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Schoretsanitis G, Correll CU, Agorastos A, Compaired Sanchez A, Erzin G, Grigoras RM, Grizelj Benussi M, Gondek TM, Guloksuz S, Højlund M, Jerotic S, Kilic O, Metaj E, Sidhu DS, Skandali N, Skuhareuski A, Tveito M, Wolthusen RPF, Chumakov E, de Filippis R. The European psychiatric association (EPA) - early career psychiatrists committee survey on trainees' and early-career psychiatrists' attitudes towards therapeutic drug monitoring (TDM) use and utility during antipsychotic treatment. World J Biol Psychiatry 2024; 25:342-351. [PMID: 38905131 DOI: 10.1080/15622975.2024.2367138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 06/07/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVES This survey assessed psychiatry residents'/early-career psychiatrists' attitudes towards the utility of therapeutic drug monitoring (TDM) of antipsychotics. METHODS A previously developed questionnaire on attitudes on TDM utility during antipsychotic treatment was cross-sectionally disseminated by national coordinators between 01/01/2022-31/12/2023. The frequency of using TDM for antipsychotics other than clozapine was the main outcome in a linear regression analysis, including sex, clinical setting, caseload, and factors generated by an exploratory factor analysis. Comparisons between residents and early-career psychiatrists, respondents working in in- and outpatient settings, and low-/middle- and high-income countries were performed. RESULTS Altogether, 1,237 respondents completed the survey, with 37.9% having never used TDM for antipsychotics. Seven factors explained 41% of response variance; six of them were associated with frequency of TDM use (p < 0.05). Items with highest loadings for factors included clinical benefits of TDM (factors A and E: 0.7), negative expectations for beliefs of patients towards TDM (factor B: 0.6-0.7), weak TDM scientific evidence (factor C: 0.8), and TDM availability (factor D: -0.8). Respondents from low-/middle-income countries were less likely to frequently/almost always use TDM compared to high-income countries (9.4% vs. 21.5%, p < 0.001). DISCUSSION TDM use for antipsychotics was poor and associated with limited knowledge and insufficient availability.
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Affiliation(s)
- Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Christoph U Correll
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- The Feinstein Institute for Medical Research, Manhasset, NY, USA
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Agorastos Agorastos
- II. Department of Psychiatry, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | | | - Gamze Erzin
- Department of Psychiatry, Dışkapı Yıldırım Beyazıt Training and Research Hospital, University of Health Sciences, Ankara, Turkey
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | | | - Tomasz M Gondek
- Institute of Social Studies, University of Lower Silesia, Wroclaw, Poland
| | - Sinan Guloksuz
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Mikkel Højlund
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department of Psychiatry, Mental Health Services Region of Southern Denmark, Aabenraa, Denmark
| | - Stefan Jerotic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Psychiatry, University Clinical Centre of Serbia, Beograd, Serbia
| | - Ozge Kilic
- Department of Psychiatry, Bezmialem Vakif University Faculty of Medicine, Istanbul, Turkey
| | - Enita Metaj
- Community Mental Health Center no. 2, Tirana, Albania
| | | | - Nikolina Skandali
- Department of Psychiatry, University of Cambridge & Addenbrooke's hospital, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | | | - Marit Tveito
- Center for Psychopharmacology, Diakonhjemmet hospital, Vinderen, Oslo, Norway
| | - Rick P F Wolthusen
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Egor Chumakov
- Department of Psychiatry and Addiction, Saint Petersburg State University, Saint Petersburg, Russia
| | - Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
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Lenk HÇ, Smith RL, O'Connell KS, Andreassen OA, Molden E. Rapid Metabolism Underlying Subtherapeutic Serum Levels of Atypical Antipsychotics Preceding Clozapine Treatment: A Retrospective Analysis of Real-World Data. CNS Drugs 2024; 38:473-480. [PMID: 38635089 PMCID: PMC11098931 DOI: 10.1007/s40263-024-01079-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Adequate antipsychotic treatment intensity is required before diagnosing resistant schizophrenia and initiating clozapine treatment. We aimed to investigate potential rapid drug metabolism underlying low dose-adjusted serum concentration (CD) of non-clozapine atypical antipsychotics preceding clozapine treatment. METHODS Patients using non-clozapine, atypical antipsychotics (aripiprazole, risperidone, olanzapine, or quetiapine) within 1 year before starting clozapine were included in this study from a therapeutic drug monitoring service in Oslo, Norway, between 2005 and 2023. Patients were assigned into low CD (LCD) and