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Hach I, Bertsch T, Nonell P. The prevalence of off-label use and supratherapeutic blood levels of outpatient psychotropic medication in suicidal adolescents. Front Psychiatry 2024; 14:1240681. [PMID: 38298931 PMCID: PMC10827976 DOI: 10.3389/fpsyt.2023.1240681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 12/20/2023] [Indexed: 02/02/2024] Open
Abstract
Introduction Adolescents with mental disorders show an increased risk of suicidal phenomena. Vice versa, suicidality is a serious adverse event of psychotropic drug therapy in adolescents. There are only a few new psychotropic agents approved for this young age group. We evaluated the (pre-pandemic) prevalence of off-label use as well as detailed blood concentrations of outpatient psychotropic medication and sex differences in a clinical population of suicidal adolescents. Methods The urine presence and serum levels of psychotropic substances of adolescents hospitalized due to their acute suicidality but without a known actual suicide attempt (i.e., no acute intoxication or serious self-injuries) were investigated routinely between 01.03.2017 and 31.01.2018. Urine (N = 205) and blood samples (N = 193) were taken at the beginning of closed inpatient admission, i.e., the results of the laboratory analysis reflect outpatient drug intake. The serum levels of psychopharmacological medication and OTC medication were measured. Results Our sample consists of 231 cases (boys: N = 54; girls: N = 177, ratio: 1:3.3), aged 12-17 years (average age: 15,4 years). The most prevalent psychiatric diagnoses were depressive episodes (54%) and adjustment disorders (25%), and girls were more often diagnosed with depressive disorders than boys (boy/girl ratio: 1:9.5, p < 0.0001). More than half of adolescents (56%) used at least one prescribed psychotropic drug at admission (24.8% ≥ two psychotropic drugs). Off-label use of second-generation antipsychotics was significantly more frequent than off-label use of antidepressants (85% vs. 31%, p < 0.01). Adolescents suffering from depressive disorders were significantly more often on-label treated than adolescents with neurotic or stress-related disorders (56% vs. 10%). Female cases with prescribed psychotropic drug use showed significantly more frequent supratherapeutic drug levels than male cases (5% vs. 27%, p < 0.05). Conclusion Female adolescents may have an increased risk of supratherapeutic blood levels, especially when outpatient prescribed psychotropic drugs are off-label used. Measurement of blood levels of outpatient-prescribed psychotropic drugs could be used to enhance the safety and efficacy of the individual psychopharmacological treatment of adolescent suicidal patients. There is an urgent need for more real-world evidence on the effective treatment of adolescents with psychotropic drugs.
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Affiliation(s)
- Isabel Hach
- Department of Education and Science, Klinikum Nürnberg, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Klinikum Nürnberg, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Patrick Nonell
- Clinic of Child and Adolescent Psychiatry and Psychotherapy, Klinikum Nürnberg, Paracelsus Medical University Nürnberg, Nürnberg, Germany
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Kolitsopoulos F, Ramaker S, Compton S, Broderick S, Orazem J, Bao W, Lokhnygina Y, Chappell P. Sertraline Pediatric Registry for the Evaluation of Safety: Design and Clinical Characteristics of Pediatric Patients Prescribed Sertraline. J Child Adolesc Psychopharmacol 2021; 31:411-420. [PMID: 34287023 DOI: 10.1089/cap.2020.0170] [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] [Indexed: 11/13/2022]
Abstract
Objectives: To describe the study design and clinical characteristics of patients in the Sertraline Pediatric RegIstry for The Evaluation of Safety (SPRITES). Methods: SPRITES is an open-label postmarketing study of development and safety outcomes in patients aged 6 to 16 years treated with sertraline (with or without psychotherapy) compared with psychotherapy alone for up to 3 years in the United States. Baseline data included demographics and psychiatric history. Primary outcomes included measures of cognitive and emotional development (Trails B, Behavior Rating Inventory of Executive Function [BRIEF]), physical development (height and weight), and pubertal status (Tanner Stage). Data were also collected on present/lifetime risk of suicide-related events using the Columbia-Suicide Severity Rating Scale. Results: SPRITES enrolled 941 patients between the ages of 6 and 16 years. Patients' baseline mean age was 11.9 years (2.9), 57.2% were female, and 84.8% were white. Most patients (78.4%) had an anxiety disorder, and 15.6% were diagnosed with obsessive-compulsive disorder. The mean age at onset of first mental illness was 7.9 years. A higher percentage of sertraline-treated patients compared with patients who received no pharmacological treatment received prior psychotherapy (59.0% vs. 34.4%, p < 0.001), psychotropic medications for a psychiatric disorder (14.1% vs. 3.3%, p < 0.001), and other non-sertraline selective serotonin reuptake inhibitors (8.6% vs. 1.2%, p < 0.001). Most patients were moderately ill on the Clinical Global Impressions-Severity scale, and a higher (p < 0.001) percentage of sertraline-treated patients had a moderate-to-severe mental illness score compared with the no pharmacological treatment group (73.0% vs. 57.8%, respectively). Although patients at high and imminent risk of a suicidal event were excluded at study entry, the sertraline-treated patients reported higher levels of lifetime suicidal behavior compared with patients treated with no pharmacological treatment (5.8% vs. 2.5%, p = 0.039). Conclusions: Baseline data from this nonrandomized observational study suggest that patients prescribed sertraline are reflective of a more mentally ill study population compared with patients receiving psychotherapy. ClinicalTrials.gov identifier: NCT01302080.
