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Vázquez GH, Bahji A, Undurraga J, Tondo L, Baldessarini RJ. Efficacy and Tolerability of Combination Treatments for Major Depression: Antidepressants plus Second-Generation Antipsychotics vs. Esketamine vs. Lithium. J Psychopharmacol 2021; 35:890-900. [PMID: 34238049 PMCID: PMC8358538 DOI: 10.1177/02698811211013579] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Successful treatment of major depressive disorder (MDD) can be challenging, and failures ("treatment-resistant depression" [TRD]) are frequent. Steps to address TRD include increasing antidepressant dose, combining antidepressants, adding adjunctive agents, or using nonpharmacological treatments. Their relative efficacy and tolerability remain inadequately tested. In particular, the value and safety of increasingly employed second-generation antipsychotics (SGAs) and new esketamine, compared to lithium as antidepressant adjuncts remain unclear. METHODS We reviewed randomized, placebo-controlled trials and used random-effects meta-analysis to compare odds ratio (OR) versus placebo, as well as numbers-needed-to-treat (NNT) and to-harm (NNH), for adding SGAs, esketamine, or lithium to antidepressants for major depressive episodes. RESULTS Analyses involved 49 drug-placebo pairs. By NNT, SGAs were more effective than placebo (NNT = 11 [CI: 9-15]); esketamine (7 [5-10]) and lithium (5 [4-10]) were even more effective. Individually, aripiprazole, olanzapine+fluoxetine, risperidone, and ziprasidone all were more effective (all NNT < 10) than quetiapine (NNT = 13), brexpiprazole (16), or cariprazine (16), with overlapping NNT CIs. Risk of adverse effects, as NNH for most-frequently reported effects, among SGAs versus placebo was 5 [4-6] overall, and highest with quetiapine (NNH = 3), lowest with brexpiprazole (19), 5 (4-6) for esketamine, and 9 (5-106) with lithium. The risk/benefit ratio (NNH/NNT) was 1.80 (1.25-10.60) for lithium and much less favorable for esketamine (0.71 [0.60-0.80]) or SGAs (0.45 [0.17-0.77]). CONCLUSIONS Several modern antipsychotics and esketamine appeared to be useful adjuncts to antidepressants for acute major depressive episodes, but lithium was somewhat more effective and better tolerated. LIMITATIONS Most trials of adding lithium involved older, mainly tricyclic, antidepressants, and the dosing of adjunctive treatments were not optimized.
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Affiliation(s)
- Gustavo H. Vázquez
- International Consortium for Mood & Psychotic Disorder Research, McLean Hospital, Belmont, MA, USA,Department of Psychiatry, Queen’s University, Kingston, Canada,Gustavo H. Vázquez, Department of Psychiatry, Queen’s University, 752 King Street, Kingston, ON K7P0H9, Canada.
| | - Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, Canada
| | - Juan Undurraga
- International Consortium for Mood & Psychotic Disorder Research, McLean Hospital, Belmont, MA, USA,Department of Neurology & Psychiatry, Clinica Alemana Universidad del Desarrollo, Santiago, Chile,Early Intervention Program, Instituto Psiquiátrico Dr J. Horwitz Barak, Santiago, Chile
| | - Leonardo Tondo
- International Consortium for Mood & Psychotic Disorder Research, McLean Hospital, Belmont, MA, USA,Department of Psychiatry, McLean Hospital & Harvard Medical School, Boston, MA, USA,Lucio Bini Mood Disorder Centers, Cagliari & Rome, Italy
| | - Ross J. Baldessarini
- International Consortium for Mood & Psychotic Disorder Research, McLean Hospital, Belmont, MA, USA,Department of Psychiatry, McLean Hospital & Harvard Medical School, Boston, MA, USA
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Taylor RW, Marwood L, Oprea E, DeAngel V, Mather S, Valentini B, Zahn R, Young AH, Cleare AJ. Pharmacological Augmentation in Unipolar Depression: A Guide to the Guidelines. Int J Neuropsychopharmacol 2020; 23:587-625. [PMID: 32402075 PMCID: PMC7710919 DOI: 10.1093/ijnp/pyaa033] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/27/2020] [Accepted: 05/12/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pharmacological augmentation is a recommended strategy for patients with treatment-resistant depression. A range of guidelines provide advice on treatment selection, prescription, monitoring and discontinuation, but variation in the content and quality of guidelines may limit the provision of objective, evidence-based care. This is of importance given the side effect burden and poorer long-term outcomes associated with polypharmacy and treatment-resistant depression. This review provides a definitive overview of pharmacological augmentation recommendations by assessing the quality of guidelines for depression and comparing the recommendations