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Taurines R, Kunkel G, Fekete S, Fegert JM, Wewetzer C, Correll CU, Holtkamp K, Böge I, Renner TJ, Imgart H, Scherf-Clavel M, Heuschmann P, Gerlach M, Romanos M, Egberts K. Serum Concentration-Dose Relationship and Modulation Factors in Children and Adolescents Treated with Fluvoxamine. Pharmaceutics 2024; 16:772. [PMID: 38931893 PMCID: PMC11207785 DOI: 10.3390/pharmaceutics16060772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION Fluvoxamine is used in children and adolescents ('youths') for treating obsessive compulsive disorder (OCD) but also off-label for depressive and anxiety disorders. This study aimed to investigate the relationship between fluvoxamine dose and serum concentrations, independent correlates of fluvoxamine concentrations, and a preliminary therapeutic reference range (TRR) for youths with OCD and treatment response. METHODS Multicenter naturalistic data of a therapeutic drug monitoring service, as well as prospective data of the 'TDM Vigil study' (EudraCT 2013-004881-33), were analyzed. Patient and treatment characteristics were assessed by standardized measures, including Clinical Global Impressions-Severity (CGI-S) and -Change (CGI-I), with CGI-I of much or very much improved defining treatment response and adverse drug reactions using the Udvalg for Kliniske Undersogelser (UKU) Side Effect Rating Scale. Multivariable regression analysis was used to evaluate the influence of sex, age, body weight, body mass index (BMI), and fluvoxamine dose on fluvoxamine serum concentrations. RESULTS The study included 70 youths (age = 6.7-19.6 years, OCD = 78%, mean fluvoxamine dose = 140.4 (range = 25-300) mg/d). A weak positive correlation between daily dose and steady-state trough serum concentrations was found (rs = 0.34, p = 0.004), with dose variation explaining 16.2% of serum concentration variability. Multivariable correlates explaining 25.3% of the variance of fluvoxamine concentrations included higher fluvoxamine dose and lower BMI. Considering responders with OCD, the estimated TRR for youths was 55-371 ng/mL, exceeding the TRR for adults with depression of 60-230 ng/mL. DISCUSSION These preliminary data contribute to the definition of a TRR in youth with OCD treated with fluvoxamine and identify higher BMI as a moderator of lower fluvoxamine concentrations.
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Affiliation(s)
- Regina Taurines
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (G.K.); (S.F.); (M.G.); (M.R.); (K.E.)
| | - Gesa Kunkel
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (G.K.); (S.F.); (M.G.); (M.R.); (K.E.)
| | - Stefanie Fekete
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (G.K.); (S.F.); (M.G.); (M.R.); (K.E.)
| | - Jörg M. Fegert
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Ulm, 89075 Ulm, Germany;
| | - Christoph Wewetzer
- Clinics of the City Cologne GmbH, Clinic for Child and Adolescent Psychiatry and Psychotherapy, 51109 Cologne, Germany;
| | - Christoph U. Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany;
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY 11004, USA
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
- German Center for Mental Health (DZPG), Partner Site Berlin, 10117 Berlin, Germany
| | | | - Isabel Böge
- Department of Child and Adolescent Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, 8036 Graz, Austria;
- Department of Child and Adolescent Psychiatry Ravensburg-Weissenau, ZFP South Wuerttemberg, 88427 Bad Schussenried, Germany
| | - Tobias Johann Renner
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Psychiatry and Psychotherapy Tuebingen, Center of Mental Health, 72076 Tuebingen, Germany;
- German Center for Mental Health (DZPG), Partner Site Tuebingen, 72076 Tuebingen, Germany
| | - Hartmut Imgart
- Parkland-Clinic, Clinic for Psychosomatics and Psychotherapy, Academic Teaching Hospital for the University Gießen, 34537 Bad Wildungen, Germany;
| | - Maike Scherf-Clavel
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, 97080 Wuerzburg, Germany;
| | - Peter Heuschmann
- Clinical Trial Center Wuerzburg, University Hospital Wuerzburg, 97080 Wuerzburg, Germany;
- Institute of Clinical Epidemiology and Biometry, University of Wuerzburg, 97080 Wuerzburg, Germany
| | - Manfred Gerlach
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (G.K.); (S.F.); (M.G.); (M.R.); (K.E.)