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Affiliation(s)
| | - Sara Ramaker
- Global Product Development, Pfizer, Collegeville, Pennsylvania, USA
| | - Scott Compton
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - John Orazem
- Global Product Development, Pfizer, New York, New York, USA
| | - Weihang Bao
- Global Product Development, Pfizer, New York, New York, USA
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Thabrew H, Moor S, Eggleston M. Same proof, different pudding: comparative views of New Zealand child psychiatrists, child psychologists and child psychotherapists regarding a proposed national child and adolescent research network. Australas Psychiatry 2020; 28:573-577. [PMID: 32174123 DOI: 10.1177/1039856220908178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study was undertaken to evaluate the views of New Zealand clinicians regarding a proposed national child and adolescent mental health research network. METHODS Child psychiatrists, child psychologists and child psychotherapists were invited to participate in an electronic survey describing their previous experience of research, current interest in research, barriers to undertaking research and interest in a national research network. RESULTS Responses were received from child psychiatrists (N = 33), child psychologists (N = 58) and child psychotherapists (N = 8), many of whom were clinicians and few of whom were researchers. Although most clinicians were interested in participating in future research, areas of interest differed between clinical groups. Clinician barriers to research included lack of time, lack of confidence and lack of research skills. Researcher barriers included lack of funding, time and administrative support. All groups were supportive of the development of a national research network. CONCLUSIONS Despite some different areas of interest, there appears to be sufficient combined support from New Zealand child psychiatrists, child psychologists and child psychotherapists to pursue the establishment of a national child and adolescent mental health research network.
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Affiliation(s)
- Hiran Thabrew
- Department of Psychological Medicine, University of Auckland, New Zealand.,Child and Family Specialty Service, New Zealand
| | - Stephanie Moor
- Department of Psychological Medicine, University of Otago, New Zealand.,Child and Family Specialty Service, New Zealand
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Li F, Welling MC, Johnson JA, Coughlin C, Mulqueen J, Jakubovski E, Coury S, Landeros-Weisenberger A, Bloch MH. N-Acetylcysteine for Pediatric Obsessive-Compulsive Disorder: A Small Pilot Study. J Child Adolesc Psychopharmacol 2020; 30:32-37. [PMID: 31800306 PMCID: PMC7133418 DOI: 10.1089/cap.2019.0041] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: Many children and adults with Obsessive-Compulsive Disorder (OCD) fail to respond to first-line pharmacological and behavioral treatments. Glutamate dysfunction may contribute to the development of OCD. N-acetylcysteine (NAC), a glutamate modulating drug, has shown to be a promising agent in adults with OCD. Methods: We conducted a double-blind, placebo-controlled clinical trial from July 2012 to January 2017. Children ages 8 to 17 years with OCD were assigned to receive NAC (up to 2700 mg/day) or the matching placebo for a period of 12 weeks. Children were required to be on stable psychiatric treatment (both medication and therapy) but were not required to be treatment-refractory. The primary outcome was OCD symptom severity as measured by the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). We used linear mixed models to analyze the effect of NAC compared to placebo. Results: Due to poor recruitment and eventual expiration of the study medication, enrollment was stopped at 11 children out of a planned sample size of 40. Nonetheless, NAC was associated with significant reduction in CY-BOCS total score compared to placebo (Satterthwaite's test: t (37) = 2.36, p = 0.024) with effects separating from placebo beginning at week 8. Mean CY-BOCS total score decreased in the NAC group from 21.4 ± 4.65 at baseline to 14.4 ± 5.55 at week 12. In the placebo group, mean CY-BOCS total score remained unchanged (21.3 ± 4.65). In the NAC group, 1 out of 5 participants achieved >35% improvement in CY-BOCS total score, while none of the six patients in placebo group reached this improvement level. NAC and placebo were well tolerated. One mild adverse event was reported in each group. Conclusions: Our trial suggests that there may be some initial improvement in OCD symptom severity with NAC treatment. NAC was well tolerated in the study population. Future trials should employ multiple sites and have a larger study population to further confirm any benefits of NAC.
