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Wisner KL, Avram MJ, George AL, Abramova TV, Yang A, Caritis SN, Costantine MM, Stika CS. Concentrations of Fluoxetine Enantiomers Decline During Pregnancy and Increase After Birth. J Clin Psychopharmacol 2024; 44:100-106. [PMID: 38421920 PMCID: PMC10906734 DOI: 10.1097/jcp.0000000000001821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
RATIONALE Few studies of the effect of the dynamic physiologic changes during pregnancy on plasma concentrations of fluoxetine (FLX) have been published. OBJECTIVES We determined the change in concentration to dose (C/D) ratios of R- and S-FLX and R- and S-norfluoxetine monthly during pregnancy and postpartum, assessed their relationships to cytochrome P450 (CYP) 2D6 and CYP2C9 metabolizer phenotypes, and evaluated the course of their depressive and anxiety symptoms. METHODS In this observational study, 10 FLX-treated pregnant individuals provided blood samples at steady state every 4 weeks during pregnancy and once postpartum for measurement of plasma FLX and norfluoxetine enantiomer concentrations. Participants were genotyped for variants in CYP2C9 and CYP2D6 using commercial assays with Taqman probes. At each assessment, depressive and anxiety symptoms were quantified. RESULTS The C/D ratios of all FLX and norfluoxetine enantiomers, and the active moiety, decreased steadily through pregnancy and rose after birth. In the final trimester, the mean C/D ratio of the active moiety was 24.9% lower compared with the mean nonpregnant, 12-week postpartum C/D ratio. One individual with CYP2D6 ultrarapid metabolizer status was prescribed the highest FLX dose among participants. In these treated individuals, the mean depressive and anxiety symptoms remained in the mild range across the perinatal period. CONCLUSIONS These data do not support a recommendation for routine plasma concentration monitoring or CYP2D6 pharmacogenetic testing for pregnant people treated with FLX; however, monitoring for symptom relapse is recommended because of declining plasma drug concentrations.
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Affiliation(s)
- Katherine L. Wisner
- Developing Brain Institute, Children’s National Hospital, 111 Michigan Ave. NW, Washington, DC 20001. This work was conducted while Dr. Wisner was at Northwestern University Feinberg School of Medicine
- Department of Obstetrics and Gynecology, Northwestern University’s Feinberg School of Medicine, 250 E Superior Street, Suite 03-2303; Chicago, IL 60611, USA
| | - Michael J. Avram
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 East Huron Street, Chicago, IL, 60611 USA
| | - Alfred L. George
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, 320 East Superior Street, Chicago, IL 60611 USA
| | - Tatiana V. Abramova
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, 320 East Superior Street, Chicago, IL 60611 USA
| | - Amy Yang
- AY Analytics, 20 Melrose St, Westmont, IL 60559 USA (contractual statistical service to Northwestern University Feinberg School of Medicine)
| | - Steve N. Caritis
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Magee Womens Hospital, 300 Halket St, Pittsburgh, PA 15213 USA
| | - Maged M. Costantine
- Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, 410 W 10 Ave, Columbus, OH 43210 USA
| | - Catherine S. Stika
- Department of Obstetrics and Gynecology, Northwestern University’s Feinberg School of Medicine, 250 E Superior Street, Suite 03-2303; Chicago, IL 60611, USA
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Yue M, Kus L, Katta S, Su I, Li L, Haas DM, Quinney SK. Pharmacokinetics of Antidepressants in Pregnancy. J Clin Pharmacol 2023; 63 Suppl 1:S137-S158. [PMID: 37317494 PMCID: PMC10442696 DOI: 10.1002/jcph.2282] [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: 12/03/2022] [Accepted: 05/08/2023] [Indexed: 06/16/2023]
Abstract
Depression is common in pregnant women. However, the rate of antidepressant treatment in pregnancy is significantly lower than in nonpregnant women. Although some antidepressants may cause potential risks to the fetus, not treating or withdrawing the treatment is associated with relapsing and adverse pregnancy outcomes such as preterm birth. Pregnancy-associated physiologic changes can alter pharmacokinetics (PK) and may impact dosing requirements during pregnancy. However, pregnant women are largely excluded from PK studies. Dose extrapolation from the nonpregnant population could lead to ineffective doses or increased risk of adverse events. To better understand PK changes during pregnancy and guide dosing decisions, we conducted a literature review to catalog PK studies of antidepressants in pregnancy, with a focus on maternal PK differences from the nonpregnant population and fetal exposure. We identified 40 studies on 15 drugs, with most data from patients taking selective serotonin reuptake inhibitors and venlafaxine. Most of the studies have relatively poor quality, with small sample sizes, reporting concentrations at delivery only, a large amount of missing data, and not including times and adequate dose information. Only four studies collected multiple samples following a dose and reported PK parameters. In general, there are limited data available regarding PK of antidepressants in pregnancy and deficiencies in data reporting. Future studies should provide accurate information on drug dosing and timing of dose, PK sample collection, and individual-level PK data.