| | - Marcel Romanos
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (G.K.); (S.F.); (M.G.); (M.R.); (K.E.)
| | - Karin Egberts
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (G.K.); (S.F.); (M.G.); (M.R.); (K.E.)
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Hart XM, Spangemacher M, Defert J, Uchida H, Gründer G. Update Lessons from PET Imaging Part II: A Systematic Critical Review on Therapeutic Plasma Concentrations of Antidepressants. Ther Drug Monit 2024; 46:155-169. [PMID: 38287888 DOI: 10.1097/ftd.0000000000001142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/29/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND Compared with antipsychotics, the relationship between antidepressant blood (plasma or serum) concentrations and target engagement is less well-established. METHODS We have discussed the literature on the relationship between plasma concentrations of antidepressant drugs and their target occupancy. Antidepressants reviewed in this work are citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine, duloxetine, milnacipran, tricyclic antidepressants (amitriptyline, nortriptyline, and clomipramine), bupropion, tranylcypromine, moclobemide, and vortioxetine. Four electronic databases were systematically searched. RESULTS We included 32 articles published 1996-2022. A strong relationship between serotonin transporter (SERT) occupancy and drug concentration is well established for selective serotonin reuptake inhibitors. Lower limits of recommended therapeutic reference ranges largely corroborate with the findings from positron emission tomography studies (80% SERT occupancy). Only a few novel studies have investigated alternative targets, that is, norepinephrine transporters (NETs), dopamine transporters (DATs), or monoamine oxidase A (MAO-A). For certain classes of drugs, positron emission tomography study data are inconclusive. Low DAT occupancy after bupropion treatment speculates its discussed mechanism of action. For MAO inhibitors, a correlation between drug concentration and MAO-A occupancy could not be established. CONCLUSIONS Neuroimaging studies are critical in TDM-guided therapy for certain antidepressants, whereas for bupropion and MAO inhibitors, the available evidence offers no further insight. Evidence for selective serotonin reuptake inhibitors is strong and justifies a titration toward suggested ranges. For SNRIs, duloxetine, and venlafaxine, NETs are sufficiently occupied, well above the SERT efficacy threshold. For these drugs, a titration toward higher concentrations (within the recommended range) should be considered in case of no response at lower concentrations.
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Affiliation(s)
- Xenia M Hart
- Department of Molecular Neuroimaging, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; and
| | - Moritz Spangemacher
- Department of Molecular Neuroimaging, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- Department of Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Julie Defert
- Department of Molecular Neuroimaging, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; and
| | - Gerhard Gründer
- Department of Molecular Neuroimaging, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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Sugimoto A, Suzuki Y, Orime N, Hayashi T, Yoshinaga K, Egawa J, Ono S, Sugai T, Inoue Y, Someya T. The lowest effective plasma concentration of atomoxetine in pediatric patients with attention deficit/hyperactivity disorder: A non-randomized prospective interventional study. Medicine (Baltimore) 2021; 100:e26552. [PMID: 34232195 PMCID: PMC8270591 DOI: 10.1097/md.0000000000026552] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 05/28/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Atomoxetine (ATX) is used as a first-line, non-stimulant treatment for attention-deficit/hyperactivity disorder (ADHD), although no studies have systematically examined the relationship between plasma concentration and clinical efficacy. We conducted this non-randomized prospective interventional study to examine the relationship between plasma concentration of ATX and clinical efficacy. METHODS Forty-three ADHD pediatric patients received ATX, and the steady-state through plasma concentration of the last daily dose that was maintained for at least 4 weeks were determined by high-performance liquid chromatography. RESULTS The receiver operating characteristic curve suggested that when plasma concentration exceeded 64.60 ng/mL, scores on the ADHD-Rating Scale improved by 50% or more (P = .14). Although 6 of the 8 final responders were unresponsive at the initial dose (.72 ± .04 mg/kg [mean ± standard deviation]), they responded after increasing the ATX dose to the final dose (1.52 ± .31 mg/kg). Excluding 7 outlier participants, the concentration was 83.3 ± 32.3 ng/mL in 7 responders and was significantly higher than 29.5 ± 23.9 ng/mL (P < .01) for the 29 non-responders. CONCLUSIONS These results suggest that a minimum effective plasma concentration of ATX is required to achieve sufficient clinical efficacy. We hypothesized a mechanism that results in the realization of a clinical effect when the plasma concentration exceeds a certain threshold in the potential response group, whereas will not improve even if the plasma concentration is increased in the unqualified non-responder group.