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Affiliation(s)
- Fenghua Li
- Child Study Center, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Maartje C. Welling
- Child Study Center, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Jessica A. Johnson
- Columbia University in the City of New York, Columbia School of Nursing, New York, New York
| | | | | | - Ewgeni Jakubovski
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hanover, Germany
| | - Samantha Coury
- Department of Psychology, Yale College, New Haven, Connecticut
| | | | - Michael H. Bloch
- Child Study Center, Yale School of Medicine, Yale University, New Haven, Connecticut.,Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, Connecticut.,Address correspondence to: Michael H. Bloch, MD, MS, Child Study Center, Yale University School of Medicine, 230 S. Frontage Road, New Haven, CT 06520
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The CANadian Pediatric Weight management Registry (CANPWR): lessons learned from developing and initiating a national, multi-centre study embedded in pediatric clinical practice. BMC Pediatr 2018; 18:237. [PMID: 30025530 PMCID: PMC6053829 DOI: 10.1186/s12887-018-1208-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 07/02/2018] [Indexed: 01/25/2023] Open
Abstract
Background There is increasing recognition of the value of “real-world evidence” in evaluating health care services. Registry-based, observational studies conducted in clinical settings represent a relevant model to achieve this directive. Starting in 2010, we undertook a longitudinal, observational study (the CANadian Pediatric Weight management Registry [CANPWR]), which is embedded in 10 multidisciplinary, pediatric weight management clinics across Canada. The objective of this paper was to share the lessons our team learned from this multi-centre project. Methods Data sources included a retrospective review of minutes from 120 teleconferences with research staff and investigators, notes taken during clinical site visits made by project leaders, information from quality control processes to ensure data accuracy and completeness, and a study-specific survey that was sent to all sites to solicit feedback from research team members (n = 9). Through an iterative process, the writing group identified key themes that surfaced during review of these information sources and final lessons learned were developed. Results Several key lessons emerged from our research, including the (1) value of pilot studies and central research coordination, (2) need for effective and regular communication, (3) importance of consensus on determining outcome measures, (4) challenge of embedding research within clinical practice, and (5) difficulty in recruiting and retaining participants. The sites were, in spite of these challenges, enthusiastic about the benefits of participating in multi-centre collaborative studies. Conclusion Despite some challenges, multi-centre observational studies embedded in pediatric weight management clinics are feasible and can contribute important, practical insights into the effectiveness of health services for managing pediatric obesity in real-world settings. Electronic supplementary material The online version of this article (10.1186/s12887-018-1208-6) contains supplementary material, which is available to authorized users.