made. METHODS A systematic literature search identified current treatment guidelines for depression published in English. Guidelines were quality assessed using the Appraisal of Guidelines for Research and Evaluation II tool. Data relating to the prescription of pharmacological augmenters were extracted from those developed with sufficient rigor, and the included recommendations compared. RESULTS Total of 1696 records were identified, 19 guidelines were assessed for quality, and 10 were included. Guidelines differed in their quality, the stage at which augmentation was recommended, the agents included, and the evidence base cited. Lithium and atypical antipsychotics were recommended by all 10, though the specific advice was not consistent. Of the 15 augmenters identified, no others were universally recommended. CONCLUSIONS This review provides a comprehensive overview of current pharmacological augmentation recommendations for major depression and will support clinicians in selecting appropriate treatment guidance. Although some variation can be accounted for by date of guideline publication, and limited evidence from clinical trials, there is a clear need for greater consistency across guidelines to ensure patients receive consistent evidence-based care.
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Affiliation(s)
- Rachael W Taylor
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,National Institute for Health Research Maudsley Biomedical Research Centre, South London & Maudsley NHS Foundation Trust, London, United Kingdom
| | - Lindsey Marwood
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,Correspondence: Lindsey Marwood, PhD, 103 Denmark Hill, PO74, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE58AF, United Kingdom ()
| | - Emanuella Oprea
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Valeria DeAngel
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,National Institute for Health Research Maudsley Biomedical Research Centre, South London & Maudsley NHS Foundation Trust, London, United Kingdom
| | - Sarah Mather
- Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Beatrice Valentini
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,Department of Psychology and Educational Sciences, University of Geneva, Geneva, Switzerland
| | - Roland Zahn
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,National Institute for Health Research Maudsley Biomedical Research Centre, South London & Maudsley NHS Foundation Trust, London, United Kingdom
| | - Allan H Young
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,South London and Maudsley NHS Foundation Trust, London, United Kingdom,National Institute for Health Research Maudsley Biomedical Research Centre, South London & Maudsley NHS Foundation Trust, London, United Kingdom
| | - Anthony J Cleare
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,South London and Maudsley NHS Foundation Trust, London, United Kingdom,National Institute for Health Research Maudsley Biomedical Research Centre, South London & Maudsley NHS Foundation Trust, London, United Kingdom
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3
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Börjesson J, Gøtzsche PC. Effect of lithium on suicide and mortality in mood disorders: A systematic review. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2020; 30:155-166. [PMID: 31381531 DOI: 10.3233/jrs-190058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess if lithium treatment in patients with mood disorders, for instance depression, bipolar disorders, and schizoaffective disorders, has an effect on total mortality and suicide. DESIGN Systematic review and meta-analysis. MAIN OUTCOME MEASURE Total mortality. Secondary outcome was suicide. DATA SOURCES PubMed and ClinicalTrials.gov. Eligible trials were randomized double-blind trials comparing lithium with placebo in patients with mood disorders who were not already on lithium before randomization in order to avoid withdrawal effects in the placebo group. DATA EXTRACTION AND ANALYSIS Two researchers extracted data independently. Data were analysed with Review Manager 5.3 (Peto odds ratio). RESULTS We found 45 eligible studies. Only four studies reported any suicides or other deaths in the lithium or placebo group. There was a significant reduction in total mortality (two versus nine), odds ratio 0.28 (95% confidence interval 0.08 to 0.93). There was no statistically significant reduction in suicides, (none versus three), odds ratio 0.13 (0.01 to 1.27). CONCLUSION According to our study, lithium reduces total mortality in mood disorders but not suicide. Because of small numbers and unreliable data, the findings should be interpreted with caution.