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Affiliation(s)
- Atsunori Sugimoto
- Department of Community Psychiatric Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
- Department of Psychiatry, Niigata Psychiatric Center, Nagaoka, Japan
| | - Yutaro Suzuki
- Department of Psychiatry, Niigata University Medical and Dental Hospital, Niigata, Japan
- Department of Psychiatry, Suehirobashi Hospital Keiaikai, Niigata, Japan
| | - Naoki Orime
- Department of Psychiatry, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Taketsugu Hayashi
- Department of Psychiatry, Niigata Psychiatric Center, Nagaoka, Japan
| | - Kiyohiro Yoshinaga
- Department of Psychiatry, Niigata Psychiatric Center, Nagaoka, Japan
- Department of Psychiatry, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Jun Egawa
- Department of Psychiatry, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Shin Ono
- Department of Community Psychiatric Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
- Department of Psychiatry, Niigata Psychiatric Center, Nagaoka, Japan
| | - Takuro Sugai
- Comprehensive Medical Education Center, Niigata University School of Medicine, Niigata, Japan
| | - Yoshimasa Inoue
- Department of Psychiatry, Dokkyo Medical University, Soka, Japan
| | - Toshiyuki Someya
- Department of Psychiatry, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Fukui N, Suzuki Y, Sugai T, Watanabe J, Ono S, Tsuneyama N, Someya T. Promoter variation in the catechol-O-methyltransferase gene is associated with remission of symptoms during fluvoxamine treatment for major depression. Psychiatry Res 2014; 218:353-5. [PMID: 24814141 DOI: 10.1016/j.psychres.2014.04.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 02/14/2014] [Accepted: 04/17/2014] [Indexed: 10/25/2022]
Abstract
We investigated the association between remission of depressive symptoms in fluvoxamine treatment and catechol-O-methyltransferase (COMT) gene. Sixteen SNPs in the COMT gene were investigated in 123 outpatients with major depression. Three single nucleotide polymorphisms located in the 5' region were associated with remission in fluvoxamine-treated outpatients with moderate to severe depression.
