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Shin W, Lee DH, Yoo H, Jung H, Bang M, Kim A. Assessing the Clinical Efficacy of Therapeutic Drug Monitoring for Risperidone and Paliperidone in Patients with Schizophrenia: Insights from a Clinical Data Warehouse. Pharmaceuticals (Basel) 2024; 17:882. [PMID: 39065735 PMCID: PMC11280477 DOI: 10.3390/ph17070882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/01/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024] Open
Abstract
This study investigated the usage patterns and impact of therapeutic drug monitoring (TDM) for risperidone and paliperidone in patients diagnosed with schizophrenia, utilizing retrospective real-world data sourced from a single center's Clinical Data Warehouse. Our study cohort comprised patients diagnosed with schizophrenia undergoing treatment with either risperidone or paliperidone. Data on demographic characteristics, comorbidities, medication utilization, and clinical outcomes were collected. Patients were categorized into two groups: those undergoing TDM and those not undergoing TDM. Additionally, within the TDM group, patients were further stratified based on their risperidone and paliperidone concentrations relative to the reference range. The findings revealed that patients in the TDM group received higher risperidone and paliperidone doses (320 mg/day and 252 mg/day, p = 0.0045) compared to their non-TDM counterparts. Nevertheless, no significant disparities were observed in hospitalization rates, duration of hospital stays, or compliance between the two groups (p = 0.9082, 0.5861, 0.7516, respectively). Subgroup analysis within the TDM cohort exhibited no notable distinctions in clinical outcomes between patients with concentrations within or surpassing the reference range. Despite the possibility of a selection bias in assigning patients to the groups, this study provides a comprehensive analysis of TDM utilization and its ramifications on schizophrenia treatment outcomes.
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Affiliation(s)
- Wonsuk Shin
- Department of Clinical Pharmacology and Therapeutics, CHA Bundang Medical Center, School of Medicine, CHA University, Seongnam-si 13496, Republic of Korea; (W.S.); (H.Y.); (H.J.)
- Department of Physiology, School of Medicine, CHA University, Seongnam-si 13488, Republic of Korea;
| | - Dong Hyeon Lee
- Department of Physiology, School of Medicine, CHA University, Seongnam-si 13488, Republic of Korea;
| | - Hyounggyoon Yoo
- Department of Clinical Pharmacology and Therapeutics, CHA Bundang Medical Center, School of Medicine, CHA University, Seongnam-si 13496, Republic of Korea; (W.S.); (H.Y.); (H.J.)
- Department of Pharmacology, School of Medicine, CHA University, Seongnam-si 13488, Republic of Korea
| | - Huiyoung Jung
- Department of Clinical Pharmacology and Therapeutics, CHA Bundang Medical Center, School of Medicine, CHA University, Seongnam-si 13496, Republic of Korea; (W.S.); (H.Y.); (H.J.)
| | - Minji Bang
- Department of Psychiatry, CHA Bundang Medical Center, School of Medicine, CHA University, Seongnam-si 13496, Republic of Korea
| | - Anhye Kim
- Department of Clinical Pharmacology and Therapeutics, CHA Bundang Medical Center, School of Medicine, CHA University, Seongnam-si 13496, Republic of Korea; (W.S.); (H.Y.); (H.J.)
- Department of Pharmacology, School of Medicine, CHA University, Seongnam-si 13488, Republic of Korea
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Ruan CJ, Olmos I, Ricciardi C, Schoretsanitis G, Vincent PD, Anıl Yağcıoğlu AE, Eap CB, Baptista T, Clark SR, Fernandez-Egea E, Kim SH, Lane HY, Leung J, Maroñas Amigo O, Motuca M, Every-Palmer S, Procyshyn RM, Rohde C, Suhas S, Schulte PFJ, Spina E, Takeuchi H, Verdoux H, Correll CU, Molden E, De Las Cuevas C, de Leon J. Exploring low clozapine C/D ratios, inverted clozapine-norclozapine ratios and undetectable concentrations as measures of non-adherence in clozapine patients: A literature review and a case series of 17 patients from 3 studies. Schizophr Res 2024; 268:293-301. [PMID: 37487869 DOI: 10.1016/j.schres.2023.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/07/2023] [Accepted: 07/08/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Up to 1/2 of outpatients prescribed clozapine may be partially/fully non-adherent, based on therapeutic drug monitoring (TDM). Three indices for measuring partial/full non-adherence are proposed a: 1) clozapine concentration/dose (C/D) ratio which drops to half or more of what is expected in the patient; 2) clozapine/norclozapine ratio that becomes inverted; and 3) clozapine concentration that becomes non-detectable. METHODS These 3 proposed indices are based on a literature review and 17 cases of possible non-adherence from 3 samples: 1) an inpatient study in a Chinese hospital, 2) an inpatient randomized clinical trial in a United States hospital, and 3) and a Uruguayan outpatient study. RESULTS The first index of non-adherence is a clozapine C/D ratio which is less than half the ratio corresponding to the patient's specific ancestry group and sex-smoking subgroup. Knowing the minimum therapeutic dose of the patient based on repeated TDM makes it much easier to establish non-adherence. The second index is inverted clozapine/norclozapine ratios in the absence of alternative explanations. The third index is undetectable concentrations. By using half-lives, the chronology of the 3 indices of non-adherence was modeled in two patients: 1) the clozapine C/D ratio dropped to ≥1/2 of what is expected from the patient (around day 2); 2) the clozapine/norclozapine ratio became inverted (around day 3); and 3) the clozapine concentration became undetectable by the laboratory (around days 9-11). CONCLUSION Prospective studies should further explore these proposed clozapine indices in average patients, poor metabolizers (3 presented) and ultrarapid metabolizers (2 presented).
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Affiliation(s)
- Can-Jun Ruan
- The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.
| | - Ismael Olmos
- Clinical Pharmacology Unit and Pharmacy Department, Vilardebó Hospital, Administración de Servicios de Salud, Montevideo, Uruguay.
| | - Carina Ricciardi
- Clinical Pharmacology Unit and Outpatient Clinic, Vilardebó Hospital, Administración de Servicios de Salud, Montevideo, Uruguay.
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland; The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA.
| | - Philippe D Vincent
- Department of Pharmacy, Institut Universitaire en Santé Mentale de Montréal (IUSMM), Montreal, Canada; Faculty of Pharmacy, Université de Montréal, Montreal, Canada; IUSMM Research Center, Montreal, Canada.
| | | | - Chin B Eap
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland; School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland; Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland; Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland.
| | - Trino Baptista
- Department of Physiology, Los Andes University Medical School, Mérida, Venezuela; Medical School, Anáhuac University, Querétaro, Mexico; Neuroorigen, Querétaro, Mexico.
| | - Scott R Clark
- University of Adelaide, Discipline of Psychiatry, Adelaide, Australia.
| | - Emilio Fernandez-Egea
- Department of Psychiatry, University of Cambridge, Cambridge, UK; Cambridgeshire and Peterborough NHS Foundation Trust, Fulbourn Hospital, Fulbourn, Cambridge, UK.
| | - Se Hyun Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Hsien-Yuan Lane
- Department of Psychiatry and Brain Disease Research Center, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan; Department of Psychology, College of Medical and Health Sciences, Asia University, Taichung, Taiwan.
| | - Jonathan Leung
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA.
| | - Olalla Maroñas Amigo
- Genomic Medicine Group, Galician Public Foundation of Genomic Medicine (FPGMX), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Galicia, Spain; Center for Research in Molecular Medicine and Chronic Diseases (CIMUS), University of Santiago de Compostela (USC), Santiago de Compostela, Spain; Center for Biomedical Research in Rare Diseases Network, Carlos III Health Institute, Madrid, Spain.
| | - Mariano Motuca
- Department of Psychiatry, School of Medicine at Universidad Nacional de Cuyo, Mendoza, Argentina.
| | - Susanna Every-Palmer
- Department of Psychological Medicine, University of Otago Wellington, Wellington, New Zealand.
| | - Ric M Procyshyn
- Department of Psychiatry, University of British Columbia, Vancouver, Canada; British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, Canada.
| | - Christopher Rohde
- Department of Affective Disorders, Aarhus University Hospital - Psychiatry, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Satish Suhas
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India.
| | - Peter F J Schulte
- Mental Health Services Noord-Holland-Noord, Alkmaar, Netherlands; Dutch Clozapine Collaboration Group, Castricum, Netherlands.
| | - Edoardo Spina
- Department of Clinical and Experimeta Medicine, University of Messina, Messina, Italy.
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.
| | - Hélène Verdoux
- Université Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France.
| | - Christoph U Correll
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany.
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway; Department of Pharmacy, University of Oslo, Oslo, Norway.
| | - Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain; Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain.
| | - Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain.
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Horvat M, Kadija M, Ščavničar A, Živković M, Šagud M, Lovrić M. Association of smoking cigarettes, age, and sex with serum concentrations of olanzapine in patients with schizophrenia. Biochem Med (Zagreb) 2023; 33:030702. [PMID: 37841771 PMCID: PMC10564155 DOI: 10.11613/bm.2023.030702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/11/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction Olanzapine is an atypical antipsychotic drug which is effective in the treatment of schizophrenia. Cigarette smoking, age, and sex could be related to the pharmacokinetics and serum concentrations of olanzapine in patients with schizophrenia. The aim of the study was to examine whether there was a significant difference in the serum olanzapine concentrations with regard to the mentioned factors. Materials and methods A total of 58 outpatients with schizophrenia (37 smokers, 42 men, 35 older than 40 years) participated in the study. Blood was sampled in serum tubes just before taking the next dose of olanzapine. Olanzapine was extracted by liquid-liquid extraction and was measured by an in-house high-performance liquid chromatography method on Shimadzu Prominence HPLC System with diode array detector SPD-M20A (Shimadzu, Kyoto, Japan). The results were expressed as the ratio of concentration to the daily dose of olanzapine (C/D). Non-parametric statistical tests were used to analyse differences between variables. Results The median C/D of olanzapine (interquartile range) in smokers was 6.0 (3.4-10.2) nmol/L/mg and in non-smokers 10.1 (5.9-17.6) nmol/L/mg; P = 0.007. The median C/D of olanzapine in patients younger than 40 years was 5.6 (4.5-10.2) nmol/L/mg and in patients older than 40 years 8.4 (5.6-13.0) nmol/L/mg; P = 0.105. The median C/D of olanzapine in male patients was 6.6 (4.6-10.4) nmol/L/mg and in female patients 9.0 (5.9-15.3) nmol/L/mg; P = 0.064. Conclusions The serum olanzapine concentration was significantly lower in smoking than in non-smoking patients with schizophrenia. No significant difference was demonstrated with regard to age and sex.
