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Genetic determinants associated with response to clozapine in schizophrenia: an umbrella review. Psychiatr Genet 2022; 32:163-170. [PMID: 35855515 DOI: 10.1097/ypg.0000000000000320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Clozapine response varies widely from person to person, which may be due to inter-individual genetic variability. This umbrella review aims to summarize the current evidence on associations between pharmacodynamic genes and response to clozapine treatment. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology, a systematic literature search was conducted in the PubMed and EMBASE databases from inception to November 2021 to identify systematic reviews and meta-analyses of studies that examined genetic determinants of clozapine response. The quality of the reviews was assessed with the AMSTAR-2 tool. RESULTS From a total of 128 records, 10 studies representing nine systematic reviews and one meta-analysis met our inclusion criteria. The overall quality of the included studies was poor. All systematic reviews concluded that the results of primary studies were largely negative or conflicting. Most evidence was found for an association with clozapine response and rs6313 and rs6314 within HTR2A and rs1062613 within HTR3A in the serotonergic system. CONCLUSIONS Conclusive evidence for associations between genetic variants and clozapine response is still lacking. Hypothesis-generating genetic studies in large, well-characterized study populations are urgently needed to obtain more consistent and clinically informative results. Future studies may also include multi-omics approaches to identify novel genetic determinants associated with clozapine response.
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Sangüesa E, Cirujeda C, Concha J, Padilla PP, García CB, Ribate MP. Pharmacokinetic interactions between clozapine and valproic acid in patients with treatment-resistant schizophrenia: Does UGT polymorphism affect these drug interactions? Chem Biol Interact 2022; 364:110042. [PMID: 35853541 DOI: 10.1016/j.cbi.2022.110042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/13/2022] [Indexed: 11/29/2022]
Abstract
The combination of valproic acid (VPA) and clozapine (CLZ) is regularly prescribed for augmentation therapy in treatment resistant schizophrenia. The VPA has been shown to reduce norclozapine (NCLZ) plasma levels, but the mechanism of this interaction remains unknown. The aim of this study is to examine the differences between patients treated with CLZ and patients treated with CLZ plus VPA. For it, various factors have been evaluated. The study was based on plasma samples from CLZ and CLZ plus VPA treated patients (n = 61) subjected to routine therapeutic drug monitoring considering clinical data, smoking status, daily dose of CLZ and VPA, concomitant medications, albumin, and renal and hepatic function. Genotyping of polymorphisms of CYP1A2, CYP3A4/5, CYP2C19, ABCB1, UGT2B10 and CYP2C19 were performed by real time PCR. CYP2D6 were genotyped using competitive allele-specific PCR and by a long PCR based method. Plasma CLZ and NCLZ concentrations were measured by Liquid Chromatography-Tandem masses (LC-MS/MS) and plasma VPA by Ultraviolet-Visible (UV-vis) spectrophotometric immunoassay. The patients presented adequate CLZ levels in relation to the dose. However, NCLZ levels were excessively low and the CLZ/NCLZ ratio very high. Patients with UGT2B10 GT (rs61750900) genotype showed lower NCLZ plasma levels and C/D NCLZ, and higher CLZ/NCLZ ratio versus patients with UGT2B10 GG genotype. VPA, smoking, the presence of UGT2B10 GT genotype and having low albumin levels indicate that the CLZ/NCLZ ratio is affected, mostly coinciding with decreased NCLZ levels and possibly with an increased risk of neutropenia.
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Affiliation(s)
- Estela Sangüesa
- Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego- Zaragoza, Spain
| | - Christine Cirujeda
- Centro Neuropsiquiátrico Nuestra Señora del Carmen, Hermanas Hospitalarias, Zaragoza, Spain
| | - Julia Concha
- Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego- Zaragoza, Spain
| | - Pedro Pablo Padilla
- Centro Neuropsiquiátrico Nuestra Señora del Carmen, Hermanas Hospitalarias, Zaragoza, Spain
| | - Cristina Belén García
- Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego- Zaragoza, Spain.
| | - María Pilar Ribate
- Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego- Zaragoza, Spain
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Sangüesa E, Cirujeda C, Concha J, Padilla PP, García CB, Ribate MP. Exploring the usefulness of plasma level determination and pharmacogenetics for patients treated with clozapine. Per Med 2022; 19:181-192. [PMID: 35259926 DOI: 10.2217/pme-2021-0029] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Aims: The aims of the present study were to assess the variance of plasma clozapine (CLZ) levels and to identify the influence of sociodemographic and pharmacogenetic factors on it and to introduce these tools in a clinical setting. Patients & methods: CLZ concentration was measured and genetic variants of CLZ pharmacokinetic and pharmacodynamic factors were assessed in 23 patients with psychotic disorders. Results: A significant association between mean concentration/dose ratio (C/D) and smoking status, age and weight were found. There was a significant difference in mean plasma CLZ levels and gender. The rs762551 AA genotype in smokers had a significantly lower C/D. Conclusion: In addition to classical factors, monitoring of plasma concentrations together with pharmacogenetics led to greater individualization of treatment.
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Affiliation(s)
- Estela Sangüesa
- Pharmacy degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego, Zaragoza, Spain
| | - Christine Cirujeda
- Centro Neuropsiquiátrico Nuestra Señora del Carmen. Hermanas Hospitalarias, Zaragoza, Spain
| | - Julia Concha
- Pharmacy degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego, Zaragoza, Spain
| | - Pedro Pablo Padilla
- Centro Neuropsiquiátrico Nuestra Señora del Carmen. Hermanas Hospitalarias, Zaragoza, Spain
| | - Cristina Belén García
- Pharmacy degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego, Zaragoza, Spain
| | - María Pilar Ribate
- Pharmacy degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego, Zaragoza, Spain
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Hino M, Kondo T, Kunii Y, Matsumoto J, Wada A, Niwa SI, Setou M, Yabe H. Tubulin/microtubules as novel clozapine targets. Neuropsychopharmacol Rep 2021; 42:32-41. [PMID: 34964309 PMCID: PMC8919115 DOI: 10.1002/npr2.12221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/16/2021] [Accepted: 11/21/2021] [Indexed: 01/06/2023] Open
Abstract
Aim Clozapine is currently the only effective drug for treatment‐resistant schizophrenia; nonetheless, its pharmacological mechanism remains unclear, and its administration is limited because of severe adverse effects. By comparing the binding proteins of clozapine and its derivative olanzapine, which is safer but less effective than clozapine, we attempted to clarify the mechanism of action specific to clozapine. Methods First, using the polyproline rod conjugates attached with clozapine or olanzapine, clozapine‐binding proteins in extracts from the cerebra of 7‐week‐old ICR mice were isolated and separated by sodium dodecyl sulfate‐polyacrylamide gel electrophoresis (SDS‐PAGE) and analyzed by liquid chromatography‐tandem mass spectrometry (LC‐MS/MS) to identify proteins. Second, the effect of clozapine on tubulin polymerization was determined turbidimetrically. Finally, the cellular effects of clozapine were observed in HeLa cells by immunofluorescence microscopy. Results Alpha and β tubulins were the most abundant clozapine‐binding proteins. We also found that clozapine directly binds with α and β tubulin heterodimers to inhibit their polymerization to form microtubules and disturbs the microtubule network, causing mitotic arrest in HeLa cells. Conclusion These results suggest that α and β tubulin heterodimers are targeted by the clozapine and the microtubules are involved in the etiology of schizophrenia. Clozapine‐binding proteins were investigated in mouse brain by using the polyproline rod method. The most abundant clozapine‐binding proteins were α and β tubulins. This figure shows immunofluorescence staining of HeLa cells treated without or with indicated doses of clozapine for 3 hours with anti‐tubulin antibody, indicating that clozapine disrupts the microtubule network in the cell. Scale bar, 20 μm.![]()
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Affiliation(s)
- Mizuki Hino
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Fukushima, