drug interactions in psychopharmacotherapy.
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Affiliation(s)
- Milica Pjevac
- Centre for Clinical Psychiatry, University Psychiatric Clinic Ljubljana, Ljubljana, Slovenia
| | - Sara Redenšek Trampuž
- Pharmacogenetics Laboratory, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tanja Blagus
- Pharmacogenetics Laboratory, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Vita Dolžan
- Pharmacogenetics Laboratory, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jurij Bon
- Centre for Clinical Psychiatry, University Psychiatric Clinic Ljubljana, Ljubljana, Slovenia
- Department of Psychiatry, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Effect of CYP2C19 polymorphisms on antidepressant prescription patterns and treatment emergent mania in bipolar disorder. THE PHARMACOGENOMICS JOURNAL 2023; 23:28-35. [PMID: 36333412 PMCID: PMC9925376 DOI: 10.1038/s41397-022-00294-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 09/13/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
Antidepressant medication is used extensively to treat bipolar depression despite uncertain efficacy. The cytochrome P450 (CYP) 2C19 enzyme metabolize several antidepressants, and polymorphisms in the corresponding gene CYP2C19 influence plasma concentration and hence treatment outcomes in major depressive disorder. Here, we investigate if CYP2C19 polymorphisms are associated with antidepressant treatment patterns and the risk of mania when antidepressants are used in bipolar disorder. Two single nucleotide polymorphisms (rs4244285 and rs12248560) were used to classify 5019 bipolar disorder patients into CYP2C19 metabolic phenotypes ranging from poor to ultra-rapid metabolizers. We used Swedish national registry data 2005-2017 on dispensed medications and inpatient care to estimate risks for early-treatment persistence, treatment discontinuation, switching to a new antidepressant medication, and mania within 3 months of treatment initiation in patients treated with citalopram, escitalopram, sertraline, amitriptyline, and clomipramine. Metabolic phenotypes of CYP2C19 were not robustly associated with the investigated treatment outcomes based on dispense patterns. Slower metabolism was associated with an increased risk of treatment emergent mania for sertraline (hazard ratio [HR] = 1.3, 95% CI = 1.04-1.62, p = 0.02) and the tricyclic antidepressants amitriptyline and clomipramine (HR = 1.46, 95% CI = 1.05-2.02, p = 0.024). In a large study of the impact of CYP2C19 metabolic phenotypes on antidepressant treatment of bipolar depression, we found an association between slower CYP2C19 metabolism and higher risk of treatment emergent mania, which is a step towards personalized risk assessments. There were, however, no clear associations with early treatment persistence, treatment discontinuation, and switching to a new antidepressant.
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Tsermpini EE, Serretti A, Dolžan V. Precision Medicine in Antidepressants Treatment. Handb Exp Pharmacol 2023; 280:131-186. [PMID: 37195310 DOI: 10.1007/164_2023_654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Precision medicine uses innovative approaches to improve disease prevention and treatment outcomes by taking into account people's genetic backgrounds, environments, and lifestyles. Treatment of depression is particularly challenging, given that 30-50% of patients do not respond adequately to antidepressants, while those who respond may experience unpleasant adverse drug reactions (ADRs) that decrease their quality of life and compliance. This chapter aims to present the available scientific data that focus on the impact of genetic variants on the efficacy and toxicity of antidepressants. We compiled data from candidate gene and genome-wide association studies that investigated associations between pharmacodynamic and pharmacokinetic genes and response to antidepressants regarding symptom improvement and ADRs. We also summarized the existing pharmacogenetic-based treatment guidelines for antidepressants, used to guide the selection of the right antidepressant and its dose based on the patient's genetic profile, aiming to achieve maximum efficacy and minimum toxicity. Finally, we reviewed the clinical implementation of pharmacogenomics studies focusing on patients on antidepressants. The available data demonstrate that precision medicine can increase the efficacy of antidepressants and reduce the occurrence of ADRs and ultimately improve patients' quality of life.
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Affiliation(s)
- Evangelia Eirini Tsermpini
- Pharmacogenetics Laboratory, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Alessandro Serretti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Vita Dolžan
- Pharmacogenetics Laboratory, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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France K, Ammend D, Brown J. Pharmacogenetic Testing and Therapeutic Drug Monitoring Of Sertraline at a Residential Treatment Center for Children and Adolescents: A Pilot Study. Innov Pharm 2022; 13:10.24926/iip.v13i4.5035. [PMID: 37305603 PMCID: PMC10256290 DOI: 10.24926/iip.v13i4.5035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024] Open
Abstract
Background: Sertraline is commonly prescribed to children for the treatment of anxiety and major depressive disorder and is metabolized in part by CYP2C19. While dosing recommendations based on CYP2C19 genotype exist, there is sparse data in children on the relationship between sertraline concentrations and CYP2C19 genotype. Additionally, although rarely utilized in the United States, therapeutic drug monitoring can also help to guide dosing. The primary objective of this pilot study was to compare sertraline concentrations with CYP2C19 genotype. Secondary objectives included exploring the feasibility of using pharmacogenetic testing and therapeutic drug monitoring in a residential treatment center for children and adolescents. Methods: This study was a prospective, open-label study of children prescribed sertraline being treated at a residential treatment center for children and adolescents. Individuals were included if they were < 18 years of age, taking sertraline for at least 2 weeks allowing them to reach steady-state concentrations, being treated through the residential treatment program, and able to understand and speak English. Results: A total of 20 participants (80% female) completed all study procedures, including pharmacogenetic testing and therapeutic drug monitoring, with an average age of 15.4 years (range: 9-17 years). Forty percent (n=8) of participants had a diagnosis of Generalized Anxiety Disorder, while 30% (n=6) had a diagnosis of Major Depressive Disorder. Overall, average sertraline and desmethylsertraline concentrations were 21.1 ng/ml (range: 1-78 ng/ml) and 52.4 ng/ml (range: 1-258 n/ml). Based on CYP2C19 genotypes, 60% (n=12) were normal metabolizers, 10% (n=2) were intermediate metabolizers, and 30% (n=6) were rapid metabolizers. Daily sertraline dose (mg/day) accounted for a significant amount of the observed variability in sertraline (p<0.0001; r2=0.62) and desmethylsertraline concentrations (p<0.001; r2=0.45). When comparing weight-based dosing by sertraline and desmethylsertraline concentrations, sertraline daily dose by weight (mg/kg/day) also accounted for a significant amount of the observed variability in sertraline (p<0.0001; r2=0.60) and desmethylsertraline (p<0.0001; r2=0.59) concentrations. Average daily and weight-based doses for CYP2C19 intermediate, normal, and rapid metabolizers were 75 mg/day, 87.5 mg/day, and 79.2 mg/day and 1.5 mg/kg/day, 1.3 mg/kg/day, and 1.1 mg/kg/day, though these were not significantly different. Conclusion: This small, pilot study showed sertraline dose to be significantly associated with sertraline and desmethylsertraline concentrations. No differences were noted between CYP2C19 metabolizer groups, likely due to the limited sample size. These results also suggest that ordering pharmacogenetic testing and therapeutic drug monitoring in the setting of a child and adolescent residential treatment center is feasible.