normal CD (NCD) subgroups. Using a reference sample with 147,964 antipsychotic measurements, LCD was defined as CDs below the 25th percentile, while patients with NCD exhibited CDs between the 25th and 75th percentile of the respective reference measurements. Metabolic ratios, doses, and frequency of subtherapeutic levels of non-clozapine antipsychotics were compared between LCD and NCD groups. RESULTS Preceding clozapine treatment, 110 out of 272 included patients (40.4%) were identified with LCD. Compared with the NCD group, LCD patients exhibited higher metabolic ratios of olanzapine (1.5-fold; p < 0.001), quetiapine (3.0-fold; p < 0.001), and risperidone (6.0-fold; p < 0.001). Metabolic ratio differences were independent of smoking and CYP2D6 genotype for olanzapine (p = 0.008) and risperidone (p = 0.016), respectively. Despite higher doses of olanzapine (1.25-fold; p = 0.054) and quetiapine (1.6-fold; p = 0.001) in LCD versus NCD patients, faster metabolism among the former was accompanied by higher frequencies of subtherapeutic levels of olanzapine (3.3-fold; p = 0.044) and quetiapine (1.8-fold; p = 0.005). CONCLUSION LCD and associated rapid metabolism of non-clozapine antipsychotics is frequent before starting clozapine treatment. For olanzapine and quetiapine, this is associated with significantly increased risk of having subtherapeutic concentrations.
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Affiliation(s)
- Hasan Çağın Lenk
- Center for Psychopharmacology, Diakonhjemmet Hospital, Vinderen, PO Box 85, 0319, Oslo, Norway.
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway.
- Division of Mental Health and Addiction, NORMENT, Centre for Mental Disorders Research, Institute of Clinical Medicine, Oslo University Hospital, University of Oslo, Oslo, Norway.
| | - Robert Løvsletten Smith
- Center for Psychopharmacology, Diakonhjemmet Hospital, Vinderen, PO Box 85, 0319, Oslo, Norway
| | - Kevin S O'Connell
- Division of Mental Health and Addiction, NORMENT, Centre for Mental Disorders Research, Institute of Clinical Medicine, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Ole A Andreassen
- Division of Mental Health and Addiction, NORMENT, Centre for Mental Disorders Research, Institute of Clinical Medicine, Oslo University Hospital, University of Oslo, Oslo, Norway
- KG Jebsen Centre for Neurodevelopmental disorders, University of Oslo, Oslo University Hospital, Oslo, Norway
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Vinderen, PO Box 85, 0319, Oslo, Norway
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
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Ruan CJ, Olmos I, Ricciardi C, Schoretsanitis G, Vincent PD, Anıl Yağcıoğlu AE, Eap CB, Baptista T, Clark SR, Fernandez-Egea E, Kim SH, Lane HY, Leung J, Maroñas Amigo O, Motuca M, Every-Palmer S, Procyshyn RM, Rohde C, Suhas S, Schulte PFJ, Spina E, Takeuchi H, Verdoux H, Correll CU, Molden E, De Las Cuevas C, de Leon J. Exploring low clozapine C/D ratios, inverted clozapine-norclozapine ratios and undetectable concentrations as measures of non-adherence in clozapine patients: A literature review and a case series of 17 patients from 3 studies. Schizophr Res 2024; 268:293-301. [PMID: 37487869 DOI: 10.1016/j.schres.2023.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/07/2023] [Accepted: 07/08/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Up to 1/2 of outpatients prescribed clozapine may be partially/fully non-adherent, based on therapeutic drug monitoring (TDM). Three indices for measuring partial/full non-adherence are proposed a: 1) clozapine concentration/dose (C/D) ratio which drops to half or more of what is expected in the patient; 2) clozapine/norclozapine ratio that becomes inverted; and 3) clozapine concentration that becomes non-detectable. METHODS These 3 proposed indices are based on a literature review and 17 cases of possible non-adherence from 3 samples: 1) an inpatient study in a Chinese hospital, 2) an inpatient randomized clinical trial in a United States hospital, and 3) and a Uruguayan outpatient study. RESULTS The first index of non-adherence is a clozapine C/D ratio which is less than half the ratio corresponding to the patient's specific ancestry group and sex-smoking subgroup. Knowing the minimum therapeutic dose of the patient based on repeated TDM makes it much easier to establish non-adherence. The second index is inverted clozapine/norclozapine ratios in the absence of alternative explanations. The third index is undetectable concentrations. By using half-lives, the chronology of the 3 indices of non-adherence was modeled in two patients: 1) the clozapine C/D ratio dropped to ≥1/2 of what is expected from the patient (around day 2); 2) the clozapine/norclozapine ratio became inverted (around day 3); and 3) the clozapine concentration became undetectable by the laboratory (around days 9-11). CONCLUSION Prospective studies should further explore these proposed clozapine indices in average patients, poor metabolizers (3 presented) and ultrarapid metabolizers (2 presented).
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Affiliation(s)
- Can-Jun Ruan
- The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.
| | - Ismael Olmos
- Clinical Pharmacology Unit and Pharmacy Department, Vilardebó Hospital, Administración de Servicios de Salud, Montevideo, Uruguay.
| | - Carina Ricciardi
- Clinical Pharmacology Unit and Outpatient Clinic, Vilardebó Hospital, Administración de Servicios de Salud, Montevideo, Uruguay.
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland; The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA.
| | - Philippe D Vincent
- Department of Pharmacy, Institut Universitaire en Santé Mentale de Montréal (IUSMM), Montreal, Canada; Faculty of Pharmacy, Université de Montréal, Montreal, Canada; IUSMM Research Center, Montreal, Canada.
| | | | - Chin B Eap
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland; School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland; Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland; Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland.
| | - Trino Baptista
- Department of Physiology, Los Andes University Medical School, Mérida, Venezuela; Medical School, Anáhuac University, Querétaro, Mexico; Neuroorigen, Querétaro, Mexico.
| | - Scott R Clark
- University of Adelaide, Discipline of Psychiatry, Adelaide, Australia.
| | - Emilio Fernandez-Egea
- Department of Psychiatry, University of Cambridge, Cambridge, UK; Cambridgeshire and Peterborough NHS Foundation Trust, Fulbourn Hospital, Fulbourn, Cambridge, UK.
| | - Se Hyun Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Hsien-Yuan Lane
- Department of Psychiatry and Brain Disease Research Center, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan; Department of Psychology, College of Medical and Health Sciences, Asia University, Taichung, Taiwan.
| | - Jonathan Leung
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA.
| | - Olalla Maroñas Amigo
- Genomic Medicine Group, Galician Public Foundation of Genomic Medicine (FPGMX), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Galicia, Spain; Center for Research in Molecular Medicine and Chronic Diseases (CIMUS), University of Santiago de Compostela (USC), Santiago de Compostela, Spain; Center for Biomedical Research in Rare Diseases Network, Carlos III Health Institute, Madrid, Spain.
| | - Mariano Motuca
- Department of Psychiatry, School of Medicine at Universidad Nacional de Cuyo, Mendoza, Argentina.
| | - Susanna Every-Palmer
- Department of Psychological Medicine, University of Otago Wellington, Wellington, New Zealand.
| | - Ric M Procyshyn
- Department of Psychiatry, University of British Columbia, Vancouver, Canada; British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, Canada.
| | - Christopher Rohde
- Department of Affective Disorders, Aarhus University Hospital - Psychiatry, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Satish Suhas
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India.
| | - Peter F J Schulte
- Mental Health Services Noord-Holland-Noord, Alkmaar, Netherlands; Dutch Clozapine Collaboration Group, Castricum, Netherlands.
| | - Edoardo Spina
- Department of Clinical and Experimeta Medicine, University of Messina, Messina, Italy.
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.
| | - Hélène Verdoux
- Université Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France.
| | - Christoph U Correll
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany.
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway; Department of Pharmacy, University of Oslo, Oslo, Norway.
| | - Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain; Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain.
| | - Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain.
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Pennazio F, Brasso C, Villari V, Rocca P. Current Status of Therapeutic Drug Monitoring in Mental Health Treatment: A Review. Pharmaceutics 2022; 14:pharmaceutics14122674. [PMID: 36559168 PMCID: PMC9783500 DOI: 10.3390/pharmaceutics14122674] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/25/2022] [Accepted: 11/26/2022] [Indexed: 12/03/2022] Open
Abstract
Therapeutic drug monitoring (TDM) receives growing interest in different psychiatric clinical settings (emergency, inpatient, and outpatient services). Despite its usefulness, TDM remains underemployed in mental health. This is partly due to the need for evidence about the relationship between drug serum concentration and efficacy and tolerability, both in the general population and even more in subpopulations with atypical pharmacokinetics. This work aims at reviewing the scientific literature published after 2017, when the most recent guidelines about the use of TDM in mental health were written. We found 164 pertinent records that we included in the review. Some promising studies highlighted the possibility of correlating early drug serum concentration and clinical efficacy and safety, especially for antipsychotics, potentially enabling clinicians to make decisions on early laboratory findings and not proceeding by trial and error. About populations with pharmacokinetic peculiarities, the latest studies confirmed very common alterations in drug blood levels in pregnant women, generally with a progressive decrease over pregnancy and a very relevant dose-adjusted concentration increase in the elderly. For adolescents also, several drugs result in having different dose-related concentration values compared to adults. These findings stress the recommendation to use TDM in these populations to ensure a safe and effective treatment. Moreover, the integration of TDM with pharmacogenetic analyses may allow clinicians to adopt precise treatments, addressing therapy on an individual pharmacometabolic basis. Mini-invasive TDM procedures that may be easily performed at home or in a point-of-care are very promising and may represent a turning point toward an extensive real-world TDM application. Although the highlighted recent evidence, research efforts have to be carried on: further studies, especially prospective and fixed-dose, are needed to replicate present findings and provide clearer knowledge on relationships between dose, serum concentration, and efficacy/safety.
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Affiliation(s)
- Filippo Pennazio
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy
| | - Claudio Brasso
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy
- Correspondence:
| | - Vincenzo Villari
- Psychiatric Emergency Service, Department of Neuroscience and Mental Health, A.O.U. “Città della Salute e della Scienza di Torino”, 10126 Turin, Italy
| | - Paola Rocca
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy
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De las Cuevas C, de Leon J. Self-Report for Measuring and Predicting Medication Adherence: Experts' Experience in Predicting Adherence in Stable Psychiatric Outpatients and in Pharmacokinetics. Patient Prefer Adherence 2020; 14:1823-1842. [PMID: 33116427 PMCID: PMC7555336 DOI: 10.2147/ppa.s242693] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 09/25/2020] [Indexed: 12/18/2022] Open
Abstract
THE PROBLEM Poor adherence to appropriately prescribed medication is a global challenge for psychiatrists. PRIOR STUDIES Measuring adherence is complicated. In our recent three-country naturalistic study including more than 1000 patients and their adherence to multiple medication prescriptions at the same time, patients' self-report of adherence to each specific drug was the only practical option for measuring adherence. Systematic literature reviews provide inconsistent results for sociodemographic, clinical and medication variables as predictors of adherence to psychiatric drugs. Our studies over the last 10 years in relatively stable psychiatric outpatients have shown that some self-reported health beliefs had consistent, strong effects and a better predictive role. Three dimensions of these health beliefs are characteristics of the individual: 1) attitudes toward psychiatric medication such as pharmacophobia (fear of taking drugs or medicines), 2) health locus of control (the belief patients have about who or what agent determines the state of their health), 3) psychological reactance (an emotional reaction in direct contradiction to rules or regulations that threaten or suppress certain freedoms in behavior). They can be measured by the Patient Health Beliefs Questionnaire on Psychiatric Treatment. The attitude toward each specific medication can be measured by the necessity-concern framework and summarized as the presence or absence of skepticism about that drug. After 25 years conducting pharmacokinetic studies in psychiatric drugs, particularly antipsychotics, we have limited understanding of how to use blood levels to predict the effects of non-adherence or to establish it. EXPERT OPINION ON FUTURE STUDIES Future studies to predict adherence should include the inpatient setting and explore insight. Studying the pharmacokinetics associated with non-adherence in each psychiatric drug is a major challenge. Medication adherence is a complex and dynamic process changing over time in the same patient. Personalizing adherence using psychological or pharmacological variables are in their initial stages.
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Affiliation(s)
- Carlos De las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, University of La Laguna, San Cristóbal de La Laguna, Canary Islands, Spain
- Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain
- Correspondence: Carlos De las CuevasDepartment of Internal Medicine, Dermatology and Psychiatry, Universidad de La Laguna,, Campus de Ofra s/n, San Cristóbal de La Laguna, Canary Islands, SpainTel +34-922-316502Fax +34-922-319353 Email
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA
- Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain
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