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Affiliation(s)
- Min Yue
- Purdue University College of Pharmacy, Indianapolis, IN
| | - Lauren Kus
- Indiana University School of Medicine, Indianapolis, IN
| | - Shilpa Katta
- School of Informatics and Computing, Indiana University, Purdue University Indianapolis, Indianapolis, IN
| | - Isaac Su
- Indiana University School of Medicine, Indianapolis, IN
| | - Lang Li
- The Ohio State University College of Medicine, Columbus, OH
| | - David M. Haas
- Indiana University School of Medicine, Indianapolis, IN
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3
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Stika CS, Wisner KL, George AL, Avram MJ, Zumpf K, Rasmussen-Torvik LJ, Mesches GA, Caritis SN, Venkataramanan R, Costantine MM, West HA, Clark S, Ciolino JD. Changes in Sertraline Plasma Concentrations Across Pregnancy and Postpartum. Clin Pharmacol Ther 2022; 112:1280-1290. [PMID: 36094046 DOI: 10.1002/cpt.2746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/05/2022] [Indexed: 01/31/2023]
Abstract
Major depressive disorder (MDD) is a common disorder in pregnancy. Although sertraline is the most frequently prescribed antidepressant for pregnant people in the United States, limited information about its pharmacokinetics in pregnancy is available. Our objectives were to characterize plasma sertraline concentration to dose (C/D) ratios across pregnancy and postpartum and investigate the effect of pharmacogenetic variability on sertraline elimination. We performed a prospective observational cohort study in people with a singleton pregnancy ≤ 18 weeks gestation and a lifetime diagnosis of MDD at the 3 Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)-funded Obstetrical-Fetal Pharmacology Research Center sites. Subjects (N = 47) were receiving maintenance sertraline therapy and chose to continue it during pregnancy. Blood samples were obtained 24-hours postdose every 4 weeks across pregnancy and twice postpartum for measurement of plasma concentrations of sertraline and desmethylsertraline. Overall mean sertraline C/D ratios were decreased at study onset and remained consistently low until after delivery. During the last 4 weeks of pregnancy the mean sertraline C/D ratio (95% confidence interval (CI)), 0.25 (95% CI, 0.19, 0.3) ng/mL/dose (mg/day), was smaller than the mean ratio at ≥ 8 weeks after delivery, 0.32 (95% CI, 0.27, 0.37) ng/mL/dose (mg/day), a 22% difference. Mean sertraline/desmethylsertraline ratios were highest after birth, which confirmed increased sertraline elimination during pregnancy. Sertraline C/D ratios in participants with functional CYP2C19 activity did not change significantly during pregnancy, whereas ratios in participants with poor or intermediate CYP2C19 activity decreased by 51%. Exploratory pharmacogenomic analysis indicated that pregnant people with poor or intermediate CYP2C19 activity are at risk for subtherapeutic sertraline concentrations during pregnancy.
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Affiliation(s)
- Catherine S Stika
- Department of Obstetrics and Gynecology, Northwestern University's Feinberg School of Medicine, Chicago, Illinois, USA
| | - Katherine L Wisner
- Department of Obstetrics and Gynecology, Northwestern University's Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alfred L George
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael J Avram
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Katelyn Zumpf
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Laura J Rasmussen-Torvik
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gabrielle A Mesches
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Steve N Caritis
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Magee Womens Hospital, Pittsburgh, Pennsylvania, USA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA.,Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Maged M Costantine
- Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Holly A West
- Department of OB/GYN, University of Texas Medical Branch, Galveston, Texas, USA
| | - Shannon Clark
- Department of OB/GYN, University of Texas Medical Branch, Galveston, Texas, USA
| | - Jody D Ciolino
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Poweleit EA, Cinibulk MA, Novotny SA, Wagner-Schuman M, Ramsey LB, Strawn JR. Selective Serotonin Reuptake Inhibitor Pharmacokinetics During Pregnancy: Clinical and Research Implications. Front Pharmacol 2022; 13:833217. [PMID: 35281909 PMCID: PMC8916222 DOI: 10.3389/fphar.2022.833217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/24/2022] [Indexed: 01/18/2023] Open
Abstract
Pregnancy and associated physiologic changes affect the pharmacokinetics of many medications, including selective serotonin reuptake inhibitors—the first-line pharmacologic interventions for depressive and anxiety disorders. During pregnancy, SSRIs exhibit extensive pharmacokinetic variability that may influence their tolerability and efficacy. Specifically, compared to non-pregnant women, the activity of cytochrome P450 (CYP) enzymes that metabolize SSRIs drastically changes (e.g., decreased CYP2C19 activity and increased CYP2D6 activity). This perspective examines the impact of pharmacokinetic genes—related to CYP activity on SSRI pharmacokinetics during pregnancy. Through a simulation-based approach, plasma concentrations for SSRIs metabolized primarily by CYP2C19 (e.g., escitalopram) and CYP2D6 (e.g., fluoxetine) are examined and the implications for dosing and future research are discussed.
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Affiliation(s)
- Ethan A. Poweleit
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Department of Pediatrics, Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Department of Pediatrics, Division of Research in Patient Services, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Margaret A. Cinibulk
- Department of Psychiatry and Behavioral Sciences, University of Southern California, Los Angeles, CA, United States
| | - Sarah A. Novotny
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Mississippi, Jackson, MS, United States
| | - Melissa Wagner-Schuman
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH, United States
| | - Laura B. Ramsey
- Department of Pediatrics, Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Department of Pediatrics, Division of Research in Patient Services, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Jeffrey R. Strawn
- Department of Pediatrics, Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH, United States
- Department of Pediatrics, Division of Child and Adolescent Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- *Correspondence: Jeffrey R. Strawn,
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Qiu W, Duarte-Guterman P, Eid RS, Go KA, Lamers Y, Galea LA. Postpartum fluoxetine increased maternal inflammatory signalling and decreased tryptophan metabolism: Clues for efficacy. Neuropharmacology 2020; 175:108174. [DOI: 10.1016/j.neuropharm.2020.108174] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023]
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Schoretsanitis G, Spigset O, Stingl JC, Deligiannidis KM, Paulzen M, Westin AA. The impact of pregnancy on the pharmacokinetics of antidepressants: a systematic critical review and meta-analysis. Expert Opin Drug Metab Toxicol 2020; 16:431-440. [PMID: 32238008 DOI: 10.1080/17425255.2020.1750598] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Pregnancy-related physiological changes exert a crucial impact on the pharmacokinetics of antidepressants; however, the current evidence presents inconsistencies. A clearer understanding of pregnancy-related effects on antidepressant disposition may facilitate the development of guidelines for appropriate dose adjustments during the course of pregnancy based on therapeutic drug monitoring.Areas covered: We systematically reviewed studies comparing antidepressant levels in the same individuals during pregnant and non-pregnant states. Using dose-adjusted plasma concentration measurements, we estimated alteration ratios between the 3rd trimester and baseline (before or after pregnancy). Additionally, we performed a meta-analysis for changes in dose-adjusted concentrations to estimate mean differences.Expert opinion: Data for several antidepressants display clear alteration patterns during pregnancy. On the basis of the alteration ratios trimipramine, fluvoxamine, and nortriptyline show a prominent decrease in dose-adjusted levels, especially in the 3rd trimester. Clomipramine, imipramine, citalopram, and paroxetine show smaller decreases in dose-adjusted concentrations in the third trimester. For escitalopram, venlafaxine and fluoxetine, changes are considered negligible. For sertraline, there was a tendency toward increased dose-adjusted concentrations in pregnancy. Available evidence suffers from major limitations and factors affecting pharmacokinetics have been insufficiently addressed. Further research is required to promote knowledge on pregnancy effects on antidepressant pharmacokinetics.
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Affiliation(s)
- Georgios Schoretsanitis
- The Zucker Hillside Hospital, Department of Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
| | - Olav Spigset
- Department of Clinical Pharmacology, St Olav University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Julia C Stingl
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, Aachen, Germany
| | - Kristina M Deligiannidis
- The Zucker Hillside Hospital, Department of Psychiatry Research, Northwell Health, Glen Oaks, NY, USA.,Zucker School of Medicine, Hempstead, New York, Manhasset, New York, USA.,The Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Michael Paulzen
- Alexianer Hospital Aachen, Aachen, Germany and Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, and JARA - Translational Brain Medicine, Aachen, Germany
| | - Andreas A Westin
- Department of Clinical Pharmacology, St Olav University Hospital, Trondheim, Norway
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7
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Mesches GA, Wisner KL, Betcher HK. A common clinical conundrum: Antidepressant treatment of depression in pregnant women. Semin Perinatol 2020; 44:151229. [PMID: 32085857 PMCID: PMC7214132 DOI: 10.1016/j.semperi.2020.151229] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Depression during pregnancy is associated with adverse maternal, pregnancy, and infant outcomes. Treatment during pregnancy requires a balanced discussion of the risks of both drug exposure and untreated depression. An updated review of the epidemiology, outcomes, and management of maternal depression is presented. Adverse outcomes are associated with both maternal depression and antidepressants. Research gaps include data on the longitudinal developmental trajectory of offspring exposed to antidepressants compared to depression, with assessment of in utero symptom exposure and environmental exposures. Additionally, neonatal syndrome associated with antidepressant use during pregnancy has no consensus definition or mechanistic explanation. With sophisticated large-scale epidemiologic studies, there has been progress in distinguishing the impact of depression processes from medication used for treatment. Optimal treatment of perinatal depression includes close symptom monitoring and medication adjustments to maintain symptom remission. This evolving field requires frequent consultation with reproductive data sources included in this article.
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Affiliation(s)
- Gabrielle A. Mesches
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katherine L. Wisner
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hannah K. Betcher
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Mayo Clinic, Rochester, MN, USA
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8
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Betcher HK, Wisner KL. Psychotropic Treatment During Pregnancy: Research Synthesis and Clinical Care Principles. J Womens Health (Larchmt) 2019; 29:310-318. [PMID: 31800350 DOI: 10.1089/jwh.2019.7781] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Psychiatric illnesses are common in women of childbearing age. The perinatal period is a particularly high-risk time for depression, bipolar, and anxiety disorders. Methods: The scope of the public health problem of perinatal mental disorders is discussed followed by an examination of the specific research methods utilized for the study of birth and developmental outcomes associated with maternal mental illness and its treatment. The evidence on exposure to common psychotropics during pregnancy and breastfeeding is reviewed. Results: Selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitor medications are not associated with higher rates of birth defects or long-term changes in mental development after adjustment for confounding factors associated with underlying psychiatric illness. Lithium exposure is associated with an increased risk for fetal cardiac malformations, but this risk is lower than previously thought (absolute risk of Ebstein's anomaly 6/1,000). Antipsychotics, other than risperidone and potentially paliperidone, have not been associated with an increase in birth defects; olanzapine and quetiapine have been linked with an elevated risk of gestational diabetes. Due to the dramatic physiological changes of pregnancy and enhanced hepatic metabolism, drug doses may need to be adjusted during pregnancy to sustain efficacy. Untreated maternal psychiatric illness also carries substantial risks for the mother, fetus, infant, and family. Conclusions: The goal of perinatal mental health treatment is to optimally provide pharmacotherapy to mitigate the somatic and psychosocial burdens of maternal psychiatric disorders. Regular symptom monitoring during pregnancy and postpartum and medication dose adjustments to sustain efficacy constitutes good practice.
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Affiliation(s)
- Hannah K Betcher
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Katherine L Wisner
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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9
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Lonstein JS. The dynamic serotonin system of the maternal brain. Arch Womens Ment Health 2019; 22:237-243. [PMID: 30032323 PMCID: PMC7001094 DOI: 10.1007/s00737-018-0887-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 06/28/2018] [Indexed: 12/16/2022]
Abstract
Many pregnant and postpartum women worldwide suffer from high anxiety and/or depression, which can have detrimental effects on maternal and infant well-being. The first-line pharmacotherapies for prepartum and postpartum affective disorders continue to be the selective serotonin reuptake inhibitors (SSRIs), despite the lack of large well-controlled studies demonstrating their efficacy in reproducing women and the potential for fetal/neonatal exposure to the drugs. Prepartum or postpartum use of SSRIs or other drugs that modulate the brain's serotonin system is also troubling because very little is known about the typical, let alone the atypical, changes that occur in the female central serotonin system across reproduction. We do know from a handful of studies of women and female laboratory rodents that numerous aspects of the central serotonin system are naturally dynamic across reproduction and are also affected by pregnancy stress (a major predisposing factor for maternal psychopathology). Thus, it should not be assumed that the maternal central serotonin system being targeted by SSRIs is identical to non-parous females or males. More information about the normative and stress-derailed changes in the maternal central serotonin system is essential for understanding how serotonin is involved in the etiology of, and the best use of SSRIs for potentially treating, affective disorders in the pregnant and postpartum populations.
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Affiliation(s)
- Joseph S. Lonstein
- Department of Psychology & Neuroscience Program, Michigan State University, 108 Giltner Hall, East Lansing, MI 48824, USA
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10
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Carvalho DM, Lanchote VL, Filgueira GCDO, Nardotto GHB, Duarte G, Cavalli RC, Moisés ECD. Pharmacokinetics and Transplacental Transfer of Fluoxetine Enantiomers and Their Metabolites in Pregnant Women. Clin Pharmacol Ther 2018; 105:1003-1008. [PMID: 30346625 DOI: 10.1002/cpt.1263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 09/29/2018] [Indexed: 11/07/2022]
Abstract
Considering that fluoxetine (FLX) is used to treat depressive states during pregnancy and that it is a cytochrome P450 (CYP)2D6 inhibitor, which is involved in the metabolism of both of its enantiomers, this study aims to describe the enantioselective distribution and metabolism of FLX and of its metabolite norfluoxetine (NorFLX) following a single oral dose. Nine healthy pregnant women received 20 mg FLX at 32 weeks of gestation and later at the day of delivery. The apparent clearance of (S)-(+)-FLX (1.45 vs. 0.66 L/hour/kg) and the area under the plasma concentration vs. time curve (AUC) of the (S)-(+)-NorFLX (AUC0-∞ 942.7 vs. 498.6 ng hour/mL) were higher (P < 0.05) than those of the respective (R)-(-) enantiomers, indicating that the (S)-(+)-FLX enantiomer is preferentially metabolized to (S)-(+)-NorFLX. The placental transfer (umbilical vein/maternal vein) of FLX and NorFLX is low (30-40%), with the predominant transfer of (S)-(+)-FLX (44 vs. 33%). The distribution of the enantiomers of FLX and NorFLX to amniotic fluid is low (< 10%).
