Cytochromes and psychotropic drug interactions

Retrospective Evaluation of Fluoxetine Hydrochloride Use in Horses: 95 Cases (2010-2019)

This study aimed to describe the clinical use of oral fluoxetine hydrochloride administration in horses using a retrospective medical records analysis and to determine owner perception of efficacy via a standardized questionnaire. The records of ninety-five horses for which fluoxetine had been prescribed by the equine service of a veterinary teaching hospital from November 2010 and February 2019 were identified, and data were collected from the medical records. A standardized questionnaire was used to obtain data from owners regarding length of administration, ease of administration, adverse effects, and whether the owner noted improvement in the horse's behavior. Ninety-five horses received fluoxetine during the study period. Fluoxetine was prescribed to facilitate stall rest in 68 horses (Group A) and for behavior-related problems in 27 horses (Group B). The mean dosage was 0.25 mg/kg (range 0.15-0.54). Forty-seven of the 66 owners (71%) that completed the follow-up questionnaire reported a perceived improvement in the animal's behavior (29/41 in Group A and 18/25 in Group B). Fifty-eight owners (88%) reported that they felt the medication was easy to administer. When used to facilitate extended stall confinement, fluoxetine appears to be perceived as efficacious by most owners. Although the number of behavioral cases was low, the results indicate that the drug may also be useful for some problem behaviors. Further controlled behavioral studies are needed to investigate the use of fluoxetine for equine behavioral problems.

Pharmacotherapy for anxiety disorders: drugs available

The human search for tranquillity has embraced the use of numerous substances of which alcohol is probably the most widely used. Alcohol acts in part by facilitating neurotransmission at γ-aminobutyric acid (GABA) synapses and until recently the pharmacological treatment of anxiety was based principally on drugs that produce similar actions on this neurotransmitter and its receptor complex (Cowen & Nutt, 1982) (Box 1).

Retrospective use of PBPK modelling to understand a clinical drug-drug interaction between dextromethorphan and GSK1034702

1. In a clinical trial, a strong drug-drug interaction (DDI) was observed between dextromethorphan (DM, the object or victim drug) and GSK1034702 (the precipitant or perpetrator drug), following single and repeat doses. This study determined the inhibition parameters of GSK1034702 in vitro and applied PBPK modelling approaches to simulate the clinical observations and provide mechanistic hypotheses to understand the DDI. 2. In vitro assays were conducted to determine the inhibition parameters of human CYP2D6 by GSK1034702. PBPK models were populated with the in vitro parameters and DDI simulations conducted and compared to the observed data from a clinical study with DM and GSK1034702. 3. GSK1034702 was a potent direct and metabolism-dependent inhibitor of human CYP2D6, with inhibition parameters of: IC₅₀=1.6 μM, K_inact = 3.7 h^-1 and K_I = 0.8 μM. Incorporating these data into PBPK models predicted a DDI after repeat, but not single, 5 mg doses of GSK1034702. 4. The DDI observed with repeat administration of GSK1034702 (5 mg) can be attributed to metabolism-dependent inhibition of CYP2D6. Further, in vitro data were generated and several potential mechanisms proposed to explain the interaction observed following a single dose of GSK1034702.

Therapeutic monitoring of valproate in psychiatry: how far have we progressed?

Valproate (VPA) is a well-established anticonvulsant drug that has found increasing use as a psychotherapeutic agent. The drug is currently used in the management of bipolar, depressive, anxiety, and psychotic disorders; alcohol withdrawal and dependence; agitation associated with dementia; and borderline personality disorder. Despite such widespread use, studies focusing on the concentration-response relationship of VPA in psychiatry are limited. This article examines the rationale for therapeutic monitoring of VPA in psychiatric disorders and reviews reports of VPA concentrations measured during efficacy studies of this drug in psychiatry. Most studies have been open-labeled and uncontrolled, and have not placed the determination of a target concentration range as a primary objective. Furthermore, most studies have used the therapeutic range (50-100 mg/L) for seizure disorders to guide dosage in the psychiatric disorders, although study outcomes have suggested the need to redefine a threshold concentration in the different psychiatric conditions. With the increasing popularity of VPA as a psychotropic agent, it is clear that further investigation of the plasma concentration range associated with efficacy in psychiatric conditions is warranted.

Psychotropic drug interactions with valproate

Valproate is a well-established anticonvulsant that is increasingly being employed, often in combination with other psychotropics, for its mood-stabilizing properties. This compound is metabolized by conjugation, beta-oxidation, and cytochrome P450 oxidation (CYP2C9, CYP2C19, and CYP2A6) and also acts as a broad-spectrum inhibitor of a variety of hepatic enzymes including glucoronyltransferase, epoxide hydrolase, and the CYP2C enzymes. In addition, it exhibits saturable protein binding and competes with many drugs for protein binding sites. It is therefore not surprising that valproate has been noted to interact with psychotropic medications of all classes. This article provides an overview of the noted pharmacokinetic psychotropic interactions with valproate, with a particular focus on the mechanisms of these interactions and potential clinical consequences.