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Findling RL, Robb AS, DelBello MP, Huss M, McNamara NK, Sarkis EH, Scheffer RE, Poulsen LH, Chen G, Lemming OM, Auby P. A 6-Month Open-Label Extension Study of Vortioxetine in Pediatric Patients with Depressive or Anxiety Disorders. J Child Adolesc Psychopharmacol 2018; 28:47-54. [PMID: 29035574 PMCID: PMC5771527 DOI: 10.1089/cap.2017.0047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES In this 6-month open-label extension (OLE) of NCT01491035 (a 14-day, open-label, pharmacokinetic/safety lead-in study), the long-term safety and tolerability of vortioxetine (5-20 mg/day) were investigated in children and adolescents with a DSM-IV-TR™ diagnosis of depressive or anxiety disorder in the United States or Germany. The study also was designed to provide data to inform dose selection and titration in future pediatric studies with vortioxetine. METHODS Safety evaluations included spontaneously reported adverse events (AEs), the Columbia Suicide Severity Rating Scale (C-SSRS), and the Pediatric Adverse Events Rating Scale (PAERS; clinician administered). Clinical effectiveness was determined by Clinical Global Impressions. Comorbid attention-deficit/hyperactivity disorder was permitted, including concomitant use of stimulant medication (US sites only). RESULTS Of the 47 patients who completed the lead-in period, 41 continued into the OLE. Most patients (n = 39 [95%]) continued their previous dose regimen. Twenty-one patients (51%) withdrew during the OLE; the most common primary reasons were administrative [n = 8], AEs [n = 4], and lack of efficacy [n = 3]. Thirty-five patients (85%) had ≥1 AE, 86% of which were mild or moderate in severity. Five patients (12%) reported a severe AE, none of which was considered related to study medication. The most common AEs (≥10%) were headache (27%), nausea (20%), dysmenorrhea (females; 19%), and vomiting (15%), with no relationship between AE intensity and age or dose. Five patients reported instances of suicidal ideation during the OLE, one of whom also reported this during the lead-in period. Two patients had nonsuicidal self-injurious behavior; one had a nonfatal suicide attempt. Throughout the study, there was a decrease over time in the incidence and intensity of AEs collected using the PAERS. Effectiveness assessment indicated a trend toward improvement based on numeric results. CONCLUSION This OLE confirms the findings from the lead-in study, which concluded that a dosing strategy of 5-20 mg/day is safe, well tolerated, and suitable for future clinical studies of vortioxetine in pediatric patients.
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Affiliation(s)
- Robert L. Findling
- The Johns Hopkins University and the Kennedy Krieger Institute, Baltimore, Maryland
| | - Adelaide S. Robb
- Children's National Health System, Washington, District of Columbia
| | | | - Michael Huss
- Universitätsmedizin, Klinik für Kinder- und Jugendpsychiatrie und -psychotherapie, Mainz, Germany
| | - Nora K. McNamara
- Department of Psychiatry–Child/Adolescent, UH Case Medical Center, Cleveland, Ohio
| | | | | | - Lis H. Poulsen
- Paediatric Neuro-Psychiatry and Quantitative Pharmacology, H. Lundbeck A/S, Valby, Denmark
| | - Grace Chen
- Quantitative Clinical Pharmacology, Takeda Pharmaceuticals U.S.A., Inc., Deerfield, Illinois
| | | | - Philippe Auby
- Paediatric Neuro-Psychiatry and Quantitative Pharmacology, H. Lundbeck A/S, Valby, Denmark
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Turner MA, Attar S, de Wildt SN, Vassal G, Mangiarini L, Giaquinto C. Roles of Clinical Research Networks in Pediatric Drug Development. Clin Ther 2017; 39:1939-1948. [PMID: 28943118 DOI: 10.1016/j.clinthera.2017.09.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/05/2017] [Accepted: 09/06/2017] [Indexed: 01/09/2023]
Abstract
The evaluation of drugs that are used in children has been neglected historically but is now well established as an essential part of clinical drug development. The increase in pediatric activity among industry, and other sectors, has highlighted the importance of joint working. All participants in pediatric drug development need to be aware of the "big picture." An increasingly important part of this big picture in pediatrics, as in other populations, is the design and conduct of clinical trials in networks. This narrative review provides an overview of the roles of clinical research networks in pediatric drug development. Networks take many forms as specialty networks and geographic networks but work toward common principles, including sharing resources between trials, and using experience with trial conduct to improve trial design. Networks develop standardized processes for trial conduct (including performance management) that increase the speed and predictability of trial conduct while reducing burdens on sites, sponsors, and intermediaries. Networks can provide validated, real-world information about natural history, participant distribution, and standards of care to inform planning of development programs, including extrapolation and clinical trial simulation. Networks can work across geographic and jurisdictional barriers to promote global interoperability of drug development. Networks support participant centrality. Networks offer an opportunity to develop relationships with investigators, sites, and methodological experts that span pre-competitive foundations for drug development and specific products. Sustainable networks benefit all stakeholders by providing a multifunctional platform that promotes the quality and timeliness of clinical drug development.