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Affiliation(s)
- Daniela Miarelli Carvalho
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Vera Lucia Lanchote
- Department of Clinical, Toxicologic and Bromatologic Analyses, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Glauco Henrique Balthazar Nardotto
- Department of Clinical, Toxicologic and Bromatologic Analyses, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Geraldo Duarte
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Ricardo Carvalho Cavalli
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Elaine Christine Dantas Moisés
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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Marwari S, Dawe GS. (R)-fluoxetine enhances cognitive flexibility and hippocampal cell proliferation in mice. J Psychopharmacol 2018; 32:441-457. [PMID: 29458297 DOI: 10.1177/0269881118754733] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Fluoxetine is a clinically successful antidepressant. It is a racemic mixture of (R) and (S) stereoisomers. In preclinical studies, chronic treatment with fluoxetine (10 mg/kg) had antidepressant effects correlated with increased hippocampal cell proliferation in adult rodents. However, the contribution of the enantiomers of fluoxetine is largely unknown. We investigated the effects of treatment with (R)- and (S)-fluoxetine on cognitive behavioral paradigms and examined cell proliferation in the hippocampus of C57BL/6J female mice. In a behavioral sequencing task using the IntelliCage system in which discriminated spatial patterns of rewarded and never-rewarded corners were reversed serially, (R)-fluoxetine-treated mice showed rapid acquisition of behavioral sequencing (compared with S-fluoxetine) and cognitive flexibility in subsequent reversal stages in intra- and inter-session analysis. (R)-fluoxetine also increased cell proliferation in the hippocampus, in particular in the suprapyramidal blade of the dentate gyrus. (R)-fluoxetine had superior effects to (S)-fluoxetine in elevated plus maze, forced-swim and tail-suspension tests. These results suggest that (R)-fluoxetine, which has been reported to have a shorter half-life than (S)-fluoxetine, has superior antidepressant effects and more consistently improves spatial learning and memory. This profile offers advantages in depression treatment and may also aid management of the neurocognitive impairments associated with depression.
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Affiliation(s)
- Subhi Marwari
- 1 Department of Pharmacology, National University of Singapore, Singapore
| | - Gavin S Dawe
- 1 Department of Pharmacology, National University of Singapore, Singapore.,2 Neurobiology and Ageing Programme, Life Sciences Institute, University of Singapore, Singapore
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12
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13
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Westin AA, Brekke M, Molden E, Skogvoll E, Castberg I, Spigset O. Treatment With Antipsychotics in Pregnancy: Changes in Drug Disposition. Clin Pharmacol Ther 2017. [PMID: 28643331 PMCID: PMC5836849 DOI: 10.1002/cpt.770] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although pregnancy is known to cause changes in drug pharmacokinetics, little is known about its impact on serum levels of antipsychotics. In this study we retrospectively assessed 201 routine serum antipsychotic therapeutic drug monitoring concentration measurements obtained from a total of 110 pregnancies in 103 women, and 512 measurements from the same women before and after pregnancy. Serum concentrations in the third trimester were significantly lower than baseline for quetiapine (-76%; confidence interval (CI), -83%, -66%; P < 0.001) and aripiprazole (-52%; CI, -62%, -39%; P < 0.001), but not for olanzapine (-9%; CI, -28%, +14%; P = 0.40). For the remaining antipsychotics (perphenazine, haloperidol, ziprasidone, risperidone, and clozapine), our dataset was limited, but it indicates that concentrations may decline at least for perphenazine and possibly also for haloperidol. Even though the clinical consequence of the serum concentrations decline remains to be elucidated, our results warrant close clinical monitoring throughout pregnancy, preferentially supported by therapeutic drug monitoring.