Toxicological interactions involving psychiatric drugs and alcohol: an update

This review focuses on the toxicological interactions between alcohol (ethanol) and psychiatric drugs (antidepressants and antipsychotics), including those leading to fatal poisoning. Acute or chronic ingestion of alcohol when combined with psychiatric drugs may lead to several clinically significant toxicological interactions. The metabolism of these drugs is generally but not always delayed by acute alcohol ingestion. Drugs undergoing metabolism may also show increased metabolic clearance with chronic alcohol ingestion. Therefore, the net effect may be influenced by internal (e.g. disease, age, gender), external (e.g. environment, diet) and pharmacokinetic (e.g. dose, timing of ingestion, gastrointestinal absorption, distribution and elimination) factors. Cases of fatal poisoning involving coadministration of psychiatric drugs, alcohol and other drugs prompted this review.

Toxicological interactions between alcohol and benzodiazepines

BACKGROUND

We review recentfindings on the toxicological interactions between alcohol (ethanol) and benzodiazepines, and the combined use of benzodiazepines and alcohol in fatal poisoning. Acute ingestion of alcohol combined with benzodiazepines is responsible for several toxicological interactions that can have significant clinical implications. In general, metabolism of these drugs is delayed when combined with acute alcohol ingestion although some reports suggest otherwise. Alternately, the drugs metabolized during chronic alcohol ingestion have an increased clearance. The net effect may also be influenced by internal (e.g., disease, age) and external (e.g., environment, diet) factors. Fatal poisoning involving coadministration of alcohol and benzodiazepine, especially triazolam, continues to be a serious problem.

Clinically significant pharmacokinetic drug interactions with psychoactive drugs: antidepressants and antipsychotics and the cytochrome P450 system

Psychotherapeutic drugs (antipsychotics and antidepressants) are widely used for treating anxiety. Many psychotherapeutic drugs are metabolized mainly by cytochrome P450 (CYP)2C19 and CYP2D6, and are often administered with other drugs. Therefore, it is necessary to be careful when co-administering psychotherapeutic drugs whose metabolism might be inhibited by other drugs. In particular, selective serotonin reuptake inhibitors (SSRIs) inhibit the metabolism of psychotherapeutic drugs mediated by CYP2C19 and CYP2D6. It is useful to phenotype CYP2C19 and CYP2D6 (extensive metabolizers or poor metabolizers) before giving such medication. Knowledge of substrates, inhibitors and inducers of CYP isoenzymes may help clinicians to anticipate and avoid psychotherapeutic drug interactions and improve rational prescribing practices. In addition, genotyping for these drugs may be also useful in preventing side-effects.

Human CYP2D6 and metabolism of m-chlorophenylpiperazine

BACKGROUND

Metabolic drug-drug interactions can occur between drugs that are substrates or inhibitors of the same cytochrome P450 (CYP) isoenzymes, but can be prevented by knowing which isoenzymes are primarily responsible for a drug's metabolism. m-Chlorophenylpiperazine (mCPP) is a psychopharmacologically active metabolite of four different psychiatric drugs. The present experiments were designed to identify the CYP isoenzymes involved in the metabolism of mCPP to its main metabolite p-hydroxy-mCPP (OH-mCPP).

METHODS

The rate of production of OH-mCPP from mCPP was correlated with isoform activities in a panel of human liver microsomes, was assessed using a panel of individual complementary DNA-expressed human CYP isoenzymes, and was investigated in the presence of a specific inhibitor of CYP2D6.

RESULTS

OH-mCPP production correlated significantly with CYP2D6 activity in human liver microsomes. Furthermore, incubations with microsomes from cells expressing CYP2D6 resulted in OH-mCPP formation, whereas no mCPP was formed from incubations with microsomes from cells expressing other individual isoforms. Finally, when the specific CYP2D6 inhibitor quinidine was preincubated with either human liver microsomes or cells expressing human CYP2D6, there was a concentration-dependent decrease in the production of OH-mCPP.

CONCLUSIONS

These results confirm that CYP2D6 is the isoform responsible for the p-hydroxylation of mCPP, and indicate that caution should be exercised in coprescribing inhibitors or substrates of CYP2D6 with drugs that have mCPP as a metabolite.

Pharmacokinetic interactions between acute alcohol ingestion and single doses of benzodiazepines, and tricyclic and tetracyclic antidepressants -- an update

Recent reports of interactions between alcohol and benzodiazepines, tricyclic and tetracyclic antidepressants during their acute concomitant use are reviewed. Acute ingestion of alcohol (ethanol) with tranquilizers or hypnotics is responsible for several pharmacokinetic interactions that can have significant clinical implications. In general, metabolism of these drugs is delayed when combined with alcohol but some reports have suggested otherwise. The amount of alcohol consumed, the presence or absence of liver disease, and differences in the dosage and administration of these drugs may account for the observed discrepancies. In recent years, the cytochrome P450 (P450 or CYP) isoenzyme that catalyses the metabolism of these drugs has also been identified. However, since changes in the pharmacogenetic metabolism of benzodiazepines and tricyclic and tetracyclic antidepressants are mainly governed by CYP2C19 and CYP2D6, caution is needed when used together with alcohol.

