1
|
Biso L, Aringhieri S, Carli M, Scarselli M, Longoni B. Therapeutic Drug Monitoring in Psychiatry: Enhancing Treatment Precision and Patient Outcomes. Pharmaceuticals (Basel) 2024; 17:642. [PMID: 38794212 PMCID: PMC11124530 DOI: 10.3390/ph17050642] [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: 04/12/2024] [Revised: 05/09/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024] Open
Abstract
Psychiatric disorders often require pharmacological interventions to alleviate symptoms and improve quality of life. However, achieving an optimal therapeutic outcome is challenging due to several factors, including variability in the individual response, inter-individual differences in drug metabolism, and drug interactions in polytherapy. Therapeutic drug monitoring (TDM), by measuring drug concentrations in biological samples, represents a valuable tool to address these challenges, by tailoring medication regimens to each individual. This review analyzes the current landscape of TDM in psychiatric practice, highlighting its significance in optimizing drug dosages, minimizing adverse effects, and improving therapeutic efficacy. The metabolism of psychiatric medications (i.e., mood stabilizers, antipsychotics, antidepressants) often exhibits significant inter-patient variability. TDM can help address this variability by enhancing treatment personalization, facilitating early suboptimal- or toxic-level detection, and allowing for timely interventions to prevent treatment failure or adverse effects. Furthermore, this review briefly discusses technological advancements and analytical methods supporting the implementation of TDM in psychiatric settings. These innovations enable quick and cost-effective drug concentration measurements, fostering the widespread adoption of TDM as a routine practice in psychiatric care. In conclusion, the integration of TDM in psychiatry can improve treatment outcomes by individualizing medication regimens within the so-called precision medicine.
Collapse
Affiliation(s)
- Letizia Biso
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
| | - Stefano Aringhieri
- Mental Health and Pathological Addiction Department, AUSL Romagna Forlì-Cesena, 47121 Forlì, Italy;
| | - Marco Carli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
| | - Marco Scarselli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
| | - Biancamaria Longoni
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
| |
Collapse
|
2
|
Duce HL, Duff CJ, Zaidi S, Parfitt C, Heald AH, Fryer AA. Evaluation of thyroid function monitoring in people treated with lithium: Advice based on real-world data. Bipolar Disord 2023; 25:402-409. [PMID: 36645255 DOI: 10.1111/bdi.13298] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Blood test monitoring is essential for the management of lithium treatment and National Institute for Health and Care Excellence guidance recommends 6-monthly serum testing of thyroid function. We examined conformity to these guidelines and the impact of monitoring outside these intervals. METHODS We extracted serum lithium and thyroid hormone results at one centre between January 2009 and December 2020. We identified 266 patients who started lithium during this period with no history of thyroid abnormality within the previous 2 years and were at risk of developing thyroid abnormalities. We examined the interval between tests, time between onset of lithium testing and first thyroid-stimulating hormone (TSH) outside the laboratory reference range and assessed impact of testing outside recommended 6-monthly intervals. RESULTS The most common testing frequency was 3 months (±1 month), accounting for 17.3% of test intervals. Kaplan-Meier analysis showed that most thyroid dysfunction manifests within 3 years (proportion with abnormal TSH at 3 years = 91.4%, 19.9% of total patients). In the first 3 months after commencing lithium therapy, eight patients developed subclinical hypothyroidism and had clinical follow-up data available. Of these, half spontaneously normalized without clinical intervention. In the remaining patients, thyroxine replacement was only initiated after multiple occasions of subclinical hypothyroidism (median = 2 years after initiating lithium, range: 6 months to 3 years). CONCLUSION The peak interval at 3 months suggests that thyroid function is frequently checked at the same time as serum lithium, indicating too frequent testing. Our data support the recommended 6-monthly testing interval and highlight poor adherence to it.
Collapse
Affiliation(s)
- Helen L Duce
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Christopher J Duff
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
- School of Medicine, Keele University, Keele, UK
| | - Syed Zaidi
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Ceri Parfitt
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | | |
Collapse
|
3
|
Hanna F, Wu P, Heald A, Fryer A. Diabetes detection in women with gestational diabetes and polycystic ovarian syndrome. BMJ 2023; 382:e071675. [PMID: 37402524 DOI: 10.1136/bmj-2022-071675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Gestational diabetes mellitus (GDM) and polycystic ovarian syndrome (PCOS) represent two of the highest risk factors for development of type 2 diabetes mellitus in young women. As these increasingly common conditions generally affect younger women, early detection of dysglycemia is key if preventative measures are to be effective. While international guidance recommends screening for type 2 diabetes, current screening strategies suffer from significant challenges.First, guidance lacks consensus in defining which tests to use and frequency of monitoring, thereby sending mixed messages to healthcare professionals.Second, conformity to guidance is poor, with only a minority of women having tests at the recommended frequency (where specified). Approaches to improve conformity have focused on healthcare related factors (largely technology driven reminder systems), but patient factors such as convenience and clear messaging around risk have been neglected.Third, and most critically, current screening strategies are too generic and rely on tests that become abnormal far too late in the trajectory towards dysglycemia to offer opportunities for effective preventative measures. Risk factors show wide interindividual variation, and insulin sensitivity and β cell function are often abnormal during pre-diabetes stage, well before frank diabetes.New, consistent, targeted screening strategies are required that incorporate early, prevention focused testing and personalised risk stratification.