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Affiliation(s)
- Andreas A Westin
- Department of Clinical Pharmacology, St Olav University Hospital, Trondheim, Norway
| | - Malin Brekke
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway.,Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Norway
| | - Eirik Skogvoll
- Department of Anaesthesiology and Intensive Care, St. Olav University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ingrid Castberg
- Department of Psychiatry, St Olav University Hospital, Trondheim, Norway
| | - Olav Spigset
- Department of Clinical Pharmacology, St Olav University Hospital, Trondheim, Norway.,Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
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Westin AA, Brekke M, Molden E, Skogvoll E, Spigset O. Selective serotonin reuptake inhibitors and venlafaxine in pregnancy: Changes in drug disposition. PLoS One 2017; 12:e0181082. [PMID: 28708853 PMCID: PMC5510868 DOI: 10.1371/journal.pone.0181082] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 06/26/2017] [Indexed: 01/24/2023] Open
Abstract
Background Pregnancy may cause changes in drug disposition. The clinical consequences may be profound and even counterintuitive; in some cases pregnant women may need more than twice their usual drug dose in order to maintain therapeutic drug levels. For antidepressants, evidence on drug disposition in pregnancy is scarce. The aim of this study was to determine the effects of pregnancy on serum levels of selective serotonin reuptake inhibitors (SSRIs) and venlafaxine in a large and naturalistic patient material, in order to provide tentative dose recommendations for pregnant women. Methods Using patient data from two routine therapeutic drug monitoring (TDM) services in Norway with linkage to the national birth registry, dose-adjusted serum drug concentrations of SSRIs and venlafaxine during pregnancy were compared to the women’s own baseline (non-pregnant) values, using a linear mixed model. Findings Overall, the TDM databases contained 196,726 serum concentration measurements from 54,393 women. After data linkage and drug selection (SSRIs or venlafaxine only), we identified 367 analyses obtained from a total of 290 pregnancies in 281 women, and 420 baseline observations from the same women. Serum concentrations in the third trimester were significantly lower than baseline for paroxetine (–51%; 95% confidence interval [CI], –66%, –30%; p<0.001), fluvoxamine (–56%; CI, –75%, –23%; p = 0.004) and citalopram (–24%; CI, –38%, –7%; p = 0,007), and higher than baseline for sertraline (+68%; CI, +37%, +106%; p<0.001). For escitalopram, fluoxetine and venlafaxine concentrations did not change significantly. Conclusions For paroxetine and fluvoxamine the pronounced decline in maternal drug serum concentrations in pregnancy may necessitate a dose increase of about 100% during the third trimester in order to maintain stable concentrations. For fluoxetine, venlafaxine, citalopram, escitalopram and sertraline, the present study indicates that dose adjustments are generally not necessary during pregnancy.
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Affiliation(s)
| | - Malin Brekke
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
- Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway
| | - Eirik Skogvoll
- Department of Anaesthesiology and Intensive Care, St. Olav University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Olav Spigset
- Department of Clinical Pharmacology, St Olav University Hospital, Trondheim, Norway
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway
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Swanson SA, Hernandez-Diaz S, Palmsten K, Mogun H, Olfson M, Huybrechts KF. Methodological considerations in assessing the effectiveness of antidepressant medication continuation during pregnancy using administrative data. Pharmacoepidemiol Drug Saf 2015; 24:934-42. [PMID: 26045370 DOI: 10.1002/pds.3798] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 04/16/2015] [Accepted: 04/20/2015] [Indexed: 11/11/2022]
Abstract
PURPOSE The decision whether to continue antidepressant use for depression during pregnancy requires weighing maternal and child risks and benefits. Little is known about the effectiveness of antidepressant therapy during pregnancy. The goal of this study is to evaluate whether standard administrative claims data can be used to evaluate the effectiveness of antidepressants. METHODS Using prescription and healthcare visit Medicaid claims (2000-2007), we identified 28 493 women with a depression diagnosis and antidepressant fill in the 90 days before their last menstrual period. Antidepressant continuation was defined based on prescription fills during the first trimester. Depression hospitalizations and deliberate self-harm served as measures of the effectiveness of treatment continuation during pregnancy. Propensity score and instrumental variable analyses were used to attempt to account for confounding. RESULTS Relative to women who discontinued antidepressant therapy, women who continued were more likely to have a depression inpatient stay (odds ratio [OR] = 2.2, 95% confidence interval [95%CI]: 2.0-2.4) and deliberate self-harm code (OR = 1.4, 95%CI: 0.7-2.7). Accounting for measured covariates in the propensity score analysis, including age, race, comorbidities, comedications, features of the depression diagnosis, and antidepressant class, led to slightly attenuated estimates (OR = 2.0, 95%CI: 1.8-2.2; OR = 1.1, 95%CI: 0.5-2.4). Similar associations were estimated in subgroups with different levels of baseline depression severity. Proposed preference-time, calendar-time-based, and geography-based instruments were unlikely to meet the required conditions for a valid analysis. CONCLUSIONS Our findings suggest that either antidepressant medications do not reduce the risk of depression relapse in pregnant women, or that administrative data alone could not be used to validly estimate the effectiveness of psychotropic medications during pregnancy.