Pindolol augmentation of antidepressant therapy

BACKGROUND

Antidepressant therapy is not always effective and is slow to take effect. In theory, these shortfalls may be caused by induction of neuronal negative feedback via pre-synaptic 5-HTIA receptors. Pindolol, an antagonist at somatodentritic pre-synaptic 5-HTIA receptors has been investigated as a potential accelerator and augmentor of antidepressant response.

METHOD

A Medline search was conducted in November 1997.

RESULTS

Six open-label studies and six controlled studies were identified for review.

CONCLUSIONS

Open-label studies strongly suggest that pindolol may accelerate and augment antidepressant response, but controlled studies do not wholly support these findings: only three of six studies clearly demonstrate benefit. Larger, well-designed, controlled trials are needed to determine definitively the effectiveness of pindolol in this context.

Fluoxetine tenth anniversary update: the progress continues

This tenth anniversary review/update of fluoxetine concentrates on the past 5 years of its clinical application. The mechanism of action of fluoxetine; its metabolism; its efficacy in patients with various diagnostic subgroups of depression, patients with coincident medical disease, children and adolescents with depression, patients with eating disorders, and patients with obsessive-compulsive disorder (OCD); its long-term (maintenance) efficacy; its side effects and toxicity; and pharmacoeconomic considerations are reviewed. Pharmacotherapy is currently the only proven method for treating major depressive disorder that is applicable to all levels of severity of major depressive illness. Since its introduction 10 years ago, fluoxetine has been available to psychiatrists, primary care physicians, and other nonpsychiatric physicians as full-dose effective pharmacotherapy for patients with depression. Fluoxetine has been widely prescribed by physicians knowledgeable in pharmacology and in the treatment of depression because of its proven efficacy (ie, equal to that of tricyclic antidepressants [TCAs]), its ease of administration (with full therapeutic dosing usually starting from day 1), its generally benign side-effect profile, its remarkable safety in over-dose, and its proven effectiveness in the most common depressed patient population--anxious, agitated, depressed patients--as well as in patients with various subtypes and severities of depression. In more recent years it has also proved effective in the treatment of bulimia, an entity for which only limited or inadequate treatment options had been previously available. In OCD, fluoxetine, with its more acceptable side-effect profile and greater ease of dosing, presents a favorable alternative to previous drug therapy and is useful in treating both obsessions and compulsions. Fluoxetine is currently recognized among clinicians as efficacious in treating anxiety disorders and is being used successfully in special depressed populations such as patients with medical comorbidity, elderly patients, adolescents, and children. Rapid discontinuation or missed doses of short-half-life selective serotonin reuptake inhibitors, TCAs, and heterocyclic antidepressants are associated with withdrawal symptoms of a somatic and psychological nature, which cannot only be disruptive, but can also be suggestive of relapse or recurrence of depression. In striking contrast to these short-half-life antidepressants, fluoxetine is rarely associated with such sequelae on sudden discontinuation or missed doses. This preventive effect against withdrawal symptoms on discontinuation of fluoxetine is attributed to the unique extended half-life of this antidepressant. Current studies show that the overall increased effectiveness of fluoxetine in treating depression compensates for its higher cost, compared with older drugs, by reducing the need for physician contact because of increased compliance and less need of titration, and by reducing premature patient discontinuation, thereby yielding fewer relapses, less recurrence, and less reutilization of mental health services.

Pharmacokinetic interactions involving clozapine

BACKGROUND

Metabolism of clozapine is complex and not fully understood. Pharmacokinetic interactions with other drugs have been described but, in some cases, their mechanism is unknown.

METHOD

Published trials and case reports relevant to the human metabolism of clozapine and to suspected pharmacokinetic interactions were reviewed.

RESULTS

Metabolism of clozapine appears to be largely controlled by the function of the hepatic cytochrome p450IA2 (CYPIA2). Compounds which induce CYPIA2 activity (carbamazepine, tobacco smoke) may reduce plasma clozapine levels. Inhibitors of CYPIA2 (caffeine, erythromycin) have the opposite effect. Drugs which inhibit the hepatic cytochrome p4502D6 (CYP2D6) have also been reported to elevate plasma clozapine levels. The mechanism of this interaction is unclear.

CONCLUSIONS

The co-administration of clozapine and compounds reported to alter its metabolism should be avoided where possible. A host of other interactions can be predicted and so caution should be exercised when co-administering drugs which affect the function of CYPIA2 and CYP2D6. The pharmacokinetics of clozapine require further investigation so that its safe use can be assured.