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Affiliation(s)
- Kate France
- University of Minnesota College of Pharmacy, Duluth, Minnesota
| | | | - Jacob Brown
- University of Minnesota College of Pharmacy, Duluth, Minnesota
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Stingl JC, Radermacher J, Wozniak J, Viviani R. Pharmacogenetic Dose Modeling Based on CYP2C19 Allelic Phenotypes. Pharmaceutics 2022; 14:pharmaceutics14122833. [PMID: 36559326 PMCID: PMC9781550 DOI: 10.3390/pharmaceutics14122833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Pharmacogenetic variability in drug metabolism leads to patient vulnerability to side effects and to therapeutic failure. Our purpose was to introduce a systematic statistical methodology to estimate quantitative dose adjustments based on pharmacokinetic differences in pharmacogenetic subgroups, addressing the concerns of sparse data, incomplete information on phenotypic groups, and heterogeneity of study design. Data on psychotropic drugs metabolized by the cytochrome P450 enzyme CYP2C19 were used as a case study. CYP2C19 activity scores were estimated, while statistically assessing the influence of methodological differences between studies, and used to estimate dose adjustments in genotypic groups. Modeling effects of activity scores in each substance as a population led to prudential predictions of adjustments when few data were available ('shrinkage'). The best results were obtained with the regularized horseshoe, an innovative Bayesian approach to estimate coefficients viewed as a sample from two populations. This approach was compared to modeling the population of substance as normally distributed, to a more traditional "fixed effects" approach, and to dose adjustments based on weighted means, as in current practice. Modeling strategies were able to assess the influence of study parameters and deliver adjustment levels when necessary, extrapolated to all phenotype groups, as well as their level of uncertainty. In addition, the horseshoe reacted sensitively to small study sizes, and provided conservative estimates of required adjustments.
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Affiliation(s)
- Julia Carolin Stingl
- Institute of Clinical Pharmacology, University Hospital of RWTH, 52074 Aachen, Germany
- Correspondence: ; Tel.: +49-241-8089131
| | - Jason Radermacher
- Institute of Clinical Pharmacology, University Hospital of RWTH, 52074 Aachen, Germany
| | - Justyna Wozniak
- Institute of Clinical Pharmacology, University Hospital of RWTH, 52074 Aachen, Germany
| | - Roberto Viviani
- Institute of Psychology, University of Innsbruck, 6020 Innsbruck, Austria
- Psychiatry and Psychotherapy Clinic, University of Ulm, 89075 Ulm, Germany
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11
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Liu M, Rossow KM, Maxwell-Horn AC, Saucier LA, Van Driest SL. Pediatric considerations for pharmacogenetic selective serotonin reuptake inhibitors clinical decision support. Pharmacotherapy 2022. [PMID: 36524442 DOI: 10.1002/phar.2751] [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: 07/15/2022] [Revised: 09/27/2022] [Accepted: 10/30/2022] [Indexed: 12/23/2022]
Abstract
Pharmacogenetic testing for psychiatry is growing at a rapid pace, with multiple sites utilizing results to help clinical decision-making. Genotype-guided dosing and drug selection have been implemented at several sites, including Vanderbilt University Medical Center, where clinical decision support (CDS) based on pharmacogenetic results went live for selective serotonin reuptake inhibitors in 2020 for both adult and pediatric patients. Effective and appropriate implementation of CYP2D6- and CYP2C19-guided CDS for the pediatric population requires consideration of the evidence for the pharmacogenetic associations, medication indications, and appropriate alternative therapies to be used when a pharmacogenetic contraindication is identified. In this article, we review these pediatric pharmacogenetic considerations for selective serotonin reuptake inhibitor CDS. We include a case study, the current literature supporting clinical recommendations, considerations when designing pediatric CDS, future implications, and examples of sertraline, (es)citalopram, paroxetine, and fluvoxamine alerts.
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Affiliation(s)
- Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Katelyn M Rossow
- Developmental-Behavioral Pediatrics, Norton Children's Development Center, Louisville, Kentucky, USA
| | - Angela C Maxwell-Horn
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leigh Ann Saucier
- Vanderbilt Institute for Clinical & Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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12
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Bråten LS, Ingelman‐Sundberg M, Jukic MM, Molden E, Kringen MK. Impact of the novel CYP2C:TG haplotype and CYP2B6 variants on sertraline exposure in a large patient population. Clin Transl Sci 2022; 15:2135-2145. [PMID: 35668575 PMCID: PMC9468554 DOI: 10.1111/cts.13347] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/19/2022] [Accepted: 05/22/2022] [Indexed: 01/25/2023] Open
Abstract
Sertraline is a commonly used SSRI antidepressant drug, metabolized by CYP2C19 and CYP2B6, that exhibits a substantial interindividual variation in clinical response, of which only a part can be attributed to known genetic variants. In the current study we have examined the role of a newly discovered ultrarapid CYP2C:TG haplotype and CYP2B6 variants in order to identify the possible missing heritability for such variation in sertraline response in a large patient population (n = 840). Compared to the reference group (CYP2C19*1/*1, n = 160), sertraline exposure was increased by 128% in CYP2C19 PMs (n = 29, p < 0.001) but decreased by about 20% in CYP2C19 ultrarapid metabolizers (Ums) (homozygous carriers of CYP2C19*17 and/or CYP2C:TG haplotype) with the diplotypes CYP2C19*17/*17, CYP2C:TG/TG, or CYP2C19*17/CYP2C:TG (n = 135, p < 0.003, p = 0.022, p < 0.003, respectively). Interestingly, in patients carrying the increased function CYP2B6*4 allele, and also carrying the CYP2C19*17 and CYP2C:TG alleles (n = 10), sertraline exposure was 35.4% lower compared to the reference group, whereas in subjects being poor metabolizers (PM) in both the CYP2C19 and CYP2B6 gene, the sertraline concentrations were raised by 189%. In summary, the CYP2C19 variants including the CYP2C:TG haplotype had a significant impact on sertraline metabolism, as well as the CYP2B6*4, *6, and *9 alleles. Knowing the CYP2B6 and CYP2C19 genotype, including the CYP2C:TG haplotype status, can prospectively be useful to clinicians in making more appropriate sertraline dosing decisions.