Collapse
Affiliation(s)
- Fahmy Hanna
- Department of Diabetes and Endocrinology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
- Centre for Health and Development, Staffordshire University, Staffordshire UK
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Pensee Wu
- School of Medicine, Keele University, Keele, Staffordshire, UK
- Department of Obstetrics and Gynaecology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
- Department of Obstetrics and Gynecology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Adrian Heald
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Anthony Fryer
- School of Medicine, Keele University, Keele, Staffordshire, UK
| |
Collapse
|
4
|
Zaidi S, Heald AH, Belgamwar RB, Fryer AA. Monitoring drug interventions in people with bipolar disorder. BMJ 2023; 380:e070678. [PMID: 36750246 DOI: 10.1136/bmj-2022-070678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Affiliation(s)
- Syed Zaidi
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | - Ravindra B Belgamwar
- Lymebrook Mental Health Centre, Bradwell Hospital, Newcastle-under-Lyme, Staffordshire, UK
| | | |
Collapse
|
5
|
BMP/Smad Pathway Is Involved in Lithium Carbonate-Induced Neural-Tube Defects in Mice and Neural Stem Cells. Int J Mol Sci 2022; 23:ijms232314831. [PMID: 36499158 PMCID: PMC9735442 DOI: 10.3390/ijms232314831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/03/2022] [Accepted: 11/25/2022] [Indexed: 12/05/2022] Open
Abstract
Neural-tube defects (NTDs) are one type of the most serious birth defects. Studies have shown that inositol deficiency is closely related to the occurrence of NTDs. Bone morphogenetic protein (BMP)-mediated Smad signaling pathways have been implicated in neurogenesis and neural-tube closure. However, the role of the BMP/Smad pathway in inositol-deficiency-induced NTDs remains unclear. Inositol-deficiency models in C57 mice and mouse neural stem cells (mNSCs) were induced with Li2CO3 treatment or inositol withdrawal. The role of the BMP/Smad pathway in the regulation of cell proliferation and the development of NTDs was determined utilizing qRT-PCR, HE staining, Western blot, immunostaining, MTT assay, EdU staining, and flow cytometry. The intraperitoneal injection of Li2CO3 at Embryonic Day 7.5 induced the occurrence of NTDs. The mRNA levels of Bmp2, Bmp4, Smad1, Smad5, Smad8 and Runx2, the phosphorylation of Smad1/5/8, and the nuclear translocation of Runx2 were significantly increased in NTD embryonic brain tissues and mNSCs exposed to Li2CO3 or an inositol-free medium, which were suppressed by BMP receptor selective inhibitor LDN-193189. The Li2CO3-induced phosphorylation of Smad1/5/8 was inhibited by inositol supplementation. Cell proliferation was significantly promoted by Li2CO3 exposure or the absence of inositol in mNSCs, which was reversed by LDN-193189. These results suggest that the activation of the BMP/Smad signaling pathway might play an important role in the development of NTDs induced by maternal Li2CO3 exposure via inositol deficiency.
Collapse
|
6
|
Heald AH, Holland D, Stedman M, Davies M, Duff CJ, Parfitt C, Green L, Scargill J, Taylor D, Fryer AA. Can we check serum lithium levels less often without compromising patient safety? BJPsych Open 2021; 8:e18. [PMID: 34915951 PMCID: PMC8715256 DOI: 10.1192/bjo.2021.1027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Lithium is viewed as the first-line long-term treatment for prevention of relapse in people with bipolar disorder. AIMS This study examined factors associated with the likelihood of maintaining serum lithium levels within the recommended range and explored whether the monitoring interval could be extended in some cases. METHOD We included 46 555 lithium rest requests in 3371 individuals over 7 years from three UK centres. Using lithium results in four categories (<0.4 mmol/L; 0.40-0.79 mmol/L; 0.80-0.99 mmol/L; ≥1.0 mmol/L), we determined the proportion of instances where lithium results remained stable or switched category on subsequent testing, considering the effects of age, duration of lithium therapy and testing history. RESULTS For tests within the recommended range (0.40-0.99 mmol/L categories), 84.5% of subsequent tests remained within this range. Overall, 3 monthly testing was associated with 90% of lithium results remaining within range, compared with 85% at 6 monthly intervals. In cases where the lithium level in the previous 12 months was on target (0.40-0.79 mmol/L; British National Formulary/National Institute for Health and Care Excellence criteria), 90% remained within the target range at 6 months. Neither age nor duration of lithium therapy had any significant effect on lithium level stability. Levels within the 0.80-0.99 mmol/L category were linked to a higher probability of moving to the ≥1.0 mmol/L category (10%) compared with those in the 0.4-0.79 mmol/L group (2%), irrespective of testing frequency. CONCLUSION We propose that for those who achieve 12 months of lithium tests within the 0.40-0.79 mmol/L range, the interval between tests could increase to 6 months, irrespective of age. Where lithium levels are 0.80-0.99 mmol/L, the test interval should remain at 3 months. This could reduce lithium test numbers by 15% and costs by ~$0.4 m p.a.
Collapse
Affiliation(s)
- Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK, and The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | | | | | | | - Chris J Duff
- School of Medicine, Keele University, Keele, Staffordshire, UK, and Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Ceri Parfitt
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Lewis Green
- St. Helens & Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - Jonathan Scargill
- Department of Clinical Biochemistry, The Royal Oldham Hospital, The Northern Care Alliance, Manchester, UK
| | | | - Anthony A Fryer
- School of Medicine, Keele University, Keele, Staffordshire, UK, and Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| |
Collapse
|