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Affiliation(s)
- Mark A Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.
| | - Sabah Attar
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud University, Nijmegen, the Netherlands; Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Gilles Vassal
- Department of Clinical Research, Gustave Roussy, Paris-Sud University, Paris, France
| | | | - Carlo Giaquinto
- Department of Women's and Children's Health, University of Padova, Padua, Italy
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8
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Findling RL, Robb AS, DelBello M, Huss M, McNamara N, Sarkis E, Scheffer R, Poulsen LH, Chen G, Lemming OM, Areberg J, Auby P. Pharmacokinetics and Safety of Vortioxetine in Pediatric Patients. J Child Adolesc Psychopharmacol 2017; 27:526-534. [PMID: 28333546 PMCID: PMC5568018 DOI: 10.1089/cap.2016.0155] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
OBJECTIVE The primary objectives of this study were to evaluate the pharmacokinetics (PK) and tolerability of single and multiple doses of vortioxetine in children and adolescents with a depressive or anxiety disorder and to provide supportive information for appropriate dosing regimens for pediatric clinical trials. METHODS This prospective, open-label, multinational, multisite, multiple-dose trial enrolled 48 patients (children and adolescents; 1:1 ratio) divided into 8 cohorts (4 adolescent and 4 child), with each cohort including 6 patients. The cohorts in each age group were assigned to receive one of four dosing regimens: vortioxetine 5, 10, 15, or 20 mg q.d. for 14 days. The total treatment period lasted 14-20 days with patients in the higher dose cohorts uptitrated over 2-6 days. Plasma samples for PK analysis were obtained on the first and last days of dosing. RESULTS Among children and adolescents, respectively, 62% and 92% had depression and 58% and 33% had anxiety disorder. Comorbid attention-deficit/hyperactivity disorder (ADHD) was present in 50% of children and 38% of adolescents. After 14 days q.d. at the target dose, the PK of vortioxetine concentrations was generally proportional to the dose in both age groups. Exposure, as assessed by maximum plasma concentrations and area under the plasma concentration-time curve from time 0 to 24 hours, was 30%-40% lower in adolescents than in children. There was no significant relationship between sex, height, or ADHD diagnosis and PK parameters. Most adverse events were mild in severity and consistent with those seen in adults. CONCLUSION The results suggest that the dosages of vortioxetine evaluated (5-20 mg q.d.; approved for treatment in adults) and the uptitration schedule used are appropriate for pediatric efficacy and safety trials.
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Affiliation(s)
- Robert L. Findling
- Department of Psychiatry and Behavioral Sciences, Kennedy Krieger Institute and Johns Hopkins University, Baltimore, Maryland
| | - Adelaide S. Robb
- Department of Psychology and Behavioral Health, Children's National Health Systems, Washington, District of Columbia
| | - Melissa DelBello
- Department of Psychiatry and Behavioral Neuroscience, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael Huss
- Universitätsmedizin, Klinik für Kinder- und Jugendpsychiatrie und -Psychotherapie, Mainz, Germany
| | - Nora McNamara
- University Hospitals Case Medical Center, Cleveland, Ohio
| | | | - Russell Scheffer
- Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine, Wichita, Kansas
| | | | - Grace Chen
- Clinical Pharmacology, Takeda Development Center Americas, Deerfield, Illinois
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Gerlach M, Egberts K, Dang SY, Plener P, Taurines R, Mehler-Wex C, Romanos M. Therapeutic drug monitoring as a measure of proactive pharmacovigilance in child and adolescent psychiatry. Expert Opin Drug Saf 2016; 15:1477-1482. [PMID: 27551945 DOI: 10.1080/14740338.2016.1225721] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Off-label or unlicensed use of psychotropic drugs is common rather than the exception in child and adolescent psychiatry. This use exposes patients to an unknown additional risk of ineffective or even harmful treatment. In addition, treatment with psychotropic drugs during a period of life when the patient undergoes marked developmental hormonal and neurobiological changes often requires different dosing regimes in later life and may result in adverse drug reactions, which are either not seen in adults at all or not in the same frequency. Areas covered: Given these critical safety issues, efficient pharmacovigilance methods as part of routine practice are essential for the improvement of patient care. The purpose of this article is to introduce methods to increase the safety of psychotropic drug use in youngsters. In particular, therapeutic drug monitoring (TDM) as a routine measure of proactive pharmacovigilance is discussed. Expert opinion: Given the special features of psychopharmacological therapy in children and adolescents in day-to-day clinical practise, proactive surveillance by using a close standardized 'patient monitoring' and long-term follow-up with TDM is very important. This approach could minimize the risk of exposing paediatric patients to ineffective treatments of uncertain or unknown risks.