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Affiliation(s)
- Line Skute Bråten
- Center for PsychopharmacologyDiakonhjemmet HospitalOsloNorway,Department of Health SciencesOsloMet – Oslo Metropolitan UniversityOsloNorway
| | - Magnus Ingelman‐Sundberg
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Biomedicum 5BKarolinska InstitutetStockholmSweden
| | - Marin M. Jukic
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Biomedicum 5BKarolinska InstitutetStockholmSweden,Department of Physiology, Faculty of PharmacyUniversity of BelgradeBelgradeSerbia
| | - Espen Molden
- Center for PsychopharmacologyDiakonhjemmet HospitalOsloNorway,Department of Pharmaceutical Biosciences, School of PharmacyUniversity of OsloOsloNorway
| | - Marianne Kristiansen Kringen
- Center for PsychopharmacologyDiakonhjemmet HospitalOsloNorway,Department of Health SciencesOsloMet – Oslo Metropolitan UniversityOsloNorway
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13
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Chen Q, Wan J, Zhang Y, He Y, Bao Y, Yu L, Yang J. Pharmacokinetic-pharmacodynamic modeling analysis for hydroxysafflor yellow A-calycosin in compatibility in normal and cerebral ischemic rats: A comparative study. Biomed Pharmacother 2022; 150:112950. [PMID: 35427818 DOI: 10.1016/j.biopha.2022.112950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/25/2022] [Accepted: 04/08/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Astragalus and Safflower are commonly used in the treatment of stroke. Studies have shown that their two active components, hydroxysafflor yellow A (HSYA) and calycosin (CA), have protective effects on cerebral ischemia-reperfusion injury (I/R). However, the pharmacokinetic-pharmacodynamic (PK-PD) modeling study of the combination of the two components has not been reported in rats. The study aimed to perform combined PK-PD modeling of HSYA and CA in normal and cerebral ischemia model rats to explain quantitatively their time-concentration-effect relationship. METHODS To make the middle cerebral artery occlusion (MCAO) model. SD rats were randomly divided into normal treated group (NTG) (n = 6), model group (MDG) (n = 6) and model treated group (MTG) (n = 6). Plasma was collected from the mandibular vein after 0, 2, 5, 10, 15, 20, 30, 45, 60, 75, 90, 120, 180, and 240 min after intravenous administration. Rats in NTG and MTG were administered the same dose of HSYA (5 mg/kg) and CA (8 mg/kg) by tail vein injection. HPLC-VWD method was used for detection and analysis. Simultaneously, ELISA was performed to detect the levels of IL-1β and caspase-9 in rat plasma at different time points. The improvement in the above indicators was compared after administration. Lastly, after combining the pharmacokinetic parameters and pharmacodynamic indicators in vivo, DAS 3.2.6 software was used to fit the PK-PD model. RESULTS The MCAO model was successfully established. Compared to NTG, there was a significant difference (P < 0.05) in t1/2α, t1/2β, V1, V2, CL1, CL2, AUC(0-t), AUC (0-∞), and K12 of MTG for HSYA, and there was a significant difference (P < 0.05) in t1/2α, V1, CL1, AUC(0-t), AUC (0-∞), and K10 of MTG for CA. Compared to NTG, the PK parameters of t1/2α, V1, V2, CL1, and K10 were higher for HSYA in MTG, while AUC(0-t), AUC (0-∞), K12, and K21 were lower; the PK parameters of t1/2α, V1, V2, AUC(0-t), and AUC(0-∞) were higher for CA in MTG, while CL1, CL2, K10, K12, and K21 were lower. Also, the results of PD showed extremely significant differences in the levels of caspase-9 and IL-1β at the different time points in MTG (P < 0.01) compared with 0 min. The levels of caspase-9 and IL-1β in NTG rats showed little fluctuation and were relatively stable; however, their levels in MTG showed a downward trend with time. There were highly significant differences in the levels of each of the pharmacodynamic indicators at every time point between NTG and MTG (P < 0.01). CONCLUSION The PK-PD model of the combined administration of HSYA and CA was successfully established in rats, and the differences in pharmacodynamic and pharmacokinetic properties between the normal and cerebral ischemic rats were evaluated. Based on comprehensive data analysis, we found that the combination of HSYA and CA may exert protective effects against I/R injury in rats via anti-apoptotic and anti-inflammatory pathways. The study provided additional insights into the development of drugs for ischemic stroke as well as the design of appropriate dosing regimens.
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Affiliation(s)
- Qianqian Chen
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, PR China.
| | - Jiayang Wan
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, PR China.
| | - Yangyang Zhang
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, PR China.
| | - Yu He
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, PR China.
| | - Yida Bao
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, PR China.
| | - Li Yu
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, PR China.
| | - Jiehong Yang
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, PR China.
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14
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Joković D, Milosavljević F, Stojanović Z, Šupić G, Vojvodić D, Uzelac B, Jukić MM, Petković Ćurčin A. CYP2C19 slow metabolizer phenotype is associated with lower antidepressant efficacy and tolerability. Psychiatry Res 2022; 312:114535. [PMID: 35398660 DOI: 10.1016/j.psychres.2022.114535] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 12/28/2022]
Abstract
The inter-individual variability in CYP2C19-mediated metabolism may affect the antidepressant treatment. The aim of this study is to evaluate differences in antidepressant efficacy and tolerability between different CYP2C19 metabolizer categories in inpatients suffering from major depressive disorder. The cohort was divided into experimental groups based on CYP2C19 genotype and it contained 24 slow (SMs), 41 normal (NMs), and 37 fast metabolizers (FMs). Efficacy and tolerability were assessed at baseline, and after two and four weeks as a follow-up. The primary efficacy measurement was the change from baseline in Hamilton's Depression Rating Scale (HAMD), while the primary tolerability measurement was the Toronto Side-Effects Scale (TSES) intensity scores at the last visit. The reduction in HAMD score was 36% less pronounced and response rate was exceedingly less prevalent (75% lower) in SMs, compared with NMs. The TSES intensity score was increased in SMs, compared with NMs, by 43% for central nervous system and by 22% for gastrointestinal adverse drug reactions. No significant differences in measured parameters were observed between NMs and FMs. Compared with NM and RM, lower antidepressant efficacy and tolerability was observed in SMs; this association is likely connected with the lower SM capacity to metabolize antidepressant drugs.