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Undurraga J, Sim K, Tondo L, Gorodischer A, Azua E, Tay KH, Tan D, Baldessarini RJ. Lithium treatment for unipolar major depressive disorder: Systematic review. J Psychopharmacol 2019; 33:167-176. [PMID: 30698058 DOI: 10.1177/0269881118822161] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The potential value of lithium treatment in particular aspects of unipolar major depressive disorder remains uncertain. METHODS With reports of controlled trials identified by systematic searching of Medline, Cochrane Library, and PsycINFO literature databases, we summarized responses with lithium and controls followed by selective random-effects meta-analyses. RESULTS We identified 36 reports with 39 randomized controlled trials: six for monotherapy and 12 for adding lithium to antidepressants for acute major depression, and 21 for long-term treatment. Data for monotherapy of acute depression were few and inconclusive. As an adjunct to antidepressants, lithium was much more effective than placebo ( p<0.0001). For long-term maintenance treatment, lithium was more effective than placebo in monotherapy ( p=0.011) and to supplement antidepressants ( p=0.038), and indistinguishable from antidepressant monotherapy. CONCLUSIONS The findings indicate efficacy of lithium as a treatment for some aspects of major depressive disorder, especially as an add-on to antidepressants and for long-term prophylaxis. It remains uncertain whether some benefits of lithium treatment occur with many major depressive disorder patients, or if efficacy is particular to a subgroup with bipolar disorder-like characteristics or mixed-features.
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Affiliation(s)
- Juan Undurraga
- 1 International Consortium for Mood and Psychotic Disorder Research, McLean Hospital, Belmont, MA, USA.,3 Early Intervention Program, J Horwitz Psychiatric Institute, Santiago, Chile
| | - Kang Sim
- 1 International Consortium for Mood and Psychotic Disorder Research, McLean Hospital, Belmont, MA, USA.,4 Research Division, Institute of Mental Health/Woodbridge Hospital, Singapore
| | - Leonardo Tondo
- 1 International Consortium for Mood and Psychotic Disorder Research, McLean Hospital, Belmont, MA, USA.,5 Department of Psychiatry, Harvard Medical School, Boston, MA, USA.,6 Lucio Bini Mood Disorder Centers, Cagliari and Rome, Italy
| | - Ariel Gorodischer
- 7 Department of Psychiatry, Universidad de Los Andes, Santiago, Chile
| | - Emilio Azua
- 8 Department of Psychiatry, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Kai Hong Tay
- 4 Research Division, Institute of Mental Health/Woodbridge Hospital, Singapore
| | - David Tan
- 4 Research Division, Institute of Mental Health/Woodbridge Hospital, Singapore
| | - Ross J Baldessarini
- 1 International Consortium for Mood and Psychotic Disorder Research, McLean Hospital, Belmont, MA, USA.,5 Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Młyniec K, Davies CL, de Agüero Sánchez IG, Pytka K, Budziszewska B, Nowak G. Essential elements in depression and anxiety. Part I. Pharmacol Rep 2014; 66:534-44. [PMID: 24948052 DOI: 10.1016/j.pharep.2014.03.001] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 02/27/2014] [Accepted: 03/03/2014] [Indexed: 12/17/2022]
Abstract
Essential elements are very important for the proper functioning of the human body. They are required for fundamental life processes such as cell division and differentiation and protein synthesis. Thus a deficiency of these essential elements is associated with an enormous health risk that can ultimately lead to death. In recent years, studies have provided valuable information on the involvement of essential elements in psychiatric disorders, in particular depression and anxiety. There is strong evidence indicating that deficiency of essential elements can lead to the development of depressive and/or anxiogenic behaviour and supplementation can enhance therapeutic effect of antidepressants and anxiolytics. This review presents the most important results from preclinical and clinical studies showing involvement of essential elements such as zinc, magnesium, lithium, iron, calcium and chromium in depression and anxiety. From these studies it is evident that different types of depression and anxiety respond to treatment at different receptors indicating that the underlying mechanisms are slightly different. Furthermore, administration of low dose antidepressants supplemented with an element is effective and can reduce unwanted side effects in different types of depression/anxiety.
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Affiliation(s)
- Katarzyna Młyniec
- Department of Biochemical Toxicology, Jagiellonian University Collegium Medicum, Kraków, Poland; Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland.
| | - Claire Linzi Davies
- Neurobiology Division, The Roslin Institute & Royal (Dick) School of Veterinary Studies University of Edinburgh, Scotland, UK
| | | | - Karolina Pytka
- Department of Pharmacodynamics, Jagiellonian University Medical College, Kraków, Poland
| | - Bogusława Budziszewska
- Department of Biochemical Toxicology, Jagiellonian University Collegium Medicum, Kraków, Poland; Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland
| | - Gabriel Nowak
- Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland; Department of Pharmacobiology, Jagiellonian University Medical College, Kraków, Poland
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Taylor MA, Fink M. Restoring melancholia in the classification of mood disorders. J Affect Disord 2008; 105:1-14. [PMID: 17659352 DOI: 10.1016/j.jad.2007.05.023] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Revised: 05/21/2007] [Accepted: 05/29/2007] [Indexed: 11/27/2022]
Abstract
The present DSM criteria for major depression poorly identify samples for treatment selection, prognosis, and assessments of pathophysiology. Melancholia, in contrast, is a disorder with definable clinical signs that can be verified by laboratory tests and treatment response. It identifies more specific populations than the present system and deserves individual identification in psychiatric classification. Its re-introduction will refine diagnosis, prognosis, treatment selection, and studies of pathophysiology of a large segment of the psychiatrically ill.
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Affiliation(s)
- Michael Alan Taylor
- Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, United States
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Abstract
Major depression is a chronic disorder with a high morbidity and mortality. Approved treatment for major depression at present includes monotherapy with antidepressants of different pharmacologic classes. There is increasingly widespread use of two other options: augmentation, the addition to an antidepressant of a second compound that is not an antidepressant when used alone; and combination, which is the use of two antidepressants concurrently to enhance or accelerate response. This review focuses on the data available to support these various augmentation and combination treatments.
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Affiliation(s)
- Russell T Joffe
- New Jersey Medical School, Department of Psychiatry, Maplewood, NJ 07040, USA.
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Abstract
Despite the prevalence and morbidity of bipolar depression, few randomized treatment trials have been conducted to assess clinical efficacy. Even fewer studies have assessed approaches that optimize treatment response for bipolar depression. This review will define three types of common combination strategies--adjunctive, acceleration and augmentation--and discuss the limited literature of controlled studies reported on acceleration and augmentation approaches.
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Affiliation(s)
- Lori L Altshuler
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, California 90095, USA
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9
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Abstract
The authors conducted an open-label study of the efficacy and tolerability of venlafaxine and of lithium augmentation in outpatients with depression who were not responding to venlafaxine. Outpatients aged 18 to 70 years were eligible if they had a minimum baseline score of 16 on the 17-item Hamilton Rating Scale for Depression (HAM-D). Patients were started on venlafaxine 37.5 mg twice daily for 1 week. For weeks 2 through 4, the dose of venlafaxine was increased to 75 mg twice daily, and for weeks 5 through 7, the dose was further increased to 75 mg three times daily. At the end of the 7-week treatment period, patients with a <50% decrease in their HAM-D scores from baseline were given lithium carbonate 600 mg once daily. The dose of lithium carbonate was adjusted to maintain plasma levels in the range of 0.6 to 1.0 mmol/mL. Efficacy was assessed with the 17-item HAM-D, Montgomery-Asberg Depression Rating Scale, and the Clinical Global Impressions Scale. Data were analyzed on an intent-to-treat basis. At the end of the 7-week treatment period, 35% of patients showed a > or = 50% decrease in their HAM-D scores from baseline. Lithium augmentation was initiated in 23 patients. The results showed that the addition of lithium was well-tolerated and led to a further decrease in the HAM-D scores, with eight patients responding and two of them presenting a remission. The addition of lithium to venlafaxine was found to be a well-tolerated strategy in treatment-resistant patients.
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Affiliation(s)
- E Hoencamp
- Parnassia, Psycho-Medical Centre, The Hague, The Netherlands
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10
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Benedetti F, Colombo C, Barbini B, Campori E, Smeraldi E. Ongoing lithium treatment prevents relapse after total sleep deprivation. J Clin Psychopharmacol 1999; 19:240-5. [PMID: 10350030 DOI: 10.1097/00004714-199906000-00007] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Forty bipolar depressed inpatients underwent three consecutive cycles of total sleep deprivation (TSD). At the beginning of the study, 20 patients were free of psychotropic drugs and 20 had been receiving lithium medication for at least 6 months. Mood was rated on the Hamilton Rating Scale for Depression before and after TSD; perceived mood changes during treatment were evaluated with self-administered visual analog scales. Patients undergoing long-term lithium treatment showed a significantly better response to TSD as rated on both scales: 13 of 20 patients (vs. 2 of 20 patients without lithium) showed a sustained response during a follow-up period of 3 months. This preliminary evidence of a positive interaction of TSD and long-term lithium treatment could be explained by a synergistic effect of both treatments on brain serotonergic function, possibly via a desensitization of 5-hydroxytryptamine-1A inhibitory autoreceptors.
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Affiliation(s)
- F Benedetti
- Department of Neuropsychiatric Sciences, Instituto Scientifico Ospedale San Raffaele, University of Milan, School of Medicine, Milano, Italy.
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Cohen LG, Biederman J, Wilens TE, Spencer TJ, Mick E, Faraone SV, Prince J, Flood JG. Desipramine clearance in children and adolescents: absence of effect of development and gender. J Am Acad Child Adolesc Psychiatry 1999; 38:79-85. [PMID: 9893420 DOI: 10.1097/00004583-199901000-00023] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the influence of development and gender on the pharmacokinetics of desipramine (DMI) in the pediatric population. METHOD DMI pharmacokinetic parameters were calculated from 407 routinely drawn, dose- and weight-normalized serum concentrations in 173 youths receiving DMI (90 children, 83 adolescents; 29 were female, 144 were male). RESULTS Mean pharmacokinetic parameters for the entire population included dose (3.78 +/- 1.51 mg/kg), weight- and dose-normalized serum concentration (45.41 +/- 47.39 [micrograms/L]/[mg/kg]), and DMI clearance (0.68 +/- 1.51 [L/kg]/hr). No between-group differences for children and adolescents were detected in dose (child, adolescent) (3.73 +/- 1.40 mg/kg, 3.83 +/- 1.68 mg/kg), weight- and dose-normalized serum concentrations (44.52 +/- 39.6 [micrograms/L]/[mg/kg], 46.34 +/- 34.89 [micrograms/L]/[mg/kg]; p = .62), and clearance (0.680 +/- 0.890 [L/kg]/hr, 0.695 +/- 1.05 [L/kg]/hr; p = .103). No between-group gender differences were detected in dose (male, female) (3.83 +/- 1.55 mg, 3.39 +/- 1.84 mg), weight- and dose-normalized serum concentrations (45.15 +/- 37.76 [micrograms/L]/[mg/kg], 47.14 +/- 34.96 [micrograms/L]/mg/kg]; p = .720), and clearance (0.699 +/- 0.89 [L/kg]/hr, 0.606 +/- 0.535 [L/kg]/hr; p = .390). CONCLUSIONS These results suggest that age and gender do not significantly influence DMI clearance or dose-normalized serum concentrations in the pediatric population.
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Affiliation(s)
- L G Cohen
- Department of Pharmacy, Massachusetts General Hospital, Boston 02114, USA
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