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Affiliation(s)
- Manfred Gerlach
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
| | - Karin Egberts
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
| | - Su-Yin Dang
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
| | - Paul Plener
- b Department of Child and Adolescent Psychiatry and Psychotherapy , Central Institute of Mental Health , Mannheim , Germany
| | - Regina Taurines
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
| | - Claudia Mehler-Wex
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany.,c HEMERA Private Hospital for Mental Health, Adolescents and Young Adults , Bad Kissingen , Germany
| | - Marcel Romanos
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
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Bloch MH, Panza KE, Yaffa A, Alvarenga PG, Jakubovski E, Mulqueen JM, Landeros-Weisenberger A, Leckman JF. N-Acetylcysteine in the Treatment of Pediatric Tourette Syndrome: Randomized, Double-Blind, Placebo-Controlled Add-On Trial. J Child Adolesc Psychopharmacol 2016; 26:327-34. [PMID: 27027204 PMCID: PMC6445198 DOI: 10.1089/cap.2015.0109] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Current pharmacological treatments for Tourette Syndrome (TS), such as antipsychotic agents and α-2 agonists, are moderately effective in the treatment of tics, but have substantial side effects that limit their use. N-acetylcysteine (NAC) modulates glutamatergic systems, and has been used safely as an antioxidant agent with minimal side effects for decades. NAC has been increasingly studied for the treatment of other obsessive-compulsive spectrum disorders. We aim to examine the efficacy of NAC for the treatment of pediatric TS in a double-blind, placebo-controlled, add-on study. METHODS Thirty-one children and adolescents 8-17 years of age with TS were randomly assigned to receive NAC or matching placebo for 12 weeks. Our primary outcome was change in severity of tics as measured by the Yale Global Tic Severity Scale (YGTSS), Total tic score. Secondary measures assessed comorbid obsessive-compulsive disorder (OCD), depression, anxiety, and attention-deficit/hyperactivity disorder (ADHD). Linear mixed models in SAS were used to examine differences between NAC and placebo. RESULTS Of 31 randomized subjects, 14 were assigned to placebo (two females; 11.5 + 2.8 years) and 17 to active NAC (five females; 12.4 + 1.4 years) treatment. No significant difference between NAC and placebo was found in reducing tic severity or any secondary outcomes. CONCLUSIONS We found no evidence for efficacy of NAC in treating tic symptoms. Our findings stand in contrast to studies suggesting benefits of NAC in the treatment of other obsessive-compulsive spectrum disorders in adults, including OCD and trichotillomania, but are similar to a recent placebo-controlled trial of pediatric trichotillomania that found no benefit of NAC.
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Affiliation(s)
- Michael H. Bloch
- Yale Child Study Center and the Department of Psychiatry of Yale University, New Haven, Connecticut
| | | | - Alisa Yaffa
- Northern California and Hawaii Tourette Syndrome Chapter of the Tourette Syndrome Association
| | - Pedro G. Alvarenga
- Department and Institute of Psychiatry, University of São Paulo Medical School of Brazil, São Paulo, Brazil
| | - Ewgeni Jakubovski
- Yale Child Study Center and the Department of Psychiatry of Yale University, New Haven, Connecticut
| | - Jilian M. Mulqueen
- Yale Child Study Center and the Department of Psychiatry of Yale University, New Haven, Connecticut
| | | | - James F. Leckman
- Yale Child Study Center and the Department of Psychiatry of Yale University, New Haven, Connecticut
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Palanca-Maresca I, Ruiz-Antorán B, Centeno-Soto G, Jiménez-Fernandez S, García-Murillo L, Siles A, Villagrá S, Blasco-Fontecilla H, Iruela-Cuadrado L, Roman-Riechman E, Avendaño-Solá C, Correll CU. SENTIA: a systematic online monitoring registry for children and adolescents treated with antipsychotics. SPRINGERPLUS 2014; 3:187. [PMID: 24790830 PMCID: PMC4000597 DOI: 10.1186/2193-1801-3-187] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 04/07/2014] [Indexed: 12/27/2022]
Abstract