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Affiliation(s)
- Danilo Joković
- Clinic for Psychiatry, Military Medical Academy, 11040 Belgrade, Serbia
| | | | - Zvezdana Stojanović
- Clinic for Psychiatry, Military Medical Academy, 11040 Belgrade, Serbia; Faculty of Medicine, Military Medical Academy, University of Defense, 11040 Belgrade, Serbia
| | - Gordana Šupić
- Faculty of Medicine, Military Medical Academy, University of Defense, 11040 Belgrade, Serbia; Institute for Medical Research, Military Medical Academy, 11040 Belgrade, Serbia
| | - Danilo Vojvodić
- Faculty of Medicine, Military Medical Academy, University of Defense, 11040 Belgrade, Serbia; Institute for Medical Research, Military Medical Academy, 11040 Belgrade, Serbia
| | - Bojana Uzelac
- Institute for Medical Research, Military Medical Academy, 11040 Belgrade, Serbia
| | - Marin M Jukić
- Faculty of Pharmacy, University of Belgrade, 11221 Belgrade, Serbia; Department of Physiology and Pharmacology, Karolinska Institute, 17177 Solna, Sweden.
| | - Aleksandra Petković Ćurčin
- Faculty of Medicine, Military Medical Academy, University of Defense, 11040 Belgrade, Serbia; Institute for Medical Research, Military Medical Academy, 11040 Belgrade, Serbia
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15
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Therapeutic drug monitoring of sertraline in children and adolescents: A naturalistic study with insights into the clinical response and treatment of obsessive-compulsive disorder. Compr Psychiatry 2022; 115:152301. [PMID: 35248877 DOI: 10.1016/j.comppsych.2022.152301] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 02/07/2022] [Accepted: 02/18/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Sertraline is a selective serotonin reuptake inhibitor with specific indications in child and adolescent psychiatry. Notwithstanding its frequent use and clinical benefits, the relationship between pharmacokinetics, pharmacodynamics, efficacy, and tolerability of sertraline across indications, particularly in non-adult patients, is not fully understood. METHOD This naturalistic therapeutic drug monitoring (TDM) study was conducted in a transdiagnostic sample of children and adolescents treated with sertraline (n = 78; mean age, 14.22 ± 2.39; range, 7-18 years) within the prospective multicenter "TDM-VIGIL" project. Associations between dose, serum concentration, and medication-specific therapeutic and side effects based on the Clinical Global Impression scale were examined. Tolerability was measured qualitatively with the 56-item Pediatric Adverse Event Rating Scale. RESULTS A strong linear positive dose-serum concentration relationship (with dose explaining 45% of the variance in concentration) and significant effects of weight and co-medication were found. Neither dose nor serum concentration were associated with side effects. An overall mild-to-moderate tolerability profile of sertraline was observed. In contrast with the transdiagnostic analysis that did not indicate an effect of concentration, when split into depression (MDD) and obsessive-compulsive disorder (OCD) diagnoses, the probability of clinical improvement significantly increased as both dose and concentration increased for OCD, but not for MDD. CONCLUSIONS This TDM-flexible-dose study revealed a significant diagnosis-specific effect between sertraline serum concentration and clinical efficacy for pediatric OCD. While TDM already guides clinical decision-making regarding compliance, dose calibration, and drug-drug interactions, combining TDM with other methods, such as pharmacogenetics, may facilitate a personalized medicine approach in psychiatry.
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16
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Campos AI, Byrne EM, Mitchell BL, Wray NR, Lind PA, Licinio J, Medland SE, Martin NG, Hickie IB, Rentería ME. Impact of CYP2C19 metaboliser status on SSRI response: a retrospective study of 9500 participants of the Australian Genetics of Depression Study. THE PHARMACOGENOMICS JOURNAL 2022; 22:130-135. [PMID: 35094016 PMCID: PMC8975743 DOI: 10.1038/s41397-022-00267-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 01/31/2023]
Abstract
Background Variation within the CYP2C19 gene has been linked to differential metabolism of selective serotonin reuptake inhibitors (SSRIs). Pharmacogenetic recommendations based on the effect of CYP2C19 variants have been made available and are used increasingly by clinical practitioners. Nonetheless, the underlying assumption linking differential metabolism to efficacy or adverse side effects remains understudied. Here, we aim to fill this gap by studying CYP2C19 polymorphisms and inferred metabolism and patient-reported antidepressant response in a sample of 9531 Australian adults who have taken SSRIs. Methods Metaboliser status was inferred for participants based on CYP2C19 alleles. Primary analysis consisted of assessing differences in treatment efficacy and tolerability between normal (reference) and: ultrarapid, rapid, intermediate and poor metabolisers. Results Across medications, poor metabolisers reported a higher efficacy, whereas rapid metabolisers reported higher tolerability. When stratified by drug, associations between metaboliser status and efficacy did not survive multiple testing correction. Intermediate metabolisers were at greater odds of reporting any side effect for sertraline and higher number of side effects across medications and for sertraline. Conclusions The effects between metaboliser status and treatment efficacy, tolerability and side effects were in the expected direction. Our power analysis suggests we would detect moderate to large effects, at least nominally. Reduced power may also be explained by heterogeneity in antidepressant dosages or concomitant medications, which we did not measure. The fact that we identify slower metabolisers to be at higher risk of side effects even without adjusting for clinical titration, and the nominally significant associations consistent with the expected metabolic effects provide new evidence for the link between CYP2C19 metabolism and SSRI response. Nonetheless, longitudinal and interventional designs such as randomized clinical trials that stratify by metaboliser status are necessary to establish the effects of CYP2C19 metabolism on SSRI treatment efficacy or adverse effects.
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Affiliation(s)
- Adrian I Campos
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia. .,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia. .,Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia.
| | - Enda M Byrne
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia
| | - Brittany L Mitchell
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.,School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Naomi R Wray
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia.,Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Penelope A Lind
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Julio Licinio
- Department of Psychiatry, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Sarah E Medland
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | | | - Ian B Hickie
- Brain and Mind Centre, University of Sydney, Camperdown, NSW, Australia
| | - Miguel E Rentería
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia. .,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia. .,School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia.
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17
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Pavez Loriè E, Baatout S, Choukér A, Buchheim JI, Baselet B, Dello Russo C, Wotring V, Monici M, Morbidelli L, Gagliardi D, Stingl JC, Surdo L, Yip VLM. The Future of Personalized Medicine in Space: From Observations to Countermeasures. Front Bioeng Biotechnol 2021; 9:739747. [PMID: 34966726 PMCID: PMC8710508 DOI: 10.3389/fbioe.2021.739747] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 11/19/2021] [Indexed: 12/12/2022] Open
Abstract
The aim of personalized medicine is to detach from a “one-size fits all approach” and improve patient health by individualization to achieve the best outcomes in disease prevention, diagnosis and treatment. Technological advances in sequencing, improved knowledge of omics, integration with bioinformatics and new in vitro testing formats, have enabled personalized medicine to become a reality. Individual variation in response to environmental factors can affect susceptibility to disease and response to treatments. Space travel exposes humans to environmental stressors that lead to physiological adaptations, from altered cell behavior to abnormal tissue responses, including immune system impairment. In the context of human space flight research, human health studies have shown a significant inter-individual variability in response to space analogue conditions. A substantial degree of variability has been noticed in response to medications (from both an efficacy and toxicity perspective) as well as in susceptibility to damage from radiation exposure and in physiological changes such as loss of bone mineral density and muscle mass in response to deconditioning. At present, personalized medicine for astronauts is limited. With the advent of longer duration missions beyond low Earth orbit, it is imperative that space agencies adopt a personalized strategy for each astronaut, starting from pre-emptive personalized pre-clinical approaches through to individualized countermeasures to minimize harmful physiological changes and find targeted treatment for disease. Advances in space medicine can also be translated to terrestrial applications, and vice versa. This review places the astronaut at the center of personalized medicine, will appraise existing evidence and future preclinical tools as well as clinical, ethical and legal considerations for future space travel.