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Affiliation(s)
- Mihovil Horvat
- Faculty of pharmacy and biochemistry, University of Zagreb, Zagreb, Croatia
| | - Mate Kadija
- Faculty of pharmacy and biochemistry, University of Zagreb, Zagreb, Croatia
| | - Andrijana Ščavničar
- Department of laboratory diagnostics, University hospital centre Zagreb, Zagreb, Croatia
| | - Maja Živković
- Clinic for psychiatry, Clinical hospital Vrapče, Zagreb, Croatia
| | - Marina Šagud
- Department of psychiatry and psychological medicine, University hospital centre Zagreb, Zagreb, Croatia
- School of medicine, University of Zagreb, Zagreb, Croatia
| | - Mila Lovrić
- Faculty of pharmacy and biochemistry, University of Zagreb, Zagreb, Croatia
- Department of laboratory diagnostics, University hospital centre Zagreb, Zagreb, Croatia
- School of medicine, University of Zagreb, Zagreb, Croatia
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Xiao Z, Xing Y, Zhu J, Liu Y, Wang J, Liu Q, Huang M, Zhong G. An effective pretreatment technique based on multi-walled carbon nanotubes to reduce the matrix effect in plasma samples analyzed by a new type probe electrospray ionization method. Anal Chim Acta 2023; 1263:341268. [PMID: 37225332 DOI: 10.1016/j.aca.2023.341268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/22/2023] [Accepted: 04/23/2023] [Indexed: 05/26/2023]
Abstract
The quantitative analysis of drug plasma samples plays an important role in the drug development and drug clinical use. Our research team developed a new electrospray ion source-Micro probe electrospray ionization (μPESI) in the early stage, which was combined with mass spectrometry (μPESI-MS/MS) showing good qualitative and quantitative analysis performance. However, matrix effect severely interfered the sensitivity in μPESI-MS/MS analysis. To solve this problem, we recently developed a Solid-phase purification method based on multi-walled carbon nanotubes (MWCNTs), which was used for removing matrix interfering substances (especially phospholipid compounds) in the preparation of plasma samples, so as to reduce the matrix effect. In this study, aripiprazole (APZ), carbamazepine (CBZ) and omeprazole (OME) were used as representative analytes, the quantitative analysis related to the plasma samples spiked with the analytes above and the mechanism of the MWCNTs to reduce matrix effect were both investigated. Compared with the ordinary protein precipitation, MWCNTs could reduced the matrix effect for several to dozens of times, which resulting from the removement of phospholipid compounds from the plasma samples by MWCNTs in the selective adsorption manner. We further validated the linearity, precision and accuracy of this pretreatment technique by the μPESI-MS/MS method. These parameters all met the requirements of FDA guidelines. It was showed that MWCNTs have a good application prospect in the drug quantitative analysis of plasma samples using the μPESI-ESI-MS/MS method.
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Affiliation(s)
- Zhenwei Xiao
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, Guangdong, 510080, China; Guangdong RangerBio Technologies Co., Ltd., Dongguan, Guangdong, 523000, China.
| | - Yunhui Xing
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, Guangdong, 510080, China; Guangdong RangerBio Technologies Co., Ltd., Dongguan, Guangdong, 523000, China.
| | - Janshon Zhu
- Guangdong RangerBio Technologies Co., Ltd., Dongguan, Guangdong, 523000, China.
| | - Yang Liu
- The Second Affiliated Hospital of Guizhou Medical University, Kaili, Guizhou, 556000, China.
| | - Jinxingyi Wang
- The Second Affiliated Hospital of Guizhou Medical University, Kaili, Guizhou, 556000, China.
| | - Qian Liu
- Guangdong RangerBio Technologies Co., Ltd., Dongguan, Guangdong, 523000, China; The Second Affiliated Hospital of Guizhou Medical University, Kaili, Guizhou, 556000, China.
| | - Min Huang
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, Guangdong, 510080, China.
| | - GuoPing Zhong
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, Guangdong, 510080, China.
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Xu T, Gao N, Li Y, Wang R, Chen B, Hu G, Zhang X. Inhibitory effects of fluoxetine and duloxetine on the pharmacokinetics of metoprolol in vivo and in vitro. Fundam Clin Pharmacol 2022; 36:1057-1065. [PMID: 35510497 DOI: 10.1111/fcp.12795] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/19/2022] [Accepted: 05/03/2022] [Indexed: 12/01/2022]
Abstract
Depression is common among people with cardiovascular diseases. Therefore, the combined use of antidepressants and cardiovascular drugs is very common, which increases the possibility of drug interaction. Simultaneously compare the effects of duloxetine and fluoxetine on metoprolol metabolism, and provide evidence-based guidance for medication safety. Sprague-Dawley rats were randomly divided into three groups: group A (10.3 mg/kg metoprolol alone), group B (10.3 mg/kg metoprolol + 6.2 mg/kg fluoxetine), and group C (10.3 mg/kg metoprolol + 6.2 mg/kg duloxetine). Tail vein blood was collected and subjected to the ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) detection. Moreover, in vitro inhibition of fluoxetine and duloxetine were assessed by incubating liver microsomes and CYP2D6.1 with metoprolol. In in vivo study, the administration of fluoxetine or duloxetine significantly increased the AUC(0-𝑡) and AUC(0-∞) of metoprolol (P < 0.05). Differences between fluoxetine and duloxetine in plasma concentration were also investigated, and their pharmacokinetic parameters such as AUC(0-𝑡) and AUC(0-∞) were significantly distinct (P < 0.05). In vitro, fluoxetine and duloxetine inhibited the metabolism of metoprolol via mixed competitive mechanism of cytochrome P450. IC50 values of fluoxetine and duloxetine were 12.86 and 2.51 μM, respectively. Moreover, the metabolism rate of metoprolol was inhibited to 19.62% and 17.14% in recombinant human CYP2D6.1 by fluoxetine and duloxetine, respectively. Duloxetine showed a more significant inhibitory potential compared to fluoxetine in vitro, but the main pharmacokinetic parameters of fluoxetine and duloxetine revealed differences in inhibiting metoprolol metabolism in vivo.
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Affiliation(s)
- Tao Xu
- Department of Pharmacy, Ningbo City First Hospital, Ningbo, Zhejiang, China
| | - Nanyong Gao
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yinghui Li
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ru Wang
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Bingbing Chen
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Guoxin Hu
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xiaodan Zhang
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China.,Department of Pharmacy, The Seventh People's Hospital of Wenzhou, Wenzhou, Zhejiang, China
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McGrane I, Spina E, Hiemke C, de Leon J. Pharmacokinetic drug interactions with oral haloperidol in adults: dose correction factors from a combined weighted analysis. Expert Opin Drug Metab Toxicol 2022; 18:135-149. [PMID: 35331064 DOI: 10.1080/17425255.2022.2057297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Pharmacokinetic (PK) drug-drug interactions (DDIs) of oral haloperidol, a first-generation antipsychotic, are systematically reviewed. AREAS COVERED After exclusions, the search for DDIs with oral haloperidol provided 47 articles as victim and 7 as perpetrator. Changes in mean haloperidol concentration-to-dose (C/D) ratios after weighting each study's size were used to calculate the effects of other drugs (inhibitors/inducers) on haloperidol. These changes of haloperidol C/D ratio were used to estimate dose-correction factors (<1 for inhibitors and >1 for inducers). EXPERT OPINION A box summarizes our recommendations for clinicians regarding our current knowledge of haloperidol PK DDIs, which will need to be updated as new information becomes available. Moderate to strong inducers (carbamazepine, phenobarbital, phenytoin, or rifampin) should be avoided since they required dose-correction factors of 2-5. Smoking appeared to be a weak inducer (dose-correction factor 1.2). Fluvoxamine, promethazine, and combinations of CYP3A4 and CYP2D6 inhibitors should be avoided. There are no long-term studies on fluoxetine to provide a dose correction factor. Limited information suggests that valproate may be an inhibitor (dose-correction factor 0.6). In most patients, haloperidol may not have clinically relevant effects as a perpetrator, but in vitro and clinical studies suggest it is a weak CYP2D6 inhibitor.
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Affiliation(s)
- Ian McGrane
- Department of Pharmacy Practice, University of Montana, Montana, USA
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Mainz, Germany
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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Davis EAK, Hightower T, Cinnamon KA. Toxic clozapine level as first indication of severe, acute infection. Ment Health Clin 2022; 12:45-48. [PMID: 35116212 PMCID: PMC8788300 DOI: 10.9740/mhc.2022.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 12/01/2021] [Indexed: 11/21/2022] Open
Abstract
Background Clozapine levels can be influenced by many factors, including pharmacogenomic variability, pharmacokinetic drug interactions, and infection/inflammation. The concentration-to-dose ratio (C/D), a measure of a medication's rate of metabolism and clearance, may increase during an acute infection due to decreased medication metabolism and clearance. Case Report A 56-year-old White man was restarted on clozapine and titrated up to 350 mg/d with therapeutic steady-state levels (C/D 1.11) on hospital day (HD) 69. At this time, he was also being treated for COPD exacerbation. For the next month, he continued to complain of cough, but vital signs and chest x-ray remained normal. Labs were unremarkable except for occasional leukocytosis that would resolve on repeat evaluation. A routine clozapine level drawn on HD 104, resulted on day 108 and showed clozapine toxicity with C/D 4.05, although the patient was asymptomatic. After receipt of labs on day 109, showing elevated WBC count, he was immediately sent to the emergency room where he was admitted for treatment of pneumonia. On return to the state hospital, the patient was continued on 100 mg clozapine and titrated to 200 mg/d based on low drug levels. He continued to do well on 200 mg/d clozapine with C/D averaging 1.13 (range, 0.75-1.52). Discussion Acute infection and illness can lead to significantly increased clozapine levels and toxicity, even if symptoms of toxicity are minimal or absent. This appears to be the first report of a toxic level being the first indication of severe medical illness.