Introduction Despite drastic increases in antipsychotic prescribing in youth, data are still limited regarding their safety in this vulnerable population, necessitating additional tools for capturing long-term, real world data. Methods We present SENTIA (SafEty of NeurolepTics in Infancy and Adolescence; https://SENTIA.es), an online registry created in 2010 to track antipsychotic adverse effects in Spanish youth <18 years old currently taking or initiating with any antipsychotic treatment. SENTIA collects information on sociodemographic, diagnostic and treatment characteristics, past personal medical/psychiatric history, healthy lifestyle habits and treatment adherence. Additionally, efficacy and adverse effect data are recorded including the Children’s Global Assessment Scale; Clinical Global Impressions scale for Severity and Improvement, the Safety Monitoring Uniform Report Form, Simpson-Angus Scale, Abnormal Involuntary Movement Scale, vital signs, blood pressure, and EKG. Finally, fasting blood is drawn for hematology, electrolytes, renal, liver and thyroid function, glucose, insulin, lipid, prolactin and sex hormone levels. Initially, a diagnostic interview and several psychopathology scales were also included. Patients are assessed regularly and followed even beyond stopping antipsychotics. Results Since 01/17/2011, 85 youth (11.5 ± 2.9 (range = 4-17) years old, 70.6% male) have been included at one inaugural center. After a mean duration of 17 ± 11 (range = 1-34) months, 78.8% are still actively followed. For feasibility reasons, the diagnostic interview and detailed psychopathology scales were dropped. The remaining data can be entered in <30 minutes. Several additional centers are currently being added to SENTIA. Conclusions Implementation of a systematic online pharmacovigilance system for antipsychotic adverse effects in youth is feasible and promises to generate important information.
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Affiliation(s)
- Inmaculada Palanca-Maresca
- Department of Psychiatry, Puerta de Hierro University Hospital, Madrid, Spain ; Calle Manuel de Falla, 1, 28222 Majadahonda, Madrid, Spain
| | - Belén Ruiz-Antorán
- Department of Clinical Pharmacology, Puerta de Hierro University Hospital, Madrid, Spain
| | - Gustavo Centeno-Soto
- Department of Clinical Pharmacology, Puerta de Hierro University Hospital, Madrid, Spain
| | | | | | - Ana Siles
- Department of Cardiology, Puerta de Hierro University Hospital, Madrid, Spain
| | - Sandra Villagrá
- Department of Pediatric Cardiology, La Paz University Hospital, Madrid, Spain
| | | | | | | | - Cristina Avendaño-Solá
- Department of Clinical Pharmacology, Puerta de Hierro University Hospital, Madrid, Spain
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Holmes JH, Elliott TE, Brown JS, Raebel MA, Davidson A, Nelson AF, Chung A, La Chance P, Steiner JF. Clinical research data warehouse governance for distributed research networks in the USA: a systematic review of the literature. J Am Med Inform Assoc 2014. [PMID: 24682495 DOI: 10.1136/amiajnl-2013-002370.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To review the published, peer-reviewed literature on clinical research data warehouse governance in distributed research networks (DRNs). MATERIALS AND METHODS Medline, PubMed, EMBASE, CINAHL, and INSPEC were searched for relevant documents published through July 31, 2013 using a systematic approach. Only documents relating to DRNs in the USA were included. Documents were analyzed using a classification framework consisting of 10 facets to identify themes. RESULTS 6641 documents were retrieved. After screening for duplicates and relevance, 38 were included in the final review. A peer-reviewed literature on data warehouse governance is emerging, but is still sparse. Peer-reviewed publications on UK research network governance were more prevalent, although not reviewed for this analysis. All 10 classification facets were used, with some documents falling into two or more classifications. No document addressed costs associated with governance. DISCUSSION Even though DRNs are emerging as vehicles for research and public health surveillance, understanding of DRN data governance policies and procedures is limited. This is expected to change as more DRN projects disseminate their governance approaches as publicly available toolkits and peer-reviewed publications. CONCLUSIONS While peer-reviewed, US-based DRN data warehouse governance publications have increased, DRN developers and administrators are encouraged to publish information about these programs.