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Affiliation(s)
| | - Sarah Baatout
- Radiobiology Unit, Belgian Nuclear Research Centre (SCK CEN), Mol, Belgium.,Department of Biotechnology, Ghent University, Ghent, Belgium
| | - Alexander Choukér
- Laboratory of Translational Research "Stress and Immunity", Department of Anesthesiology, Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Judith-Irina Buchheim
- Laboratory of Translational Research "Stress and Immunity", Department of Anesthesiology, Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Bjorn Baselet
- Radiobiology Unit, Belgian Nuclear Research Centre (SCK CEN), Mol, Belgium
| | - Cinzia Dello Russo
- Department of Healthcare Surveillance and Bioethics, Section of Pharmacology, Università Cattolica Del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,MRC Centre for Drug Safety Science and Wolfson Centre for Personalized Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, United Kingdom
| | | | - Monica Monici
- ASA Campus Joint Laboratory, ASA Research Division, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | | | - Dimitri Gagliardi
- Manchester Institute of Innovation Research, Alliance Manchester Business School, The University of Manchester, Manchester, United Kingdom
| | - Julia Caroline Stingl
- Institute of Clinical Pharmacology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Leonardo Surdo
- Space Applications Services NV/SA for the European Space Agency, Noordwijk, Netherlands
| | - Vincent Lai Ming Yip
- MRC Centre for Drug Safety Science and Wolfson Centre for Personalized Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, United Kingdom
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18
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Cacabelos R, Naidoo V, Corzo L, Cacabelos N, Carril JC. Genophenotypic Factors and Pharmacogenomics in Adverse Drug Reactions. Int J Mol Sci 2021; 22:ijms222413302. [PMID: 34948113 PMCID: PMC8704264 DOI: 10.3390/ijms222413302] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 02/06/2023] Open
Abstract
Adverse drug reactions (ADRs) rank as one of the top 10 leading causes of death and illness in developed countries. ADRs show differential features depending upon genotype, age, sex, race, pathology, drug category, route of administration, and drug–drug interactions. Pharmacogenomics (PGx) provides the physician effective clues for optimizing drug efficacy and safety in major problems of health such as cardiovascular disease and associated disorders, cancer and brain disorders. Important aspects to be considered are also the impact of immunopharmacogenomics in cutaneous ADRs as well as the influence of genomic factors associated with COVID-19 and vaccination strategies. Major limitations for the routine use of PGx procedures for ADRs prevention are the lack of education and training in physicians and pharmacists, poor characterization of drug-related PGx, unspecific biomarkers of drug efficacy and toxicity, cost-effectiveness, administrative problems in health organizations, and insufficient regulation for the generalized use of PGx in the clinical setting. The implementation of PGx requires: (i) education of physicians and all other parties involved in the use and benefits of PGx; (ii) prospective studies to demonstrate the benefits of PGx genotyping; (iii) standardization of PGx procedures and development of clinical guidelines; (iv) NGS and microarrays to cover genes with high PGx potential; and (v) new regulations for PGx-related drug development and PGx drug labelling.
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Affiliation(s)
- Ramón Cacabelos
- Department of Genomic Medicine, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain
- Correspondence: ; Tel.: +34-981-780-505
| | - Vinogran Naidoo
- Department of Neuroscience, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain;
| | - Lola Corzo
- Department of Medical Biochemistry, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain;
| | - Natalia Cacabelos
- Department of Medical Documentation, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain;
| | - Juan C. Carril
- Departments of Genomics and Pharmacogenomics, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain;
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19
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Understanding genetic risk factors for common side effects of antidepressant medications. COMMUNICATIONS MEDICINE 2021; 1:45. [PMID: 35602235 PMCID: PMC9053224 DOI: 10.1038/s43856-021-00046-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 10/21/2021] [Indexed: 01/03/2023] Open
Abstract
Background Major depression is one of the most disabling health conditions internationally. In recent years, new generation antidepressant medicines have become very widely prescribed. While these medicines are efficacious, side effects are common and frequently result in discontinuation of treatment. Compared with specific pharmacological properties of the different medications, the relevance of individual vulnerability is understudied. Methods We used data from the Australian Genetics of Depression Study to gain insights into the aetiology and genetic risk factors to antidepressant side effects. To this end, we employed structural equation modelling, polygenic risk scoring and regressions. Results Here we show that participants reporting a specific side effect for one antidepressant are more likely to report the same side effect for other antidepressants, suggesting the presence of shared individual or pharmacological factors. Polygenic risk scores (PRS) for depression associated with side effects that overlapped with depressive symptoms, including suicidality and anxiety. Body Mass Index PRS are strongly associated with weight gain from all medications. PRS for headaches are associated with headaches from sertraline. Insomnia PRS show some evidence of predicting insomnia from amitriptyline and escitalopram. Conclusions Our results suggest a set of common factors underlying the risk for antidepressant side effects. These factors seem to be partly explained by genetic liability related to depression severity and the nature of the side effect. Future studies on the genetic aetiology of side effects will enable insights into their underlying mechanisms and the possibility of risk stratification and prophylaxis strategies. Antidepressants are commonly prescribed medications, but adverse side effects are cause for treatment discontinuation. We analysed data from a large group of adults who have taken antidepressants to understand why some people experience specific side effects. Our results suggest that a person’s genetic characteristics play a role. For example, participants genetically predisposed to a higher body mass index were more likely to report weight gain from antidepressants. These results open up the possibility of predicting adverse side effects as we increase our knowledge on the genetics of related complex traits. Future studies can focus on performing large-scale genetic studies of antidepressant side effects to gain further insights into the mechanisms underlying antidepressant side effects and to identify genetic markers of side effects that could be used in the clinic. Campos et al. study the genetic aetiology of antidepressant side effects. Using data from the Australian Genetics of Depression study, the authors show that polygenic risk scores for traits such as BMI, insomnia and headaches have a shared genetic basis with side effects to commonly used antidepressant drugs.
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20
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Shalimova A, Babasieva V, Chubarev VN, Tarasov VV, Schiöth HB, Mwinyi J. Therapy response prediction in major depressive disorder: current and novel genomic markers influencing pharmacokinetics and pharmacodynamics. Pharmacogenomics 2021; 22:485-503. [PMID: 34018822 DOI: 10.2217/pgs-2020-0157] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Major depressive disorder is connected with high rates of functional disability and mortality. About a third of the patients are at risk of therapy failure. Several pharmacogenetic markers especially located in CYP450 genes such as CYP2D6 or CYP2C19 are of relevance for therapy outcome prediction in major depressive disorder but a further optimization of predictive tools is warranted. The article summarizes the current knowledge on pharmacogenetic variants, therapy effects and side effects of important antidepressive therapeutics, and sheds light on new methodological approaches for therapy response estimation based on genetic markers with relevance for pharmacokinetics, pharmacodynamics and disease pathology identified in genome-wide association study analyses, highlighting polygenic risk score analysis as a tool for further optimization of individualized therapy outcome prediction.