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Affiliation(s)
| | - Tyler Hightower
- Psychiatrist and Director of Forensic Services, Springfield Hospital Center, Sykesville, Maryland
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de Leon J, Schoretsanitis G, Smith RL, Molden E, Solismaa A, Seppälä N, Kopeček M, Švancer P, Olmos I, Ricciardi C, Iglesias-Garcia C, Iglesias-Alonso A, Spina E, Ruan CJ, Wang CY, Wang G, Tang YL, Lin SK, Lane HY, Kim YS, Kim SH, Rajkumar AP, González-Esquivel DF, Jung-Cook H, Baptista T, Rohde C, Nielsen J, Verdoux H, Quiles C, Sanz EJ, Las Cuevas CD, Cohen D, Schulte PFJ, Ertuğrul A, Yağcıoğlu AEA, Chopra N, McCollum B, Shelton C, Cotes RO, Kaithi AR, Kane JM, Farooq S, Ng CH, Bilbily J, Hiemke C, López-Jaramillo C, McGrane I, Lana F, Eap CB, Arrojo-Romero M, Rădulescu FŞ, Seifritz E, Every-Palmer S, Bousman CA, Bebawi E, Bhattacharya R, Kelly DL, Otsuka Y, Lazary J, Torres R, Yecora A, Motuca M, Chan SKW, Zolezzi M, Ouanes S, Berardis DD, Grover S, Procyshyn RM, Adebayo RA, Kirilochev OO, Soloviev A, Fountoulakis KN, Wilkowska A, Cubała WJ, Ayub M, Silva A, Bonelli RM, Villagrán-Moreno JM, Crespo-Facorro B, Temmingh H, Decloedt E, Pedro MR, Takeuchi H, Tsukahara M, Gründer G, Sagud M, Celofiga A, Ristic DI, Ortiz BB, Elkis H, Pacheco Palha AJ, LLerena A, Fernandez-Egea E, Siskind D, Weizman A, Masmoudi R, Saffian SM, Leung JG, Buckley PF, Marder SR, Citrome L, Freudenreich O, Correll CU, Müller DJ. An International Adult Guideline for Making Clozapine Titration Safer by Using Six Ancestry-Based Personalized Dosing Titrations, CRP, and Clozapine Levels. PHARMACOPSYCHIATRY 2021; 55:73-86. [PMID: 34911124 DOI: 10.1055/a-1625-6388] [Citation(s) in RCA: 104] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This international guideline proposes improving clozapine package inserts worldwide by using ancestry-based dosing and titration. Adverse drug reaction (ADR) databases suggest that clozapine is the third most toxic drug in the United States (US), and it produces four times higher worldwide pneumonia mortality than that by agranulocytosis or myocarditis. For trough steady-state clozapine serum concentrations, the therapeutic reference range is narrow, from 350 to 600 ng/mL with the potential for toxicity and ADRs as concentrations increase. Clozapine is mainly metabolized by CYP1A2 (female non-smokers, the lowest dose; male smokers, the highest dose). Poor metabolizer status through phenotypic conversion is associated with co-prescription of inhibitors (including oral contraceptives and valproate), obesity, or inflammation with C-reactive protein (CRP) elevations. The Asian population (Pakistan to Japan) or the Americas' original inhabitants have lower CYP1A2 activity and require lower clozapine doses to reach concentrations of 350 ng/mL. In the US, daily doses of 300-600 mg/day are recommended. Slow personalized titration may prevent early ADRs (including syncope, myocarditis, and pneumonia). This guideline defines six personalized titration schedules for inpatients: 1) ancestry from Asia or the original people from the Americas with lower metabolism (obesity or valproate) needing minimum therapeutic dosages of 75-150 mg/day, 2) ancestry from Asia or the original people from the Americas with average metabolism needing 175-300 mg/day, 3) European/Western Asian ancestry with lower metabolism (obesity or valproate) needing 100-200 mg/day, 4) European/Western Asian ancestry with average metabolism needing 250-400 mg/day, 5) in the US with ancestries other than from Asia or the original people from the Americas with lower clozapine metabolism (obesity or valproate) needing 150-300 mg/day, and 6) in the US with ancestries other than from Asia or the original people from the Americas with average clozapine metabolism needing 300-600 mg/day. Baseline and weekly CRP monitoring for at least four weeks is required to identify any inflammation, including inflammation secondary to clozapine rapid titration.
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Affiliation(s)
- Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA.,Department of Psychiatry, University of Kentucky, Lexington, KY, USA.,Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland.,The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA
| | - Robert L Smith
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway.,Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Anssi Solismaa
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Psychiatry, Tampere University Hospital, Tampere, Finland
| | | | - Miloslav Kopeček
- National Institute of Mental Health, Klecany, Czech Republic.,Department of Psychiatry, Charles University, Third Faculty of Medicine, Prague, Czech Republic
| | - Patrik Švancer
- National Institute of Mental Health, Klecany, Czech Republic.,Department of Psychiatry, Charles University, Third Faculty of Medicine, Prague, Czech Republic
| | - Ismael Olmos
- Clinical Pharmacology Unit and Pharmacy Department, Vilardebó Hospital, Administración de Servicios de Salud, Montevideo, Uruguay
| | - Carina Ricciardi
- Clinical Pharmacology Unit and Outpatient Clinic, Vilardebó Hospital, Administración de Servicios de Salud, Montevideo, Uruguay
| | - Celso Iglesias-Garcia
- Universidad de Oviedo. CIBERSAM. INEUROPA. ISPA-FIMBA, Oviedo, Spain.,Hospital Valle del Nalón, Langreo, Spain
| | | | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology, Beijing Anding Hospital, Capital Medical University, Beijing, China.,The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Chuan-Yue Wang
- The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China.,Department of Psychiatry, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Gang Wang
- The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Yi-Lang Tang
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.,Substance Abuse Treatment Program, Atlanta VA Medical Center, Decatur, Georgia, USA
| | - Shih-Ku Lin
- Department of Psychiatry, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsien-Yuan Lane
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan.,Department of Psychiatry and Brain Disease Research Center, China Medical University Hospital, Taichung, Taiwan.,Department of Psychology, College of Medical and Health Sciences, Asia University, Taichung, Taiwan
| | - Yong Sik Kim
- Department of Neuropsychiatry, Nowon Eulji Medical Center, Eulji University, School of Medicine, Seoul, Korea
| | - Se Hyun Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Anto P Rajkumar
- Department of Psychiatry, Christian Medical College, Vellore, India.,Institute of Mental Health, Jubilee Campus, University of Nottingham, Triumph Road, Nottingham, United Kingdom
| | | | - Helgi Jung-Cook
- Instituto Nacional de Neurología y Neurocirugía, México City, México.,Facultad de Química, Universidad Nacional Autónoma de México (UNAM), México City, México
| | - Trino Baptista
- Department of Physiology, Los Andes University Medical School, Mérida, Venezuela
| | - Christopher Rohde
- Department of Affective Disorders, Aarhus University Hospital - Psychiatry, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jimmi Nielsen
- Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France
| | - Clelia Quiles
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain.,Hospital Universitario de Canarias, Tenerife, Spain
| | - Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, and Instituto Universitario de Neurociencia (IUNE), University of La Laguna, Canary Islands, Spain
| | - Dan Cohen
- Dutch Clozapine Collaboration Group, Castricum, The Netherlands.,FACT-team in Heerhugowaard, Department of Severe Mental Illness, Mental Health Services North-Holland North, The Netherlands
| | - Peter F J Schulte
- Dutch Clozapine Collaboration Group, Castricum, The Netherlands.,Mental Health Team Alkmaar, Mental Health Services Noord-Holland-Noord, Alkmaar, The Netherlands
| | - Aygün Ertuğrul
- Department of Psychiatry, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - Nitin Chopra
- Addictions Division, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | | | - Charles Shelton
- Department of Psychiatry, University of Kentucky, Lexington, KY, USA.,Eastern State Hospital, Lexington, Kentucky, USA
| | - Robert O Cotes
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Hempstead, New York, USA
| | - Saeed Farooq
- School of Medicine, Keele University, Staffordshire, and Midlands Partnership NHS Foundation Trust, Staffordshire, United Kingdom
| | - Chee H Ng
- Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - John Bilbily
- Department of Psychiatry, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Germany
| | - Carlos López-Jaramillo
- Grupo de Investigación en Psiquiatría GIPSI, Departamento de Psiquiatría, Facultad de Medicina, Universidad de Antioquia, Medellin, Colombia.,Programa Trastornos del Ánimo, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Ian McGrane
- Department of Pharmacy Practice, University of Montana, Missoula, USA
| | - Fernando Lana
- Institute of Neuropsychiatry and Addictions (INAD), Parc de Salut Mar, Barcelona, Spain.,Department of Psychiatry, Autonomous University of Barcelona, Spain
| | - Chin B Eap
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Switzerland
| | - Manuel Arrojo-Romero
- Department of Psychiatry, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Flavian Ş Rădulescu
- Center for Drug Sciences, Faculty of Pharmacy, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland
| | - Susanna Every-Palmer
- Te Korowai Whāriki Central Regional Forensic Service, Capital and Coast District Health Board, Wellington, New Zealand.,Department of Psychological Medicine, University of Otago, Wellington, New Zealand
| | - Chad A Bousman
- Departments of Medical Genetics, Psychiatry, Physiology & Pharmacology, and Community Health Sciences University of Calgary, Alberta, Canada
| | - Emmanuel Bebawi
- Faculty of Medicine, University of Montreal, Montreal, Canada.,Department of Pharmacy, Hôpital du Sacré-Cœur de Montréal, Montreal, Canada
| | - Rahul Bhattacharya
- East London NHS Foundation Trust, London, United Kingdom.,Honorary Clinical Senior Lecturer, Barts and the London School of Medicine, Queen Mary University of London, United Kingdom
| | - Deanna L Kelly
- Department of Psychiatry, School of Medicine, Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Yuji Otsuka
- Department of Psychiatry, Asahi General Hospital, Chiba, Japan
| | - Judit Lazary
- National Institute of Mental Health, Neurology and Neurosurgery, Budapest, Hungary
| | - Rafael Torres
- Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Agustin Yecora
- Secretaría de Salud Mental y Adicciones, Ministerio de Salud de la Provincia de Jujuy, San Salvador de Jujuy, Argentina
| | - Mariano Motuca
- Instituto Vilapriño, Center for Studies, Assistance and Research in Neurosciences, Mendoza, Argentina
| | - Sherry K W Chan
- Department of Psychiatry, LSK Faculty of Medicine, The University of Hong Kong, Hong Kong SAR.,State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR
| | - Monica Zolezzi
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Sami Ouanes
- Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | | | - Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ric M Procyshyn
- British Columbia Mental Health and Substance Use Research Institute, Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | | | - Oleg O Kirilochev
- Department of Clinical Pharmacology, Astrakhan State Medical University, Astrakhan, Russian Federation
| | - Andrey Soloviev
- Department of Psychiatry and Clinical Psychology, Northern State Medical University, Arkhangelsk, Russia
| | - Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, Division of Neurosciences, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Alina Wilkowska
- Department of Psychiatry, Medical University of Gdańsk, Gdańsk, Poland
| | - Wiesław J Cubała
- Department of Psychiatry, Medical University of Gdańsk, Gdańsk, Poland
| | - Muhammad Ayub
- Department of Psychiatry, Queens University, Kingston, Canada
| | - Alzira Silva
- Psychiatry Department, Centro Hospitalar Universitário de S. João, Porto, Portugal., Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - José M Villagrán-Moreno
- Department of Neurosciences, Jerez University Hospital, Andalusian Health Service, University of Cadiz, Jerez, Spain
| | - Benedicto Crespo-Facorro
- Department of Psychiatry, School of Medicine, University Hospital Virgen del Rocio-IBIS, Sevilla, Spain., Spanish Network for Research in Mental Health (CIBERSAM), Sevilla, Spain
| | - Henk Temmingh
- Department of Psychiatry and Mental Health, University of Cape Town, Valkenberg Hospital, Western Cape, Cape Town, South Africa
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Tsukahara
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Gerhard Gründer
- Central Institute of Mental Health, Department of Molecular Neuroimaging, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Marina Sagud
- Department of Psychiatry, School of Medicine, University of Zagreb, Zagreb, Croatia.,Department for Psychiatry and Psychological Medicine, University Hospital Center Zagreb, Croatia
| | - Andreja Celofiga
- Department of Psychiatry, University Medical Centre Maribor, Maribor, Slovenia
| | | | - Bruno B Ortiz
- Group of Resistant Schizophrenia (GER), Schizophrenia Program (Proesq), Federal University of Sao Paulo, SP, Brazil
| | - Helio Elkis
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Sao Paulo, Brazil
| | - António J Pacheco Palha
- Department and Institute of Psychiatry and Mental Health, Oporto Faculty of Medicine, Oporto, Portugal.,Casa de Salidedo Som Jesus (Psychiatric Hospital), Oporto, Portugal
| | - Adrián LLerena
- INUBE Biosanitary Research Institute of Extremadura. Extremadura University Hospital and Medical School, Badajoz, Spain.,Spanish Network for Research in Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
| | - Emilio Fernandez-Egea
- Cambridge Psychosis Centre, Cambrigeshire and Peterborough NHS Foundation Trust & Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Dan Siskind
- Metro South Addiction and Mental Health Service, Brisbane, Australia.,Queensland Centre for Mental Health Research and School of Clinical Medicine, University of Queensland, Brisbane, Australia
| | - Abraham Weizman
- Research Unit, Geha Mental Health Center and Molecular Psychiatry Laboratory, Felsenstein Medical Research Center, Tel Aviv, Israel.,Department of Psychiatry Sackler Faculty of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Rim Masmoudi
- Psychiatry "A" Department, Hedi Chaker University Hospital, Sfax, Tunisia.,Faculty of Medicine, University of Sfax, Sfax, Tunisia
| | - Shamin Mohd Saffian
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | | | - Peter F Buckley
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephen R Marder
- Semel Institute for Neuroscience at UCLA, Los Angeles, CA, USA.,VA Desert Pacific Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, USA
| | - Leslie Citrome
- New York Medical College, Department of Psychiatry and Behavioral Sciences, Valhalla, NY, USA
| | - Oliver Freudenreich
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christoph U Correll
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Hempstead, New York, USA.,Charité Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany
| | - Daniel J Müller
- Addictions Division, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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European Whites May Need Lower Minimum Therapeutic Clozapine Doses Than Those Customarily Proposed. J Clin Psychopharmacol 2021; 41:140-147. [PMID: 33587398 DOI: 10.1097/jcp.0000000000001341] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE/BACKGROUND A nomogram from a British naturalistic study proposed that the clozapine dosing needed to reach a serum concentration of 350 ng/mL ranged from 265 mg/d (female nonsmokers) to 525 mg/d (male smokers). Some European reviews have used these dosing recommendations, which seem greater than what we found in an Italian White sample ranging from 245 mg/d (female nonsmokers) to 299 mg/d (male smokers). Five other published samples of European Whites were added to the Italian sample to estimate clozapine doses recommended for reaching 350 ng/mL. METHODS/PROCEDURES Average clozapine metabolizers were obtained by eliminating outliers with confounding variables: (1) psychiatric inducers and inhibitors; (2) doses less than 100 mg/d; and (3) when possible, patients with inflammation, obesity, or using oral contraceptives. The study included 1363 average metabolizer European Whites: the Italian sample and 5 new samples. Mean averages that reached serum concentration levels of 350 ng/mL were calculated after stratification by sex and smoking status in each sample. Then, weighted mean averages were obtained by combining the 6 samples. FINDINGS/RESULTS The estimated weighted mean clozapine dosages ranged from 236 to 368 mg/d (236 mg/d in 218 female nonsmokers, 256 mg/d in 340 male nonsmokers, 357 mg/d in 269 female smokers, and 368 mg/d in 546 male smokers). IMPLICATIONS/CONCLUSIONS Our recommended dosages are less than those recommended in Europe. Future studies in European Whites need to replicate these recommended doses for average metabolizer patients after sex and smoking stratification and further explore clozapine dosing for those with relevant clinical confounders.
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10
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Rajalu BM, Jayarajan D, Muliyala KP, Sharma P, Gandhi S, Chand PK, Thirthalli J, Murthy P. Non-pharmacological interventions for smoking in persons with schizophrenia spectrum disorders - A systematic review. Asian J Psychiatr 2021; 56:102530. [PMID: 33465747 DOI: 10.1016/j.ajp.2020.102530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/20/2020] [Accepted: 12/16/2020] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The rates and intensity of tobacco use are higher in persons with schizophrenia spectrum disorders (PwS) compared to the general population, contributing to increased morbidity and mortality. We aimed to systematically review randomised control trials (RCTs) that used non-pharmacological interventions to reduce or cease tobacco use in PwS. METHODS We searched PubMed, EBSCO, ProQuest and PsycINFO for RCTs, published between January 2004 and December 2019, which included adult PwS. Studies providing self-reported or biochemically measured reduction of tobacco use and cessation after a minimum follow-up period of 6 months were included. We used the Cochrane Risk of Bias (ROB) tool for assessing the quality of selected studies. RESULTS Of the six included trials, two compared non-pharmacological interventions alone while four compared combinations with pharmacological interventions with routine care. The non-pharmacological interventions varied widely. Continuous abstinence and seven days point-prevalence abstinence (7 PPA) were reported in 2 and 4 studies respectively, with one study assessing both. All six trials measured reduction in the number of cigarettes smoked, but only two trials reported significant reductions in intervention groups. No worsening of psychiatric symptoms was reported. CONCLUSIONS Two trials were rated as "low risk", and 4 trials as "some concerns" on the ROB tool. Heterogeneity among trials precluded meta-analysis. Abstinence was significantly higher among groups who were given combination interventions, and intervention groups in studies showed significantly greater or a trend towards reduction in the number of cigarettes smoked than controls. No specific method of non-pharmacological management was conclusively favoured. IMPLICATIONS Reduction in cigarettes smoked seemed to significantly favour or show non-significant trends favouring intervention groups over controls, while abstinence was significantly higher among groups in studies that used specific combination interventions. Combinations of pharmacological and non-pharmacological treatment were better than non-pharmacological interventions used in isolation, for facilitating abstinence and reduction in cigarettes smoked. Specific interventions such as home visits and contingent reinforcement merit further study. Trials included in this study were conducted in high-income and upper-middle-income countries. Thus, the application of these interventions to low and middle-income countries (LAMICs) needs to be further studied.
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Affiliation(s)
- Banu Manickam Rajalu
- Psychiatric Rehabilitation Services, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
| | - Deepak Jayarajan
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
| | - Krishna Prasad Muliyala
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
| | - Priyamvada Sharma
- Centre for Addiction Medicine, Department of Clinical Pharmacology and Neurotoxicology, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
| | - Sailaxmi Gandhi
- Department of Nursing, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
| | - Prabhat Kumar Chand
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
| | - Jagadisha Thirthalli
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
| | - Pratima Murthy
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
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11
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de Leon J, Schoretsanitis G, Kane JM, Ruan CJ. Using therapeutic drug monitoring to personalize clozapine dosing in Asians. Asia Pac Psychiatry 2020; 12:e12384. [PMID: 32119764 DOI: 10.1111/appy.12384] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/19/2020] [Accepted: 02/10/2020] [Indexed: 12/27/2022]
Abstract
This narrative review on clozapine blood levels or therapeutic drug monitoring (TDM) includes sections focused on drug clearance and TDM, personalized dosing with TDM, clinical applications of TDM in Asians, and areas needing further study. Asian patients need half the clozapine dose (D) used in the United States to get the same blood concentrations (C). The concentration-to-dose (C/D) ratio measures drug clearance. In the United States, the average clozapine patient usually needs from 300 to 600 mg/day to reach 350 ng/mL. US male smokers reach this therapeutic C with a D of 600 mg/day (C/D ratio of 0.60 = 600/350), whereas US female nonsmokers usually need a D of 300 mg/day (C/D ratio of 1.17 = 300/350). While in the United States, average CLO C/D ratios typically are 0.6-1.2 ng/mL per mg/day, in Asian populations they range from 1.20 in male smokers to 2.40 in female smokers, requiring Ds of 300 to 150 mg/day to obtain 350 ng/mL. Asian patients can become clozapine poor metabolizers (PMs), needing very low Ds (50-150 mg/day) to get therapeutic Cs, by taking inhibitors (fluvoxamine, oral contraceptives and valproic acid), due to obesity, or during inflammations with systemic effects. In 573 Asian patients from five samples, around 1% were PMs due to taking inhibitors, 1% due to inflammation, 1% due to obesity, and 7% were potential genetic PMs. The potential genetic PMs ranged between 3% and 13%, but this prevalence will have to be better established in future studies including genetic testing for possible CYP1A2 mutations, which may explain PM status.
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Affiliation(s)
- Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, Kentucky.,Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain
| | - Georgios Schoretsanitis
- Department of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York
| | - John M Kane
- Department of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology & The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
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12
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de Leon J, Ruan CJ, Schoretsanitis G, De las Cuevas C. A Rational Use of Clozapine Based on Adverse Drug Reactions, Pharmacokinetics, and Clinical Pharmacopsychology. PSYCHOTHERAPY AND PSYCHOSOMATICS 2020; 89:200-214. [PMID: 32289791 PMCID: PMC7206357 DOI: 10.1159/000507638] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022]
Abstract
Using Richardson and Davidson's model and the sciences of pharmacokinetics and clinical pharmacopsychology, this article reviewed the: (1) poor life expectancy associated with treatment-resistant schizophrenia (TRS), which may be improved in patients who adhere to clozapine; (2) findings that clozapine is the best treatment for TRS (according to efficacy, effectiveness and well-being); and (3) potential for clozapine to cause vulnerabilities, including potentially lethal adverse drug reactions such as agranulocytosis, pneumonia, and myocarditis. Rational use requires: (1) modification of the clozapine package insert worldwide to include lower doses for Asians and to avoid the lethality associated with pneumonia, (2) the use of clozapine levels for personalizing dosing, and (3) the use of slow and personalized titration. This may make clozapine as safe as possible and contribute to increased life expectancy and well-being. In the absence of data on COVID-19 in clozapine patients, clozapine possibly impairs immunological mechanisms and may increase pneumonia risk in infected patients. Psychiatrists should call their clozapine patients and families and explain to them that if the patient develops fever or flu-like symptoms, the psychiatrist should be called and should consider halving the clozapine dose. If the patient is hospitalized with pneumonia, the treating physician needs to assess for symptoms of clozapine intoxication since halving the dose may not be enough for all patients; consider decreasing it to one-third or even stopping it. Once the signs of inflammation and fever have disappeared, the clozapine dose can be slowly increased to the prior dosage level.
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Affiliation(s)
- Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, Kentucky, USA, .,Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain, .,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain,
| | - Can-Jun Ruan
- The National Clinical Research Centre for Mental Disorders, Beijing Key Laboratory of Mental Disorders, and Laboratory of Clinical Psychopharmacology, Beijing Anding Hospital, Capital Medical University, Beijing, China,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Georgios Schoretsanitis
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York, USA
| | - Carlos De las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, University of La Laguna, San Cristóbal de La Laguna, Spain
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Schoretsanitis G, Kane JM, Ruan CJ, Spina E, Hiemke C, de Leon J. A comprehensive review of the clinical utility of and a combined analysis of the clozapine/norclozapine ratio in therapeutic drug monitoring for adult patients. Expert Rev Clin Pharmacol 2019; 12:603-621. [DOI: 10.1080/17512433.2019.1617695] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Georgios Schoretsanitis
- Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Hofstra Northwell School of Medicine, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - John M. Kane
- Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Hofstra Northwell School of Medicine, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology & The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Mainz, Germany
| | - Jose de Leon
- University of Kentucky Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA
- Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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Why Do You Keep Telling Me That Drug-Drug Interactions Are Important in Psychopharmacology When I Do Not See Them in My Clinical Practice?: My Failure to Convince Clinicians. J Clin Psychopharmacol 2019; 39:1-4. [PMID: 30212396 DOI: 10.1097/jcp.0000000000000924] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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15
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Pharmacokinetics and Short-term Safety of ALKS 3831, a Fixed-dose Combination of Olanzapine and Samidorphan, in Adult Subjects with Schizophrenia. Clin Ther 2018; 40:1845-1854.e2. [DOI: 10.1016/j.clinthera.2018.09.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/10/2018] [Accepted: 09/06/2018] [Indexed: 11/23/2022]
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16
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Ruan CJ, Zhang XL, Guo W, Li WB, Zhuang HY, Li YQ, Wang CY, Tang YL, Zhou FC, de Leon J. Two cases of high serum clozapine concentrations occurring during inflammation in Chinese patients. Int J Psychiatry Med 2018; 53:292-305. [PMID: 29292668 DOI: 10.1177/0091217417749799] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective Serious infections or inflammations have been associated with serum clozapine concentration increases and sometimes with clozapine toxicity. Method These two cases describe Chinese patients (Case 1: a 57-year-old female nonsmoker with severe dermatitis and Case 2: a 47-year-old male nonsmoker with influenza and secondary infection). Results In both cases, the Drug Interaction Probability Scale established the presence of a probable drug-drug interaction. In both cases, the clozapine and the total clozapine concentration-to-dose ratios followed a temporal pattern (normal-high-normal), consistent with an inhibition of clozapine metabolism during peak inflammation. In the first case, the total clozapine concentration-to-dose ratio (8 with no/low inflammation: median of 3.10 and 2 at peak inflammation: median of 3.90) provided a significant difference (P = 0.044). In the second patient, because of the smaller sample size and reduced statistical power (4 with no infection: a median of 1.59 and 2 at peak infection: 3.46), the increase did not reach significance (P = 0.13). In the first case, the median baseline clozapine concentration-to-dose ratio increased by a factor of 1.45 from 2.00 to a peak of 2.89. To compensate for the inhibition of clozapine metabolism, the dose correction factor was 0.69 (1/1.45) or a decrease in dose of approximately one-third. In the second case, the median baseline clozapine concentration-to-dose ratio increased by a factor of 2.56 from 1.15 to a peak of 2.94. Conclusion This provided a dose correction factor of 0.40 (1/2.56) or approximately half the dose, similar to published cases in Caucasians with serious respiratory infections.
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Affiliation(s)
- Can-Jun Ruan
- 1 Laboratory of Clinical Psychopharmacology & The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Xiao-Ling Zhang
- 2 Department of Pharmacy, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Guo
- 3 Department of Pharmacy & The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Wen-Biao Li
- 1 Laboratory of Clinical Psychopharmacology & The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Hong-Yan Zhuang
- 3 Department of Pharmacy & The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Ya-Qiong Li
- 4 Department of Psychiatry, Atlanta VA Medical Center, The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders & Beijing Institute for Brain Disorders Center of Schizophrenia, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Chuan-Yue Wang
- 4 Department of Psychiatry, Atlanta VA Medical Center, The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders & Beijing Institute for Brain Disorders Center of Schizophrenia, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Yi-Lang Tang
- 4 Department of Psychiatry, Atlanta VA Medical Center, The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders & Beijing Institute for Brain Disorders Center of Schizophrenia, Beijing Anding Hospital, Capital Medical University, Beijing, China.,5 Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, USA
| | - Fu-Chun Zhou
- 4 Department of Psychiatry, Atlanta VA Medical Center, The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders & Beijing Institute for Brain Disorders Center of Schizophrenia, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Jose de Leon
- 6 Mental Health Research Center, Eastern State Hospital, Lexington, USA.,7 Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain.,8 Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain
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Schoretsanitis G, de Leon J, Diaz FJ. Prolactin levels: sex differences in the effects of risperidone, 9-hydroxyrisperidone levels, CYP2D6 and ABCB1 variants. Pharmacogenomics 2018; 19:815-823. [PMID: 29914302 DOI: 10.2217/pgs-2018-0053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
AIM The role of sex on the association of plasma prolactin levels with risperidone (R) and 9-hydroxyrisperidone (9-OHR) concentrations is investigated. METHODS Plasma R and prolactin concentrations, CYP2D6 and exon 21 and 26 ABCB1 gene variants were studied in 110 patients. RESULTS In females, a 1 ng/ml increase in R levels was associated with a significant 1.02% increase in prolactin levels. In males, a 1 ng/ml increase in 9-OHR levels was associated with a significant 1.18% increase in prolactin levels. ABCB1 haplotype 12 had significant but opposite effects in males and females. In the combined sample, 9-OHR, but not R levels had significant effects on prolactin levels. CONCLUSION Genes had sex-specific effects on risperidone-associated prolactin elevations.
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Affiliation(s)
- Georgios Schoretsanitis
- University Hospital of Psychiatry, Bern, Switzerland.,Department of Psychiatry, Psychotherapy & Psychosomatics, RWTH Aachen University, Aachen, Germany, & JARA - Translational Brain Medicine
| | - Jose de Leon
- University of Kentucky Mental Health Research Center at Eastern State Hospital, Lexington, KY 40508, USA.,Psychiatry & Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
| | - Francisco J Diaz
- Department of Biostatistics, The University of Kansas Medical Center, Kansas City, KS, USA
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Wojnicz A, Belmonte C, Koller D, Ruiz-Nuño A, Román M, Ochoa D, Abad-Santos F. Effective phospholipids removing microelution-solid phase extraction LC-MS/MS method for simultaneous plasma quantification of aripiprazole and dehydro-aripiprazole: Application to human pharmacokinetic studies. J Pharm Biomed Anal 2018; 151:116-125. [DOI: 10.1016/j.jpba.2017.12.049] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 12/18/2017] [Accepted: 12/22/2017] [Indexed: 12/15/2022]
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Cigarette smoking has a differential effect on the plasma level of clozapine in Taiwanese schizophrenic patients associated with the CYP1A2 gene -163A/C single nucleotide polymorphism. Psychiatr Genet 2017; 26:172-7. [PMID: 27203225 DOI: 10.1097/ypg.0000000000000139] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The efficacy of clozapine clearance has been shown to be associated with smoking and genetic polymorphism of CYP1A2. This study aims to investigate the effect of smoking on the plasma level of clozapine in Taiwanese schizophrenic patients and its relevance to the CYP1A2 gene -163A/C single nucleotide polymorphism. MATERIALS AND METHODS A total of 143 hospitalized schizophrenic patients who had received clozapine therapy for at least 14 days were enrolled in this study. The trough plasma concentration of clozapine was measured with LC/MS/MS. The -163A/C variant in the CYP1A2 gene was identified by DNA sequencing and restriction fragment length polymorphism analysis. The effect of smoking on the clozapine level was examined by multiple linear regression analysis and its relation to the -163A/C variant of the CYP1A2 gene was analyzed using a general linear model with Bonferroni correction. RESULTS Patients with smoking habits showed a significantly lower plasma level of clozapine than those without smoking habits (P=0.022) and the difference in clozapine levels between smokers and nonsmokers appeared to be significant in the individuals carrying the homozygous -163A allele (P=0.02). It was also found that nonsmokers carrying the -163A allele tended to have higher plasma levels of clozapine. This tendency was not found in the individuals with smoking habits. CONCLUSION Cigarette smoking has a significant impact on the plasma level of clozapine in Taiwanese schizophrenic patients carrying the homozygous -163A allele in the CYP1A2 gene. Cigarette smoking may increase the clearance of clozapine in these patients.
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Rafaniello C, Sessa M, Bernardi FF, Pozzi M, Cheli S, Cattaneo D, Baldelli S, Molteni M, Bernardini R, Rossi F, Clementi E, Bravaccio C, Radice S, Capuano A. The predictive value of ABCB1, ABCG2, CYP3A4/5 and CYP2D6 polymorphisms for risperidone and aripiprazole plasma concentrations and the occurrence of adverse drug reactions. THE PHARMACOGENOMICS JOURNAL 2017; 18:422-430. [PMID: 28719598 DOI: 10.1038/tpj.2017.38] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 04/06/2017] [Accepted: 06/07/2017] [Indexed: 01/07/2023]
Abstract
We investigated in ninety Caucasian pediatric patients the impact of the main polymorphisms occurring in CYP3A, CYP2D6, ABCB1 and ABCG2 genes on second-generation antipsychotics plasma concentrations, and their association with the occurrence of adverse drug reactions. Patients with the CA/AA ABCG2 genotype had a statistically significant lower risperidone plasma concentration/dose ratio (Ct/ds) (P-value: 0.007) and an higher estimated marginal probability of developing metabolism and nutrition disorders as compared to the ABCG2 c.421 non-CA/AA genotypes (P-value: 0.008). Multivariate analysis revealed that the ABCG2 c.421 CA/AA genotype was found associated to a higher hazard (P-value: 0.004) of developing adverse drug reactions classified as metabolism and nutrition disorders. The ABCB1 2677TT/3435TT genotype had a statistically significant lower aripiprazole Ct/ds if compared with patients with others ABCB1 genotypes (P-value: 0.026). Information obtained on ABCB1 and ABCG2 gene variants may result useful to tailor treatments with these drugs in Caucasian pediatric patients.
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Affiliation(s)
- C Rafaniello
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", Second University of Naples, Naples, Italy
| | - M Sessa
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", Second University of Naples, Naples, Italy
| | - F F Bernardi
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", Second University of Naples, Naples, Italy
| | - M Pozzi
- Scientific Institute IRCCS Eugenio Medea, Bosisio Parini, Italy
| | - S Cheli
- Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Unit of Clinical Pharmacology, CNR Institute of Neuroscience, University of Milan, Milan, Italy
| | - D Cattaneo
- Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Unit of Clinical Pharmacology, CNR Institute of Neuroscience, University of Milan, Milan, Italy
| | - S Baldelli
- Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Unit of Clinical Pharmacology, CNR Institute of Neuroscience, University of Milan, Milan, Italy
| | - M Molteni
- Scientific Institute IRCCS Eugenio Medea, Bosisio Parini, Italy
| | - R Bernardini
- Department of Clinical and Molecular Biomedicine, Section of Pharmacology and Biochemistry, School of Medicine, University of Catania, Catania, Italy
| | - F Rossi
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", Second University of Naples, Naples, Italy
| | - E Clementi
- Scientific Institute IRCCS Eugenio Medea, Bosisio Parini, Italy.,Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Unit of Clinical Pharmacology, CNR Institute of Neuroscience, University of Milan, Milan, Italy
| | - C Bravaccio
- Department of Translational Medical Sciences, Section of Neuropsychiatry, University "Federico II", Naples, Italy
| | - S Radice
- Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Unit of Clinical Pharmacology, CNR Institute of Neuroscience, University of Milan, Milan, Italy
| | - A Capuano
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", Second University of Naples, Naples, Italy
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Du Plooy JL, Macharia M, Verster C. Cigarette smoking, nicotine dependence, and motivation to quit smoking in South African male psychiatric inpatients. BMC Psychiatry 2016; 16:403. [PMID: 27852297 PMCID: PMC5112714 DOI: 10.1186/s12888-016-1123-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 11/10/2016] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Smoking is the leading cause of preventable death worldwide and the prevalence is particularly high among psychiatric patients but recent international studies demonstrated that psychiatric patients are able and motivated to quit. The aim of this study was to evaluate cigarette smoking, nicotine dependence, and motivation for smoking cessation in male psychiatric inpatients in a sample of South African acute-care male psychiatric inpatients. METHODS All inpatients admitted during a 2-month period (April to May 2016) to the Stikland Hospital Acute Male Admissions Unit in Cape Town, Western Cape, were included. Subjects completed a survey including a set of tests: Global Adult Tobacco Survey (GATS), the Fagerström Test for Nicotine Dependence (FTND), and the Decisional Balance for Cigarette Smoking (DBCS) (6-item version). Demographic data were obtained from patients' clinical charts. RESULTS Among the 160 new inpatients, 72.5% (n = 116) completed the survey. Of the 116 participants, 91.4% (n = 106) were current smokers of whom 82% (n = 87) smoked daily and 55.6% (n = 59) were identified as having high nicotine dependence (FTND ≥ 6). Although a large majority (71.7%; n = 76) of current smokers expressed positive perceptions regarding smoking, a notable proportion (59.4%; n = 63) still attempted to quit the habit in the preceding 12 months and daily smokers were less likely to quit. However, only a minor proportion of all current (43.4%; n = 46) and specifically daily (40.2%; n = 35) smokers were advised on smoking cessation by a health worker. CONCLUSION This study confirms that, similar to populations elsewhere, rates of cigarette smoking among psychiatric inpatients in South Africa is exceedingly high. While patients are motivated to quit smoking, few were provided with the necessary advice. Our findings provide further support for the integration of smoking cessation support in mental health care.