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Affiliation(s)
- Naoki Fukui
- Department of Psychiatry, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yutaro Suzuki
- Department of Psychiatry, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takuro Sugai
- Department of Psychiatry, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Junzo Watanabe
- Department of Psychiatry, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Shin Ono
- Department of Psychiatry, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Nobuto Tsuneyama
- Department of Psychiatry, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Toshiyuki Someya
- Department of Psychiatry, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
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Eggart V, Hiemke C, Zernig G. "There is no dose-response relationship in psychopharmacotherapy" vs "pharmacotherapy in psychiatry is based on ligand-receptor interaction": a unifying hypothesis and the need for plasma concentration based clinical trials. Psychopharmacology (Berl) 2011; 217:297-300. [PMID: 21537937 DOI: 10.1007/s00213-011-2319-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 04/14/2011] [Indexed: 10/18/2022]
Affiliation(s)
- Vincent Eggart
- Experimental Psychiatry Unit, Center of Psychiatry and Psychotherapy, Department of General Psychiatry and Social Psychiatry, Medical University Innsbruck, Innrain 66 a, room 35-G1-010, A-6020, Innsbruck, Austria
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Suzuki Y, Sugai T, Fukui N, Watanabe J, Ono S, Inoue Y, Ozdemir V, Someya T. CYP2D6 genotype and smoking influence fluvoxamine steady-state concentration in Japanese psychiatric patients: lessons for genotype-phenotype association study design in translational pharmacogenetics. J Psychopharmacol 2011; 25:908-14. [PMID: 20547595 DOI: 10.1177/0269881110370504] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The CYP2D6 enzyme is a capacity-limited high-affinity drug elimination pathway that metabolizes numerous psychiatric medicines. The capacity-limited nature of this enzyme suggests that drug dose may serve as an important factor that influence genotype-phenotype associations. However, dose dependency of CYP2D6 genotype contributions to drug elimination, and its interaction with environmental factors (e.g., smoking) did not receive adequate attention in translational study designs. Fluvoxamine is a selective serotonin reuptake inhibitor antidepressant. Fluvoxamine concentration is one of the factors previously linked to clinical remission in moderate to severe depression. We investigated the joint effect of smoking (an inducer of CYP1A2) and CYP2D6 genotype on interindividual variability in fluvoxamine steady-state concentration. Fluvoxamine concentration was measured in 87 patients treated with 50, 100, 150 or 200 mg/d. While CYP2D6 genotype significantly influenced fluvoxamine concentration in all four dose groups (p < 0.05), the percentage variance explained (R²) by CYP2D6 decreased as the dose of fluvoxamine increased. Smoking status (nonsmokers vs. smoking 20 or more cigarettes/d) significantly affected fluvoxamine concentration in the 50 mg/d group only (p = 0.005). Together, CYP2D6 genotype and smoking status explained 23% of the variance in fluvoxamine concentration but only at the low 50 mg/d dose group. These findings contribute to evidence-based and personalized choice of fluvoxamine dose using smoking status and CYP2D6 genetic variation. Additionally, these data lend evidence for drug dose as an important variable in translational pharmacogenetic study design and pharmaceutical phenotype associations with capacity-limited drug metabolism pathways such as CYP2D6.
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Affiliation(s)
- Yutaro Suzuki
- Department of Psychiatry, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Cytochrome P450 CYP1A2, CYP2C9, CYP2C19 and CYP2D6 genes are not associated with response and remission in a sample of depressive patients. Int Clin Psychopharmacol 2009; 24:250-6. [PMID: 19593158 DOI: 10.1097/yic.0b013e32832e5b0d] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cytochrome P450 genes are involved in the metabolism of antidepressants and could influence treatment response. The aim of this study was to investigate the role of allelic variations of the cytochrome P450 CYP1A2, CYP2C9, CYP2C19 and CYP2D6 genes in antidepressant treatment response and remission rates. Two hundred and seventy-eight patients affected by major depression, responders (N = 81) and nonresponders (N=197) to at least one adequate antidepressant treatment, were recruited with a multicentre design for resistant depression and genotyped for all relevant variations. None of the considered metabolic profiles (e.g. poor, intermediate, extensive and ultrarapid metabolizers) was found to be associated with either response or remission rates. In conclusion, the investigated cytochrome genes do not seem to play a major role in antidepressant response in the present sample of depressive patients. Nevertheless, methodological and sample size limitations of this study do not allow definitive conclusions.
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Rudberg I, Hermann M, Refsum H, Molden E. Serum concentrations of sertraline and N-desmethyl sertraline in relation to CYP2C19 genotype in psychiatric patients. Eur J Clin Pharmacol 2008; 64:1181-8. [DOI: 10.1007/s00228-008-0533-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Accepted: 06/27/2008] [Indexed: 11/28/2022]
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