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Affiliation(s)
- Alena Shalimova
- Department of Neuroscience, Functional Pharmacology, University of Uppsala, Uppsala, 751 24, Sweden.,Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, 119991, Russia
| | - Viktoria Babasieva
- Department of Neuroscience, Functional Pharmacology, University of Uppsala, Uppsala, 751 24, Sweden.,Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, 119991, Russia
| | - Vladimir N Chubarev
- Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, 119991, Russia
| | - Vadim V Tarasov
- Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, 119991, Russia.,Institute of Translational Medicine & Biotechnology, I. M. Sechenov First Moscow State Medical University, Moscow, 119991, Russia
| | - Helgi B Schiöth
- Department of Neuroscience, Functional Pharmacology, University of Uppsala, Uppsala, 751 24, Sweden.,Institute of Translational Medicine & Biotechnology, I. M. Sechenov First Moscow State Medical University, Moscow, 119991, Russia
| | - Jessica Mwinyi
- Department of Neuroscience, Functional Pharmacology, University of Uppsala, Uppsala, 751 24, Sweden
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21
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Russell LE, Zhou Y, Almousa AA, Sodhi JK, Nwabufo CK, Lauschke VM. Pharmacogenomics in the era of next generation sequencing - from byte to bedside. Drug Metab Rev 2021; 53:253-278. [PMID: 33820459 DOI: 10.1080/03602532.2021.1909613] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pharmacogenetic research has resulted in the identification of a multitude of genetic variants that impact drug response or toxicity. These polymorphisms are mostly common and have been included as actionable information in the labels of numerous drugs. In addition to common variants, recent advances in Next Generation Sequencing (NGS) technologies have resulted in the identification of a plethora of rare and population-specific pharmacogenetic variations with unclear functional consequences that are not accessible by conventional forward genetics strategies. In this review, we discuss how comprehensive sequencing information can be translated into personalized pharmacogenomic advice in the age of NGS. Specifically, we provide an update of the functional impacts of rare pharmacogenetic variability and how this information can be leveraged to improve pharmacogenetic guidance. Furthermore, we critically discuss the current status of implementation of pharmacogenetic testing across drug development and layers of care. We identify major gaps and provide perspectives on how these can be minimized to optimize the utilization of NGS data for personalized clinical decision-support.
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Affiliation(s)
| | - Yitian Zhou
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Ahmed A Almousa
- Department of Pharmacy, London Health Sciences Center, Victoria Hospital, London, ON, Canada
| | - Jasleen K Sodhi
- Department of Bioengineering and Therapeutic Sciences, Schools of Pharmacy and Medicine, University of California San Francisco, San Francisco, CA, USA.,Department of Drug Metabolism and Pharmacokinetics, Plexxikon, Inc., Berkeley, CA, USA
| | | | - Volker M Lauschke
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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22
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Almurjan A, Macfarlane H, Badhan RKS. The application of precision dosing in the use of sertraline throughout pregnancy for poor and ultrarapid metabolizer CYP 2C19 subjects: A virtual clinical trial pharmacokinetics study. Biopharm Drug Dispos 2021; 42:252-262. [PMID: 33851424 DOI: 10.1002/bdd.2278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/07/2021] [Accepted: 03/29/2021] [Indexed: 12/14/2022]
Abstract
Sertraline is known to undergo changes in pharmacokinetics during pregnancy. CYP 2C19 has been implicated in the interindividual variation in clinical effect associated with sertraline activity. However, knowledge of suitable dose titrations during pregnancy and within CYP 2C19 phenotypes is lacking. A pharmacokinetic modeling virtual clinical trials approach was implemented to: (i) assess gestational changes in sertraline trough plasma concentrations for CYP 2C19 phenotypes, and (ii) identify appropriate dose titration strategies to stabilize sertraline levels within a defined therapeutic range throughout gestation. Sertraline trough plasma concentrations decreased throughout gestation, with maternal volume expansion and reduction in plasma albumin being identified as possible causative reasons. All CYP 2C19 phenotypes required a dose increase throughout gestation. For extensive metabolizer (EM) and ultrarapid metabolizer (UM) phenotypes, doses of 100-150 mg daily are required throughout gestation. For poor metabolizers (PM), 50 mg daily during trimester 1 followed by a dose of 100 mg daily in trimesters 2 and 3 are required.
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Affiliation(s)
- Aminah Almurjan
- Medicines Optimisation Research Group, Aston Pharmacy School, Aston University, Birmingham, UK
| | - Hannah Macfarlane
- Medicines Optimisation Research Group, Aston Pharmacy School, Aston University, Birmingham, UK
| | - Raj K S Badhan
- Medicines Optimisation Research Group, Aston Pharmacy School, Aston University, Birmingham, UK
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23
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Milosavljević F, Bukvić N, Pavlović Z, Miljević Č, Pešić V, Molden E, Ingelman-Sundberg M, Leucht S, Jukić MM. Association of CYP2C19 and CYP2D6 Poor and Intermediate Metabolizer Status With Antidepressant and Antipsychotic Exposure: A Systematic Review and Meta-analysis. JAMA Psychiatry 2021; 78:270-280. [PMID: 33237321 PMCID: PMC7702196 DOI: 10.1001/jamapsychiatry.2020.3643] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Precise estimation of the drug metabolism capacity for individual patients is crucial for adequate dose personalization. OBJECTIVE To quantify the difference in the antipsychotic and antidepressant exposure among patients with genetically associated CYP2C19 and CYP2D6 poor (PM), intermediate (IM), and normal (NM) metabolizers. DATA SOURCES PubMed, Clinicaltrialsregister.eu, ClinicalTrials.gov, International Clinical Trials Registry Platform, and CENTRAL databases were screened for studies from January 1, 1990, to June 30, 2020, with no language restrictions. STUDY SELECTION Two independent reviewers performed study screening and assessed the following inclusion criteria: (1) appropriate CYP2C19 or CYP2D6 genotyping was performed, (2) genotype-based classification into CYP2C19 or CYP2D6 NM, IM, and PM categories was possible, and (3) 3 patients per metabolizer category were available. DATA EXTRACTION AND SYNTHESIS The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed for extracting data and quality, validity, and risk of bias assessments. A fixed-effects model was used for pooling the effect sizes of the included studies. MAIN OUTCOMES AND MEASURES Drug exposure was measured as (1) dose-normalized area under the plasma level (time) curve, (2) dose-normalized steady-state plasma level, or (3) reciprocal apparent total drug clearance. The ratio of means (RoM) was calculated by dividing the mean drug exposure for PM, IM, or pooled PM plus IM categories by the mean drug exposure for the NM category. RESULTS Based on the data derived from 94 unique studies and 8379 unique individuals, the most profound differences were observed in the patients treated with aripiprazole (CYP2D6 PM plus IM vs NM RoM, 1.48; 95% CI, 1.41-1.57; 12 studies; 1038 patients), haloperidol lactate (CYP2D6 PM vs NM RoM, 1.68; 95% CI, 1.40-2.02; 9 studies; 423 patients), risperidone (CYP2D6 PM plus IM vs NM RoM, 1.36; 95% CI, 1.28-1.44; 23 studies; 1492 patients), escitalopram oxalate (CYP2C19 PM vs NM, RoM, 2.63; 95% CI, 2.40-2.89; 4 studies; 1262 patients), and sertraline hydrochloride (CYP2C19 IM vs NM RoM, 1.38; 95% CI, 1.27-1.51; 3 studies; 917 patients). Exposure differences were also observed for clozapine, quetiapine fumarate, amitriptyline hydrochloride, mirtazapine, nortriptyline hydrochloride, fluoxetine hydrochloride, fluvoxamine maleate, paroxetine hydrochloride, and venlafaxine hydrochloride; however, these differences were marginal, ambiguous, or based on less than 3 independent studies. CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, the association between CYP2C19/CYP2D6 genotype and drug levels of several psychiatric drugs was quantified with sufficient precision as to be useful as a scientific foundation for CYP2D6/CYP2C19 genotype-based dosing recommendations.
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Affiliation(s)
- Filip Milosavljević
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Nikola Bukvić
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Zorana Pavlović
- Department of Psychiatry, Faculty of Medicine, University of Belgrade, Belgrade, Serbia,Psychiatry Clinic, Clinical Centre of Serbia, Belgrade
| | - Čedo Miljević
- Department of Psychiatry, Faculty of Medicine, University of Belgrade, Belgrade, Serbia,Institute for Mental Health, Belgrade, Belgrade, Serbia
| | - Vesna Pešić
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Espen Molden
- Department of Pharmacokinetics, University of Oslo Pharmacy School, Oslo, Norway
| | - Magnus Ingelman-Sundberg
- Pharmacogenetics Section, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technische Universität München School of Medicine, Munich, Germany
| | - Marin M. Jukić
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia,Pharmacogenetics Section, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
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24
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Jeremić A, Milosavljević F, Vladimirov S, Batinić B, Marković B, Jukić M. Validation of a quick and simple chromatographic method for simultaneous quantification of sertraline, escitalopram, risperidone and paliperidone levels in the human plasma. ARHIV ZA FARMACIJU 2021. [DOI: 10.5937/arhfarm71-31163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Simultaneous quantification of multiple psychiatric drugs is important for the therapeutic drug monitoring of psychiatric patients. In addition, it would be highly advantageous if the method could be simple, straightforward, and not time-consuming. A 200 µl plasma sample was deproteinized, drugs were separated by a ZORBAX Eclipse XDB-Phenyl column with the mobile phase composed of acetonitrile and 0.1 % formic acid in water (60:40, v/v), and recorded in the MRM mode by using a positive electrospray source with tandem mass spectrometry detection. The dynamic range was 2-256 ng/ml for all the analyzed drugs, except escitalopram (8-256 ng/ml). Quality control samples were prepared in quintuplicates in three relevant concentrations for each drug. Coefficients of determination (R2 ) were higher than 0.99, while the relative difference between nominal and measured concentrations (RE) and CV were lower than 15% for all targets. High performance liquid chromatography coupled with the mass detector (HPLC-MS/MS) method for simultaneous determination of sertraline, escitalopram, risperidone and paliperidone in human plasma was validated with respect to selectivity, linearity, accuracy, precision, matrix effect and stability. This method has significant advantages in terms of low sample volume (200 µl), short preparation time (3 hours) and short runtime per sample (4 minutes).
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25
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Bousman CA, Bengesser SA, Aitchison KJ, Amare AT, Aschauer H, Baune BT, Asl BB, Bishop JR, Burmeister M, Chaumette B, Chen LS, Cordner ZA, Deckert J, Degenhardt F, DeLisi LE, Folkersen L, Kennedy JL, Klein TE, McClay JL, McMahon FJ, Musil R, Saccone NL, Sangkuhl K, Stowe RM, Tan EC, Tiwari AK, Zai CC, Zai G, Zhang J, Gaedigk A, Müller DJ. Review and Consensus on Pharmacogenomic Testing in
Psychiatry. PHARMACOPSYCHIATRY 2020; 54:5-17. [DOI: 10.1055/a-1288-1061] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AbstractThe implementation of pharmacogenomic (PGx) testing in psychiatry remains modest,
in part due to divergent perceptions of the quality and completeness of the
evidence base and diverse perspectives on the clinical utility of PGx testing
among psychiatrists and other healthcare providers. Recognizing the current lack
of consensus within the field, the International Society of Psychiatric Genetics
assembled a group of experts to conduct a narrative synthesis of the PGx
literature, prescribing guidelines, and product labels related to psychotropic
medications as well as the key considerations and limitations related to the use
of PGx testing in psychiatry. The group concluded that to inform medication
selection and dosing of several commonly-used antidepressant and antipsychotic
medications, current published evidence, prescribing guidelines, and product
labels support the use of PGx testing for 2 cytochrome P450 genes (CYP2D6,
CYP2C19). In addition, the evidence supports testing for human leukocyte
antigen genes when using the mood stabilizers carbamazepine (HLA-A and
HLA-B), oxcarbazepine (HLA-B), and phenytoin (CYP2C9, HLA-B). For
valproate, screening for variants in certain genes (POLG, OTC, CSP1) is
recommended when a mitochondrial disorder or a urea cycle disorder is suspected.
Although barriers to implementing PGx testing remain to be fully resolved, the
current trajectory of discovery and innovation in the field suggests these
barriers will be overcome and testing will become an important tool in
psychiatry.
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Affiliation(s)
- Chad A. Bousman
- Departments of Medical Genetics, Psychiatry, Physiology &
Pharmacology, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of
Calgary, Calgary, AB, Canada
- Alberta Children’s Hospital Research Institute, Calgary, AB,
Canada
- Department of Psychiatry, Melbourne Medical School, The University of
Melbourne, Melbourne, VIC, Australia
| | - Susanne A. Bengesser
- Department of Psychiatry and Psychotherapeutic Medicine, Medical
University of Graz, Austria
| | - Katherine J. Aitchison
- Departments of Psychiatry, Medical Genetics and the Neuroscience and
Mental Health Institute, University of Alberta, Edmonton, AB,
Canada
| | - Azmeraw T. Amare
- Discipline of Psychiatry, School of Medicine, University of Adelaide,
Adelaide, SA, Australia
- South Australian Health and Medical Research Institute (SAHMRI),
Adelaide, SA, Australia
| | - Harald Aschauer
- Biopsychosocial Corporation (BioPsyC), non-profit association, Vienna,
Austria
| | - Bernhard T. Baune
- Department of Psychiatry and Psychotherapy, University of
Münster, Germany
- Department of Psychiatry, Melbourne Medical School, The University of
Melbourne, Melbourne, VIC, Australia
- The Florey Institute of Neuroscience and Mental Health, The University
of Melbourne, Parkville, VIC, Australia
| | - Bahareh Behroozi Asl
- Departments of Psychiatry, Medical Genetics and the Neuroscience and
Mental Health Institute, University of Alberta, Edmonton, AB,
Canada
| | - Jeffrey R. Bishop
- Department of Experimental and Clinical Pharmacology, University of
Minnesota College of Pharmacy and Department of Psychiatry, University of
Minnesota Medical School, Minneapolis, MN, USA
| | - Margit Burmeister
- Michigan Neuroscience Institute and Departments of Computational
Medicine & Bioinformatics, Human Genetics and Psychiatry, The University
of Michigan, Ann Arbor MI, USA
| | - Boris Chaumette
- Institute of Psychiatry and Neuroscience of Paris, GHU Paris
Psychiatrie & Neurosciences, University of Paris, Paris,
France
- Department of Psychiatry, McGill University, Montreal,
Canada
| | - Li-Shiun Chen
- Departments of Psychiatry and Genetics, Washington University School of
Medicine in St. Louis, USA
| | - Zachary A. Cordner
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins
University School of Medicine, Baltimore, MD, USA
| | - Jürgen Deckert
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of
Mental Health, Würzburg, Germany
| | - Franziska Degenhardt
- Institute of Human Genetics, University of Bonn, School of Medicine
& University Hospital Bonn, Bonn, Germany
- Department of Child and Adolescent Psychiatry, Psychosomatics and
Psychotherapy, University Hospital Essen, University of Duisburg-Essen,
Duisburg, Germany
| | - Lynn E. DeLisi
- Department of Psychiatry, Harvard Medical School, Cambridge Health
Alliance, Cambridge, Massachusetts, USA
| | - Lasse Folkersen
- Institute of Biological Psychiatry, Capital Region Hospitals,
Copenhagen, Denmark
| | - James L. Kennedy
- Department of Psychiatry, University of Toronto, Toronto, Ontario,
Canada
- Centre for Addiction and Mental Health, University of Toronto, Toronto,
Ontario, Canada
| | - Teri E. Klein
- Department of Biomedical Data Science, Stanford University, Stanford,
California, USA
| | - Joseph L. McClay
- Department of Pharmacotherapy and Outcome Science, Virginia
Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Francis J. McMahon
- Human Genetics Branch, National Institute of Mental Health, Bethesda,
MD, USA
| | - Richard Musil
- Department of Psychiatry and Psychotherapy,
Ludwig-Maximilians-University, Munich, Germany
| | - Nancy L. Saccone
- Departments of Psychiatry and Genetics, Washington University School of
Medicine in St. Louis, USA
| | - Katrin Sangkuhl
- Department of Biomedical Data Science, Stanford University, Stanford,
California, USA
| | - Robert M. Stowe
- Departments of Psychiatry and Neurology (Medicine), University of
British Columbia, USA
| | - Ene-Choo Tan
- KK Research Centre, KK Women’s and Children’s Hospital,
Singapore, Singapore
| | - Arun K. Tiwari
- Department of Psychiatry, University of Toronto, Toronto, Ontario,
Canada
- Centre for Addiction and Mental Health, University of Toronto, Toronto,
Ontario, Canada
| | - Clement C. Zai
- Department of Psychiatry, University of Toronto, Toronto, Ontario,
Canada
- Centre for Addiction and Mental Health, University of Toronto, Toronto,
Ontario, Canada
| | - Gwyneth Zai
- Department of Psychiatry, University of Toronto, Toronto, Ontario,
Canada
- Centre for Addiction and Mental Health, University of Toronto, Toronto,
Ontario, Canada
| | - Jianping Zhang
- Department of Psychiatry, Weill Cornell Medical College, New
York-Presbyterian Westchester Division, White Plains, NY, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic
Innovation, Children’s Mercy Kansas City, Kansas City and School of
Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Daniel J Müller
- Department of Psychiatry, University of Toronto, Toronto, Ontario,
Canada
- Centre for Addiction and Mental Health, University of Toronto, Toronto,
Ontario, Canada
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van Westrhenen R, Aitchison KJ, Ingelman-Sundberg M, Jukić MM. Pharmacogenomics of Antidepressant and Antipsychotic Treatment: How Far Have We Got and Where Are We Going? Front Psychiatry 2020; 11:94. [PMID: 32226396 PMCID: PMC7080976 DOI: 10.3389/fpsyt.2020.00094] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 02/05/2020] [Indexed: 12/11/2022] Open
Abstract
In recent decades, very few new psychiatric drugs have entered the market. Thus, improvement in the use of antidepressant and antipsychotic therapy has to focus mainly on enhanced and more personalized treatment with the currently available drugs. One important aspect of such individualization is emphasizing interindividual differences in genes relevant to treatment, an area that can be termed neuropsychopharmacogenomics. Here, we review previous efforts to identify such critical genetic variants and summarize the results obtained to date. We conclude that most clinically relevant genetic variation is connected to phase I drug metabolism, in particular to genetic polymorphism of CYP2C19 and CYP2D6. To further improve individualized pharmacotherapy, there is a need to take both common and rare relevant mutations into consideration; we discuss the present and future possibilities of using whole genome sequencing to identify patient-specific genetic variation relevant to treatment in psychiatry. Translation of pharmacogenomic knowledge into clinical practice can be considered for specific drugs, but this requires education of clinicians, instructive guidelines, as well as full attention to polypharmacy and other clinically relevant factors. Recent large patient studies (n > 1,000) have replicated previous findings and produced robust evidence warranting the clinical utility of relevant genetic biomarkers. To further judge the clinical and financial benefits of preemptive genotyping in psychiatry, large prospective randomized trials are needed to quantify the value of genetic-based patient stratification in neuropsychopharmacotherapy and to demonstrate the cost-effectiveness of such interventions.
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Affiliation(s)
- Roos van Westrhenen
- Department of Psychiatry, Parnassia Group, Amsterdam, Netherlands.,Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Katherine J Aitchison
- Departments of Psychiatry and Medical Genetics, University of Alberta, Edmonton, AB, Canada
| | - Magnus Ingelman-Sundberg
- Pharmacogenetics Section, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Marin M Jukić
- Pharmacogenetics Section, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
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