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Affiliation(s)
- Jean-Louis Du Plooy
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Muiruri Macharia
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Chris Verster
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Spina E, Hiemke C, de Leon J. Assessing drug-drug interactions through therapeutic drug monitoring when administering oral second-generation antipsychotics. Expert Opin Drug Metab Toxicol 2016; 12:407-22. [DOI: 10.1517/17425255.2016.1154043] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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23
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Efectos de los inductores antiepilépticos en la neuropsicofarmacología: una cuestión ignorada. Parte II: cuestiones farmacológicas y comprensión adicional. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2015; 8:167-88. [DOI: 10.1016/j.rpsm.2014.10.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 10/23/2014] [Indexed: 12/19/2022]
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Arrojo-Romero M, Armas Barbazán C, López-Moriñigo JD, Ramos-Ríos R, Gurpegui M, Martínez-Ortega JM, Jurado D, Diaz FJ, de Leon J. Caffeine consumption in a long-term psychiatric hospital: Tobacco smoking may explain in large part the apparent association between schizophrenia and caffeine use. Schizophr Res 2015; 164:234-41. [PMID: 25702972 DOI: 10.1016/j.schres.2015.01.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 01/24/2015] [Accepted: 01/28/2015] [Indexed: 10/24/2022]
Abstract
This study further explores the association between schizophrenia and caffeine use by combining two prior published Spanish samples (250 schizophrenia outpatients and 290 controls from the general population) with two Spanish long-term inpatient samples from the same hospital (145 with schizophrenia and 64 with other severe mental illnesses). The specific aims were to establish whether or not, after controlling for confounders including tobacco smoking, the association between schizophrenia and caffeine is consistent across schizophrenia samples and across different definitions of caffeine use. The frequency of caffeine use in schizophrenia inpatients was not significantly higher than that in non-schizophrenia inpatients (77%, 111/145 vs. 75%, 48/64) or controls but was significantly higher than in schizophrenia outpatients. The frequency of high caffeine users among caffeine users in schizophrenia inpatients was not significantly higher than in non-schizophrenia inpatients (45%, 50/111 vs. 52%, 25/48) or controls, but was significantly lower than in schizophrenia outpatients. Smoking was significantly associated with caffeine use across all samples and definitions. Between 2 and 3% of schizophrenia inpatients, schizophrenia outpatients and non-schizophrenia inpatients showed caffeinism (>700 mg/day in smokers). Several of these smoking patients with caffeinism were also taking other inducers, particularly omeprazole. The lack of consistent association between schizophrenia and caffeine use is surprising when compared with the very consistent association between tobacco smoking and caffeine use across all of our analyses (use and high use in users) and all our samples. The confounding effects of tobacco smoking may explain in large part the apparent association between schizophrenia and caffeine use.
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Affiliation(s)
- Manuel Arrojo-Romero
- Psychiatry Department (EOXI de Santiago), Gallegan Health System (Servicio Gallego de Salud), Santiago de Compostela, Spain
| | - Carmen Armas Barbazán
- Psychiatry Department (EOXI de Lugo), Gallegan Health System (Servicio Gallego de Salud), Lugo, Spain
| | - Javier D López-Moriñigo
- Department of Psychosis Studies, Institute of Psychiatry, King's College London, London, UK; Servicio de Psiquiatría, EOXI Santiago, Servicio Gallego de Salud, Spain
| | - Ramón Ramos-Ríos
- Psychiatry Department (EOXI de Santiago), Gallegan Health System (Servicio Gallego de Salud), Santiago de Compostela, Spain
| | - Manuel Gurpegui
- Department of Psychiatry, University of Granada, Granada, Spain; Institute of Neurosciences, Center for Biomedical Research, University of Granada, Granada, Spain
| | - José M Martínez-Ortega
- Department of Psychiatry, University of Granada, Granada, Spain; Institute of Neurosciences, Center for Biomedical Research, University of Granada, Granada, Spain
| | - Dolores Jurado
- Institute of Neurosciences, Center for Biomedical Research, University of Granada, Granada, Spain; Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
| | - Francisco J Diaz
- Department of Biostatistics, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Jose de Leon
- Institute of Neurosciences, Center for Biomedical Research, University of Granada, Granada, Spain; Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA.
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The effects of antiepileptic inducers in neuropsychopharmacology, a neglected issue. Part I: A summary of the current state for clinicians. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.rpsmen.2015.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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The effects of antiepileptic inducers in neuropsychopharmacology, a neglected issue. Part I: A summary of the current state for clinicians. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2015; 8:97-115. [PMID: 25745819 DOI: 10.1016/j.rpsm.2014.10.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 10/23/2014] [Indexed: 12/18/2022]
Abstract
The literature on inducers in epilepsy and bipolar disorder is seriously contaminated by false negative findings. This is part i of a comprehensive review on antiepileptic drug (AED) inducers using both mechanistic pharmacological and evidence-based medicine to provide practical recommendations to neurologists and psychiatrists concerning how to control for them. Carbamazepine, phenobarbital and phenytoin, are clinically relevant AED inducers; correction factors were calculated for studied induced drugs. These correction factors are rough simplifications for orienting clinicians, since there is great variability in the population regarding inductive effects. As new information is published, the correction factors may need to be modified. Some of the correction factors are so high that the drugs (e.g., bupropion, quetiapine or lurasidone) should not co-prescribed with potent inducers. Clobazam, eslicarbazepine, felbamate, lamotrigine, oxcarbazepine, rufinamide, topiramate, vigabatrin and valproic acid are grouped as mild inducers which may (i)be inducers only in high doses; (ii)frequently combine with inhibitory properties; and (iii)take months to reach maximum effects or de-induction, definitively longer than the potent inducers. Potent inducers, definitively, and mild inducers, possibly, have relevant effects in the endogenous metabolism of (i)sexual hormones, (ii) vitamin D, (iii)thyroid hormones, (iv)lipid metabolism, and (v)folic acid.
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Altamura AC, Caldiroli A, Buoli M. Pharmacokinetic evaluation of fluvoxamine for the treatment of anxiety disorders. Expert Opin Drug Metab Toxicol 2015; 11:649-60. [DOI: 10.1517/17425255.2015.1021331] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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28
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Pharmacogenetics informed decision making in adolescent psychiatric treatment: a clinical case report. Int J Mol Sci 2015; 16:4416-28. [PMID: 25710722 PMCID: PMC4394428 DOI: 10.3390/ijms16034416] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 02/11/2015] [Accepted: 02/12/2015] [Indexed: 01/09/2023] Open
Abstract
Advances made in genetic testing and tools applied to pharmacogenetics are increasingly being used to inform clinicians in fields such as oncology, hematology, diabetes (endocrinology), cardiology and expanding into psychiatry by examining the influences of genetics on drug efficacy and metabolism. We present a clinical case example of an adolescent male with anxiety, attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder who did not tolerate numerous medications and dosages over several years in attempts to manage his symptoms. Pharmacogenetics testing was performed and DNA results on this individual elucidated the potential pitfalls in medication use because of specific pharmacodynamic and pharmacokinetic differences specifically involving polymorphisms of genes in the cytochrome p450 enzyme system. Future studies and reports are needed to further illustrate and determine the type of individualized medicine approach required to treat individuals based on their specific gene patterns. Growing evidence supports this biological approach for standard of care in psychiatry.
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Pocklington AJ, O'Donovan M, Owen MJ. The synapse in schizophrenia. Eur J Neurosci 2014; 39:1059-67. [PMID: 24712986 DOI: 10.1111/ejn.12489] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 12/19/2013] [Accepted: 12/20/2013] [Indexed: 02/06/2023]
Abstract
It has been several decades since synaptic dysfunction was first suggested to play a role in schizophrenia, but only in the last few years has convincing evidence been obtained as progress has been made in elucidating the genetic underpinnings of the disorder. In the intervening years much has been learned concerning the complex macromolecular structure of the synapse itself, and genetic studies are now beginning to draw upon these advances. Here we outline our current understanding of the genetic architecture of schizophrenia and examine the evidence for synaptic involvement. A strong case can now be made that disruption of glutamatergic signalling pathways regulating synaptic plasticity contributes to the aetiology of schizophrenia.
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Affiliation(s)
- Andrew J Pocklington
- MRC Centre for Neuropsychiatric Genetics and Genomics, Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Hadyn Ellis Building, Maindy Road, Cathays, Cardiff, CF24 4HQ, UK
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A molecular pathway analysis of the glutamatergic-monoaminergic interplay serves to investigate the number of depressive records during citalopram treatment. J Neural Transm (Vienna) 2014; 122:465-75. [PMID: 24986638 DOI: 10.1007/s00702-014-1267-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 06/24/2014] [Indexed: 12/28/2022]
Abstract
The efficacy of current antidepressant (AD) drugs for the treatment of major depressive disorder (MDD) lays behind expectations. The correct genetic differentiation between severe and less severe cases before treatment may pave the way to the most correct clinical choices in clinical practice. Genetics may pave the way such identification, which in turns may provide perspectives for the synthesis of new ADs by correcting the molecular unbalances that differentiate severe and less severe depressive patients. We investigated 1,903 MDD patients from the STAR*D study. Outcome was the number of severe depressive records, defined as a Quick Inventory of Depressive Symptomatology (QIDS)-Clinician rated (C) total score >15, corrected for the number of observations for each patient during the first 14 weeks of citalopram treatment. Predictors were the genetic variations harbored by genes involved in the glutamatergic-monoaminergic interplay as defined in a previous work published by our group. Clinical and socio-demographic stratification factor analyses were taken in cases and controls. Covariated linear regression was the statistical model for the analysis. SNPs were analyzed in groups (molecular pathway analysis) testing the hypothesis that the distribution of significant (p < 0.05) associations between SNPs and the outcome segregates within each pathway/gene subset. The best associated results are relative to two signle SNPs, (rs7744492 in AKAP12 p = 0.0004 and rs17046113 in CAMK2D p = 0.0006) and a molecular pathway (cAMP biosynthetic process p = 0.005). After correction for multitesting, none of them resulted to be significantly associated. These results are consistent with previous findings in literature and further stress that the molecular mechanisms targeted by current ADs may not be the key biological variables that differentiate severe from mild depression.