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Affiliation(s)
- Sonja A Swanson
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | | | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School
| | - Mark Olfson
- New York State Psychiatric Institute, New York; the Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School
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Pharmacotherapy for mood disorders in pregnancy: a review of pharmacokinetic changes and clinical recommendations for therapeutic drug monitoring. J Clin Psychopharmacol 2014; 34:244-55. [PMID: 24525634 PMCID: PMC4105343 DOI: 10.1097/jcp.0000000000000087] [Citation(s) in RCA: 144] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Pharmacotherapy for mood disorders during pregnancy is often complicated by pregnancy-related pharmacokinetic changes and the need for dose adjustments. The objectives of this review are to summarize the evidence for change in perinatal pharmacokinetics of commonly used pharmacotherapies for mood disorders, discuss the implications for clinical and therapeutic drug monitoring (TDM), and make clinical recommendations. METHODS The English-language literature indexed on MEDLINE/PubMed was searched for original observational studies (controlled and uncontrolled, prospective and retrospective), case reports, and case series that evaluated or described pharmacokinetic changes or TDM during pregnancy or the postpartum period. RESULTS Pregnancy-associated changes in absorption, distribution, metabolism, and elimination may result in lowered psychotropic drug levels and possible treatment effects, particularly in late pregnancy. Mechanisms include changes in both phase 1 hepatic cytochrome P450 and phase 2 uridine diphosphate glucuronosyltransferase enzyme activities, changes in hepatic and renal blood flow, and glomerular filtration rate. Therapeutic drug monitoring, in combination with clinical monitoring, is indicated for tricyclic antidepressants and mood stabilizers during the perinatal period. CONCLUSIONS Substantial pharmacokinetic changes can occur during pregnancy in a number of commonly used antidepressants and mood stabilizers. Dose increases may be indicated for antidepressants including citalopram, clomipramine, imipramine, fluoxetine, fluvoxamine, nortriptyline, paroxetine, and sertraline, especially late in pregnancy. Antenatal dose increases may also be needed for lithium, lamotrigine, and valproic acid because of perinatal changes in metabolism. Close clinical monitoring of perinatal mood disorders and TDM of tricyclic antidepressants and mood stabilizers are recommended.
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McCormack SA, Best BM. Obstetric Pharmacokinetic Dosing Studies are Urgently Needed. Front Pediatr 2014; 2:9. [PMID: 24575394 PMCID: PMC3920104 DOI: 10.3389/fped.2014.00009] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/26/2014] [Indexed: 12/28/2022] Open
Abstract
Use of pharmacotherapy during pregnancy is common and increasing. Physiologic changes during pregnancy may significantly alter the overall systemic drug exposure, necessitating dose changes. A search of PubMed for pharmacokinetic clinical trials showed 494 publications during pregnancy out of 35,921 total pharmacokinetic published studies (1.29%), from the late 1960s through August 31, 2013. Closer examination of pharmacokinetic studies in pregnant women published since 2008 (81 studies) revealed that about a third of the trials were for treatment of acute labor and delivery issues, a third included studies of infectious disease treatment during pregnancy, and the remaining third were for varied ante-partum indications. Approximately, two-thirds of these recent studies were primarily funded by government agencies worldwide, one-quarter were supported by private non-profit foundations or combinations of government and private funding, and slightly <10% were supported by pharmaceutical industry. As highlighted in this review, vast gaps exist in pharmacology information and evidence for appropriate dosing of medications in pregnant women. This lack of knowledge and understanding of drug disposition throughout pregnancy place both the mother and the fetus at risk for avoidable therapeutic misadventures - suboptimal efficacy or excess toxicity - with medication use in pregnancy. Increased efforts to perform and support obstetric dosing and pharmacokinetic studies are greatly needed.
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Affiliation(s)
- Shelley A McCormack
- Pediatrics Department, School of Medicine, Rady Children's Hospital San Diego, University of California San Diego , San Diego, CA , USA
| | - Brookie M Best
- Pediatrics Department, School of Medicine, Rady Children's Hospital San Diego, University of California San Diego , San Diego, CA , USA ; Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego , La Jolla, CA , USA
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Abstract
UNLABELLED Perinatal depression is an increasingly common comorbidity of pregnancy and is associated with adverse birth outcomes. Newer classes of antidepressants have been developed with a variety of mechanisms and improved side effect profiles. There is increasing use of these medications in reproductive-aged women. Medical providers have to balance the need to prevent relapse of maternal depressive symptoms with the need to minimize fetal exposure to medications. We review the literature on 10 of the most commonly used antidepressant medications: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine, duloxetine, bupropion, and mirtazapine. The pharmacokinetic properties of the medications are detailed, as well as practical considerations for their use in pregnant and lactating women. Guidance on counseling and management of pregnancies complicated by perinatal depression is discussed. TARGET AUDIENCE Obstetricians & Gynecologists and Family Physicians. LEARNING OBJECTIVES After completing this CME activity, physicians should be better able to differentiate the current classes of medications utilized commonly for perinatal depression, evaluate the reported adverse effects of antidepressant medications on the patient and developing fetus and choose the appropriate antidepressant medications for a depressed patient who is breast-feeding.
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Hamad GG, Helsel JC, Perel JM, Kozak GM, McShea MC, Hughes C, Confer AL, Sit DK, McCloskey CA, Wisner KL. The effect of gastric bypass on the pharmacokinetics of serotonin reuptake inhibitors. Am J Psychiatry 2012; 169:256-63. [PMID: 22407114 PMCID: PMC3583374 DOI: 10.1176/appi.ajp.2011.11050719] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Morbidly obese patients frequently present with mood and anxiety disorders, which are often treated with serotonin reuptake inhibitors (SRIs). Having observed that patients treated with SRIs frequently relapse after Roux-en-Y gastric bypass surgery, the authors sought to assess whether SRI bioavailability is reduced postoperatively. METHOD Twelve gastric bypass candidates treated with an SRI for primary mood or anxiety disorders were studied prospectively. Timed blood samples for SRI plasma levels were drawn for pharmacokinetic studies before surgery and 1, 6, and 12 months afterward. Maximum concentration, time to maximum concentration, and area under the concentration/time curve (AUC) were determined. RESULTS In eight of the 12 patients, AUC values 1 month after surgery dropped to an average of 54% (SD=18) of preoperative levels (range=36%-80%); in six of these patients, AUC values returned to baseline levels (or greater) by 6 months. Four patients had an exacerbation of depressive symptoms, which resolved by 12 months in three of them. Three of the four patients had a reduced AUC level at 1 month and either gained weight or failed to lose weight between 6 and 12 months. Normalization of the AUC was associated with improvement in symptom scores. CONCLUSIONS Patients taking SRIs in this study were at risk for reduced drug bioavailability 1 month after Roux-en-Y gastric bypass. The authors recommend close psychiatric monitoring after surgery.
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Sit D, Perel JM, Wisniewski SR, Helsel JC, Luther JF, Wisner KL. Mother-infant antidepressant concentrations, maternal depression, and perinatal events. J Clin Psychiatry 2011; 72:994-1001. [PMID: 21824458 PMCID: PMC3158589 DOI: 10.4088/jcp.10m06461] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 10/26/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The authors explored the relationship of cord-maternal antidepressant concentration ratios and maternal depression with perinatal events and preterm birth. METHOD The investigators examined 21 mother-infant pairs that had antidepressant exposure during pregnancy. The antidepressants included serotonin reuptake inhibitors (SRIs) and nortriptyline (a norepinephrine inhibitor and mild SRI). The mothers were evaluated with the Structured Clinical Interview for DSM-IV. Depression ratings were repeated at 20, 30, and 36 weeks' pregnancy. At delivery, investigators assessed cord and maternal antidepressant concentrations, neonatal outcomes on the Peripartum Events Scale (PES), and gestational weeks at birth. The investigators performed this study at the Women's Behavioral HealthCARE Program, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pennsylvania, from April 2003 until September 2006. RESULTS Mean ± SD cord-to-maternal concentration ratios were 0.52 ± 0.35 (range, 0.00-1.64) for the parent drug and 0.54 ± 0.17 (range, 0.28-0.79) for the metabolite. Nine of 21 mothers (43%) had a major depressive episode. From examining the maximum depression ratings, the mean ± SD Structured Interview Guide for the Hamilton Depression Rating Scale, Atypical Depression Symptoms Version score was 16.0 ± 7.6. One third (7/21) of infants had at least 1 perinatal event (PES ≥ 1). The frequency of deliveries complicated by any perinatal event was similar in depressed and nondepressed mothers. There was no significant association between perinatal events and cord-to-maternal antidepressant concentration ratios or maternal depression levels. Exposure to short half-life antidepressants compared to fluoxetine resulted in more perinatal events (7/16 = 44% vs 0/5 = 0%; P = .06). Fourteen percent (3/21) of infants were preterm. Preterm birth was not associated with cord-to-maternal metabolite concentration ratios, depression levels, or exposure to fluoxetine. CONCLUSIONS Antidepressant-exposed infants experienced a limited number of transient perinatal events. No association between cord-maternal concentration ratios or maternal depression and perinatal events could be identified. Contrary to other reports, we detected no increased risk for perinatal events with fluoxetine therapy compared to the short half-life antidepressants. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00279370.
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Affiliation(s)
- Dorothy Sit
- Women's Behavioral HealthCARE, Western Psychiatric Institute and Clinic, University of Pittsburgh, 3811 O'Hara St, Oxford 410, Pittsburgh, PA 15213, USA.
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