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Affiliation(s)
- John H Holmes
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Thomas E Elliott
- University of Minnesota Medical School, HealthPartners Institute for Education and Research, Duluth, Minnesota, USA
| | - Jeffrey S Brown
- Harvard Medical School Department of Population Medicine, Boston, Massachusetts, USA
| | - Marsha A Raebel
- Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado, USA
| | | | - Andrew F Nelson
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota, USA
| | - Annie Chung
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Pierre La Chance
- Research Informatics, Center for Health Research, Kaiser Permanente, Portland, Oregon, USA
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Holmes JH, Elliott TE, Brown JS, Raebel MA, Davidson A, Nelson AF, Chung A, La Chance P, Steiner JF. Clinical research data warehouse governance for distributed research networks in the USA: a systematic review of the literature. J Am Med Inform Assoc 2014; 21:730-6. [PMID: 24682495 DOI: 10.1136/amiajnl-2013-002370] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To review the published, peer-reviewed literature on clinical research data warehouse governance in distributed research networks (DRNs). MATERIALS AND METHODS Medline, PubMed, EMBASE, CINAHL, and INSPEC were searched for relevant documents published through July 31, 2013 using a systematic approach. Only documents relating to DRNs in the USA were included. Documents were analyzed using a classification framework consisting of 10 facets to identify themes. RESULTS 6641 documents were retrieved. After screening for duplicates and relevance, 38 were included in the final review. A peer-reviewed literature on data warehouse governance is emerging, but is still sparse. Peer-reviewed publications on UK research network governance were more prevalent, although not reviewed for this analysis. All 10 classification facets were used, with some documents falling into two or more classifications. No document addressed costs associated with governance. DISCUSSION Even though DRNs are emerging as vehicles for research and public health surveillance, understanding of DRN data governance policies and procedures is limited. This is expected to change as more DRN projects disseminate their governance approaches as publicly available toolkits and peer-reviewed publications. CONCLUSIONS While peer-reviewed, US-based DRN data warehouse governance publications have increased, DRN developers and administrators are encouraged to publish information about these programs.
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Affiliation(s)
- John H Holmes
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Thomas E Elliott
- University of Minnesota Medical School, HealthPartners Institute for Education and Research, Duluth, Minnesota, USA
| | - Jeffrey S Brown
- Harvard Medical School Department of Population Medicine, Boston, Massachusetts, USA
| | - Marsha A Raebel
- Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado, USA
| | | | - Andrew F Nelson
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota, USA
| | - Annie Chung
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Pierre La Chance
- Research Informatics, Center for Health Research, Kaiser Permanente, Portland, Oregon, USA
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N-Acetylcysteine in the treatment of pediatric trichotillomania: a randomized, double-blind, placebo-controlled add-on trial. J Am Acad Child Adolesc Psychiatry 2013; 52:231-40. [PMID: 23452680 PMCID: PMC3745012 DOI: 10.1016/j.jaac.2012.12.020] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 12/18/2012] [Accepted: 12/26/2012] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To examine the efficacy of N-acetylcysteine (NAC) for the treatment of pediatric trichotillomania (TTM) in a double-blind, placebo-controlled, add-on study. METHOD A total of 39 children and adolescents aged 8 to 17 years with pediatric trichotillomania were randomly assigned to receive NAC or matching placebo for 12 weeks. Our primary outcome was change in severity of hairpulling as measured by the Massachusetts General Hospital-Hairpulling Scale (MGH-HPS). Secondary measures assessed hairpulling severity, automatic versus focused pulling, clinician-rated improvement, and comorbid anxiety and depression. Outcomes were examined using linear mixed models to test the treatment×time interaction in an intention-to-treat population. RESULTS No significant difference between N-acetylcysteine and placebo was found on any of the primary or secondary outcome measures. On several measures of hairpulling, subjects significantly improved with time regardless of treatment assignment. In the NAC group, 25% of subjects were judged as treatment responders, compared to 21% in the placebo group. CONCLUSIONS We observed no benefit of NAC for the treatment of children with trichotillomania. Our findings stand in contrast to a previous, similarly designed trial in adults with TTM, which demonstrated a very large, statistically significant benefit of NAC. Based on the differing results of NAC in pediatric and adult TTM populations, the assumption that pharmacological interventions demonstrated to be effective in adults with TTM will be as effective in children, may be inaccurate. This trial highlights the importance of referring children with TTM to appropriate behavioral therapy before initiating pharmacological interventions, as behavioral therapy has demonstrated efficacy in both children and adults with trichotillomania.
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Affiliation(s)
- Martin E. Franklin
- Child/Adolescent OCD, Tics, Trichotillomania and Anxiety Group, Department of Psychiatry, University of Pennsylvania School of Medicine, and Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104
| | - Edna B. Foa
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104;
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