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False-negative studies may systematically contaminate the literature on the effects of inducers in neuropsychopharmacology: part II: focus on bipolar disorder. J Clin Psychopharmacol 2014; 34:291-6. [PMID: 24717257 DOI: 10.1097/jcp.0000000000000115] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Diaz FJ, Eap CB, Ansermot N, Crettol S, Spina E, de Leon J. Can valproic acid be an inducer of clozapine metabolism? PHARMACOPSYCHIATRY 2014; 47:89-96. [PMID: 24764199 DOI: 10.1055/s-0034-1371866] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Prior clozapine studies indicated no effects, mild inhibition or induction of valproic acid (VPA) on clozapine metabolism. The hypotheses that (i) VPA is a net inducer of clozapine metabolism, and (ii) smoking modifies this inductive effect were tested in a therapeutic drug monitoring study. METHODS After excluding strong inhibitors and inducers, 353 steady-state total clozapine (clozapine plus norclozapine) concentrations provided by 151 patients were analyzed using a random intercept linear model. RESULTS VPA appeared to be an inducer of clozapine metabolism since total plasma clozapine concentrations in subjects taking VPA were significantly lower (27% lower; 95% confidence interval, 14-39%) after controlling for confounding variables including smoking (35% lower, 28-56%). DISCUSSION Prospective studies are needed to definitively establish that VPA may (i) be an inducer of clozapine metabolism when induction prevails over competitive inhibition, and (ii) be an inducer even in smokers who are under the influence of smoking inductive effects on clozapine metabolism.
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Affiliation(s)
- F J Diaz
- Department of Biostatistics, The University of Kansas Medical Center, -Kansas City, KS, USA
| | - C B Eap
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neurosciences, Department of Psychiatry, Lausanne University, Hospital of Cery, Prilly-Lausanne, Switzerland
| | - N Ansermot
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neurosciences, Department of Psychiatry, Lausanne University, Hospital of Cery, Prilly-Lausanne, Switzerland
| | - S Crettol
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neurosciences, Department of Psychiatry, Lausanne University, Hospital of Cery, Prilly-Lausanne, Switzerland
| | - E Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - J de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA
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Treatment of Comorbid Tobacco Addiction in Substance Use and Psychiatric Disorders. CURRENT ADDICTION REPORTS 2013. [DOI: 10.1007/s40429-013-0001-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Ruaño G, Szarek BL, Villagra D, Gorowski K, Kocherla M, Seip RL, Goethe JW, Schwartz HI. Length of psychiatric hospitalization is correlated with CYP2D6 functional status in inpatients with major depressive disorder. Biomark Med 2013; 7:429-39. [PMID: 23734807 DOI: 10.2217/bmm.13.16] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
AIM This study aimed to determine the effect of the CYP2D6 genotype on the length of hospitalization stay for patients treated for major depressive disorder. METHODS A total of 149 inpatients with a diagnosis of major depressive disorder at the Institute of Living, Hartford Hospital (CT, USA), were genotyped to detect altered alleles in the CYP2D6 gene. Prospectively defined drug metabolism indices (metabolic reserve, metabolic alteration and allele alteration) were determined quantitatively and assessed for their relationship to length of hospitalization stay. RESULTS Hospital stay was significantly longer in deficient CYP2D6 metabolizers (metabolic reserve <2) compared with functional or suprafunctional metabolizers (metabolic reserve ≥2; 7.8 vs 5.7 days, respectively; p = 0.002). CONCLUSION CYP2D6 enzymatic functional status significantly affected length of hospital stay, perhaps due to reduced efficacy or increased side effects of the medications metabolized by the CYP2D6 isoenzyme. Functional scoring of CYP2D6 alleles may have a substantial impact on the quality of care, patient satisfaction and the economics of psychiatric treatment.
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Affiliation(s)
- Gualberto Ruaño
- Genetics Research Center, Hartford Hospital, 67 Jefferson Street, Hartford, CT 06106, USA
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Hefner G, Laib AK, Sigurdsson H, Hohner M, Hiemke C. The value of drug and metabolite concentration in blood as a biomarker of psychopharmacological therapy. Int Rev Psychiatry 2013; 25:494-508. [PMID: 24151798 DOI: 10.3109/09540261.2013.836475] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Desirable and undesirable effects of a drug are related to its concentration at various sites of actions. For many psychotropic drugs, it has been shown that drug concentration in brain correlates with concentration in blood. The latter is also an available estimate of clearance and bioavailability. Its monitoring enables identification of multiple factors that have an impact on clinical outcomes, especially uncertain compliance and pharmacokinetic peculiarities. For this review we analysed for antidepressants if drug concentration in blood can be used as biomarker for psychopharmacological treatment. Systematic review of the literature revealed for new and old antidepressant drugs that drug and metabolite concentrations in blood are measures of the pharmacokinetic phenotype and related differentially to occupancy of primary target structures, therapeutic effects and unwanted anticholinergic, cardiac and other side effects. Drug concentration in blood can therefore be used as biomarker in clinical practice to guide psychopharmacological treatment with established antidepressant drugs. Monitoring of drug concentration is suitable to improve efficacy and safety of the pharmacotherapy, especially in elderly patients who require complex pharmacological therapies.
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Affiliation(s)
- Gudrun Hefner
- Department of Psychiatry and Psychotherapy, University Medical Centre Mainz , Germany
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Clobazam therapeutic drug monitoring: a comprehensive review of the literature with proposals to improve future studies. Ther Drug Monit 2013; 35:30-47. [PMID: 23318278 DOI: 10.1097/ftd.0b013e31827ada88] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Clobazam was recently approved for Lennox-Gastaut syndrome in the United States. There is no published review article focused on clobazam therapeutic drug monitoring (TDM) in English. METHODS More than 200 clobazam articles identified by a PubMed search were carefully reviewed for information on clobazam pharmacokinetics. Clobazam is mainly metabolized by a cytochrome P450 (CYP) isoenzyme, CYP3A4, to its active metabolite, N-desmethylclobazam. Then, N-desmethylclobazam is mainly metabolized by CYP2C19 unless the individual has no CYP2C19 activity [poor metabolizer (PM)]. RESULTS Using a mechanistic approach to reinterpret the published findings of steady-state TDM and single-dosing pharmacokinetic studies, 4 different serum clobazam concentration ratios were studied. The available limited steady-state TDM data suggest that the serum N-desmethylclobazam/clobazam ratio can be useful for clinicians, including identifying CYP2C19 PMs (ratio >25 in the absence of inhibitors). There are 3 possible concentration/dose (C/D) ratios. The clobazam C/D ratio has the potential to measure the contribution of CYP3A4 activity to the clearance of clobazam from the body. The N-desmethylclobazam C/D ratio does not seem to be a good measure of clobazam clearance and should be substituted with the total (clobazam + N-desmethylclobazam) C/D ratio. CONCLUSIONS Future clobazam TDM studies need to use trough concentrations after steady state has been reached (>3 weeks in normal individuals and several months in CYP2C19 PMs). These future studies need to explore the potential of clobazam and total C/D ratios. Better studies on the relative potency of N-desmethylclobazam compared with the parent compound are needed to provide weighted total serum concentrations that correct for the possible lower N-desmethylclobazam pharmacodynamic activity. Standardization and more studies of C/D ratios from clobazam and other drugs can be helpful to move TDM forward.
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Llerena A, Berecz R, Peñas-Lledó E, Süveges A, Fariñas H. Pharmacogenetics of clinical response to risperidone. Pharmacogenomics 2013; 14:177-94. [PMID: 23327578 DOI: 10.2217/pgs.12.201] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Despite risperidone's proven safety and efficacy, existing pharmacogenetic knowledge could be applied to improve its clinical use. The present work aims to summarize the information about genetic polymorphisms affecting risperidone adverse reactions and efficacy during routine clinical practice. The most relevant genes involved in the metabolism of the drug (i.e., CYP2D6, CYP3A and ABCB1) appear to have the greatest potential to predict differences in plasma concentrations of the drug and its interactions, but also relate to side effects, such as neuroleptic syndrome, weight gain or polydipsia. Other genes that have been found in association at least twice with any adverse reactions including metabolic changes, extrapyramidal symptoms or prolactine increase are: 5HT2A; 5HT2C; 5HT6; DRD2; DRD3; and BDNF. Some of these genes (5HTR2A, DRD2 and DRD3), along with 5-HTTLPR and COMT, have also been reported to be related with negative clinical outcomes. However, there is not yet enough evidence to support their routine screening during clinical practice.
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Affiliation(s)
- Adrián Llerena
- University of Extremadura Medical School, Badajoz, Spain.
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Intramuscular Aripiprazole in the Acute Management of Psychomotor Agitation. Pharmacotherapy 2013; 33:603-14. [DOI: 10.1002/phar.1260] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Lombard J, Doraiswamy PM. What is the role of pharmacogenetics in clinical psychiatry? Expert Opin Drug Metab Toxicol 2012. [DOI: 10.1517/17425255.2013.733696] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Villagra D, Goethe J, Schwartz HI, Szarek B, Kocherla M, Gorowski K, Windemuth A, Ruaño G. Novel drug metabolism indices for pharmacogenetic functional status based on combinatory genotyping of CYP2C9, CYP2C19 and CYP2D6 genes. Biomark Med 2012; 5:427-38. [PMID: 21861665 DOI: 10.2217/bmm.11.32] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIMS We aim to demonstrate clinical relevance and utility of four novel drug-metabolism indices derived from a combinatory (multigene) approach to CYP2C9, CYP2C19 and CYP2D6 allele scoring. Each index considers all three genes as complementary components of a liver enzyme drug metabolism system and uniquely benchmarks innate hepatic drug metabolism reserve or alteration through CYP450 combinatory genotype scores. METHODS A total of 1199 psychiatric referrals were genotyped for polymorphisms in the CYP2C9, CYP2C19 and CYP2D6 gene loci and were scored on each of the four indices. The data were used to create distributions and rankings of innate drug metabolism capacity to which individuals can be compared. Drug-specific indices are a combination of the drug metabolism indices with substrate-specific coefficients. RESULTS The combinatory drug metabolism indices proved useful in positioning individuals relative to a population with regard to innate drug metabolism capacity prior to pharmacotherapy. Drug-specific indices generate pharmacogenetic guidance of immediate clinical relevance, and can be further modified to incorporate covariates in particular clinical cases. CONCLUSIONS We believe that this combinatory approach represents an improvement over the current gene-by-gene reporting by providing greater scope while still allowing for the resolution of a single-gene index when needed. This method will result in novel clinical and research applications, facilitating the translation from pharmacogenomics to personalized medicine, particularly in psychiatry where many drugs are metabolized or activated by multiple CYP450 isoenzymes.
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Murray M. Cytochromes P450: Roles in the Biotransformation of Chemicals in Cigarette Smoke and Impact of Smoking Cessation on Concurrent Drug Therapy. J Smok Cessat 2012. [DOI: 10.1375/jsc.5.2.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AbstractCigarette smoke contains polycyclic aromatic hydrocarbons (PAHs) that activate the expression of cytochrome P450 family 1 (CYP1) enzymes in liver and other tissues; this process is dependent on the aryl hydrocarbon receptor (AhR) transcription factor. An important CYP1 enzyme, CYP1A2, has a critical role in the oxidation of drugs such as clozapine, olanzapine and theophylline; these drugs exhibit a high incidence of adverse effects that are linked to plasma concentrations. This article reviews the impact of smoking and smoking cessation on therapy with toxic drugs that undergo CYP-mediated elimination. PAHs in cigarette smoke activate the AhR and upregulate CYP1A2, which enhances the clearance of these drugs, diminishes their efficacy and necessitates the use of higher doses. However, smoking cessation decreases PAH exposure, which leads to a decline in clearance of CYP1A2 substrate drugs. Dose reductions and close therapeutic monitoring for such drugs are recommended in patients who cease smoking.
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Magro L, Moretti U, Leone R. Epidemiology and characteristics of adverse drug reactions caused by drug-drug interactions. Expert Opin Drug Saf 2011; 11:83-94. [PMID: 22022824 DOI: 10.1517/14740338.2012.631910] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Drug-drug interactions (DDIs) arise in numerous different ways, involving pharmacokinetic or pharmacodynamic mechanisms. Adverse drug reactions are a possible consequence of DDIs and health operators are often unaware of the clinical risks of certain drug combinations. Many papers on drug interactions have been published in recent years, but most of them focused on potential DDIs while few studies have been conducted on actual interactions. AREAS COVERED This paper reviews the epidemiology of actual DDIs in outpatients as well as in hospital settings and in spontaneous reporting databases. The incidence of actual DDIs is consistently lower than that of potential DDIs. However, the absolute number of patients involved is high, representing a significant proportion of adverse drug reactions. The importance of risk factors such as age, polypharmacy and genetic polymorphisms is also evaluated. The relevance and efficacy of tools for recognizing and preventing DDIs are discussed. EXPERT OPINION Potential DDIs far outnumber actual drug interactions. The potential for an adverse interaction to occur is often theoretical, and clinically important adverse effects occur only in the presence of specific risk factors. Several studies have shown the efficacy of computers in early detection of DDIs. However, a correct risk-benefit evaluation by the prescribing physician, together with a careful clinical, physiological and biochemical monitoring of patients, is essential. Future directions of drug interaction research include the increasing importance of pharmacogenetics in preventing DDIs and the evaluation of interactions with biological drugs.
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Affiliation(s)
- Lara Magro
- University of Verona, Faculty of Medicine, Department of Public Health and Community Medicine, Section of Pharmacology, p.le L.A. Scuro 10, 37134 Verona, Italy
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Landino J, Buckley J, Roy JM, Villagra D, Gorowski K, Kocherla M, Windemuth A, Ruaño G. Guidance of pharmacotherapy in a complex psychiatric case by CYP450 DNA typing. ACTA ACUST UNITED AC 2011; 23:459-63. [DOI: 10.1111/j.1745-7599.2011.00640.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Knadler MP, Lobo E, Chappell J, Bergstrom R. Duloxetine: clinical pharmacokinetics and drug interactions. Clin Pharmacokinet 2011; 50:281-94. [PMID: 21366359 DOI: 10.2165/11539240-000000000-00000] [Citation(s) in RCA: 133] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Duloxetine, a potent reuptake inhibitor of serotonin (5-HT) and norepinephrine, is effective for the treatment of major depressive disorder, diabetic neuropathic pain, stress urinary incontinence, generalized anxiety disorder and fibromyalgia. Duloxetine achieves a maximum plasma concentration (C(max)) of approximately 47 ng/mL (40 mg twice-daily dosing) to 110 ng/mL (80 mg twice-daily dosing) approximately 6 hours after dosing. The elimination half-life of duloxetine is approximately 10-12 hours and the volume of distribution is approximately 1640 L. The goal of this paper is to provide a review of the literature on intrinsic and extrinsic factors that may impact the pharmacokinetics of duloxetine with a focus on concomitant medications and their clinical implications. Patient demographic characteristics found to influence the pharmacokinetics of duloxetine include sex, smoking status, age, ethnicity, cytochrome P450 (CYP) 2D6 genotype, hepatic function and renal function. Of these, only impaired hepatic function or severely impaired renal function warrant specific warnings or dose recommendations. Pharmacokinetic results from drug interaction studies show that activated charcoal decreases duloxetine exposure, and that CYP1A2 inhibition increases duloxetine exposure to a clinically significant degree. Specifically, following oral administration in the presence of fluvoxamine, the area under the plasma concentration-time curve and C(max) of duloxetine significantly increased by 460% (90% CI 359, 584) and 141% (90% CI 93, 200), respectively. In addition, smoking is associated with a 30% decrease in duloxetine concentration. The exposure of duloxetine with CYP2D6 inhibitors or in CYP2D6 poor metabolizers is increased to a lesser extent than that observed with CYP1A2 inhibition and does not require a dose adjustment. In addition, duloxetine increases the exposure of drugs that are metabolized by CYP2D6, but not CYP1A2. Pharmacodynamic study results indicate that duloxetine may enhance the effects of benzodiazepines, but not alcohol or warfarin. An increase in gastric pH produced by histamine H(2)-receptor antagonists or antacids did not impact the absorption of duloxetine. While duloxetine is generally well tolerated, it is important to be knowledgeable about the potential for pharmacokinetic interactions between duloxetine and drugs that inhibit CYP1A2 or drugs that are metabolized by CYP2D6 enzymes.
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Gelenberg AJ, de Leon J, Evins AE, Parks JJ, Rigotti NA. Smoking cessation in patients with psychiatric disorders. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2011; 10:52-8. [PMID: 18311422 DOI: 10.4088/pcc.v10n0109] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Highlights of drug package inserts and the website DailyMed: the need for further improvement in package inserts to help busy prescribers. J Clin Psychopharmacol 2011; 31:263-5. [PMID: 21508855 DOI: 10.1097/jcp.0b013e318218f3e4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Yang FW, Liang CS. Multiple intracerebral hemorrhages in an elderly patient after adding quetiapine to a stable warfarin regimen. Gen Hosp Psychiatry 2011; 33:302.e1-2. [PMID: 21601733 DOI: 10.1016/j.genhosppsych.2011.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 01/05/2011] [Accepted: 01/06/2011] [Indexed: 11/24/2022]
Abstract
The efficacy of antipsychotics in patients with dementia exhibiting psychiatric symptoms has been overshadowed by safety concerns in recent years. Evidence suggests that the long-term use of antipsychotics in older adults is associated with a greater risk of cerebrovascular adverse events than accrues with short-term use (less than 30 days) [J Clin Psychiatry. 2010;71(6):689-98]. Here, we present an elderly male patient with dementia who developed multiple intracerebral hemorrhages (ICHs) 3 days after the addition of quetiapine to his stable warfarin regimen. To our knowledge, this is the second case of possible interaction between quetiapine and warfarin. We suggest mechanisms that may account for the patient's clinical presentation and highlight that combining treatment with quetiapine and warfarin may cause serious complications in patients with risk factors for ICH.
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Affiliation(s)
- Fei-Wen Yang
- Department of Psychiatry, Beitou Armed Forces Hospital, Taipein 112, Taiwan, ROC
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Frois C, Guerin A, Saraogi A, Panish J, Dirani R. Perceptions and prescribing considerations among US psychiatrists regarding drug-drug interactions associated with oral atypical antipsychotics. Curr Med Res Opin 2010; 26:2735-44. [PMID: 21034374 DOI: 10.1185/03007995.2010.530159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Contemporary literature has demonstrated the potential for drug-drug interactions (DDIs) with oral atypical antipsychotic (OAA) agents. However, less is known about psychiatrists' perceptions about DDIs when prescribing OAAs. This study addresses this gap by surveying US psychiatrists about their perceptions of DDI when prescribing a new OAA. METHODS An online survey of 131 US psychiatrists was conducted to assess if considerations of DDIs were taken into account when prescribing a new OAA within their practice and prescribing patterns. For each survey question, results are presented as the proportion of psychiatrists in each rating category. Data were collected on physicians' awareness and concern about DDIs when prescribing OAAs, perception of frequency and severity of OAA-related DDIs, and methods of monitoring and preventing OAA-related DDIs. RESULTS Of the psychiatrists surveyed, 9.2% considered themselves well-informed (rating of 10/10) about OAA-related DDIs. In the 3-month period preceding the survey date, psychiatrists reported that on average 7.5 (SD 12.4) of their patients experienced a potentially OAA-related DDI event which represented an average of 2.5% (SD 4.8%) of their total number of patients. In all, 19.8% of the psychiatrists reported they were currently tracking the level of confirmed OAA-related DDI events in their practices; these psychiatrists reported a mean 21.1% incidence rate of confirmed DDI events experienced by patients starting a new OAA therapy in their practice. The psychiatrists ranked the risks of cardiovascular events and of neurological impairment as the two most frequent and severe potential DDI events to consider when prescribing a new OAA, in combination with selective serotonin reuptake inhibitors, mood stabilizers, and antihypertensive agents, the drugs most frequently associated with the most severe OAA-related DDIs. CONCLUSIONS Psychiatrists, on recall of recent cases, perceive DDI events to be frequent in patients starting a new OAA therapy. While there appears to be some awareness of DDI-related issues among psychiatrists, this survey of psychiatrists perceptions suggests the need for systematic tracking of OAA-related DDI events and additional psychiatrist training on optimal OAA choice to prevent DDIs.
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Schizophrenia, "just the facts" 5. Treatment and prevention. Past, present, and future. Schizophr Res 2010; 122:1-23. [PMID: 20655178 DOI: 10.1016/j.schres.2010.05.025] [Citation(s) in RCA: 231] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Revised: 05/22/2010] [Accepted: 05/25/2010] [Indexed: 12/20/2022]
Abstract
The introduction of second-generation antipsychotics and cognitive therapies for schizophrenia over the past two decades generated considerable optimism about possibilities for recovery. To what extent have these developments resulted in better outcomes for affected individuals? What is the current state of our science and how might we address the many unmet needs in the prevention and treatment of schizophrenia? We trace the evolution of various treatments for schizophrenia and summarize current knowledge about available pharmacological and psychosocial treatments. We consider the widely prevalent efficacy-effectiveness gap in the application of available treatments and note the significant variability in individual treatment response and outcome. We outline an individualized treatment approach which emphasizes careful monitoring and collaborative decision-making in the context of ongoing benefit-risk assessment. We note that the evolution of both pharmacological and psychosocial treatments thus far has been based principally on serendipity and intuition. In view of our improved understanding of the etiology and pathophysiology of schizophrenia, there is an opportunity to develop prevention strategies and treatments based on this enhanced knowledge. In this context, we discuss potential psychopathological treatment targets and enumerate current pharmacological and psychosocial development efforts directed at them. Considering the stages of schizophrenic illness, we review approaches to prevent progression from the pre-symptomatic high-risk to the prodrome to the initial psychotic phase to chronicity. In view of the heterogeneity of risk factors, we summarize approaches towards targeted prevention. We evaluate the potential contribution of pharmacogenomics and other biological markers in optimizing individual treatment and outcome in the future.
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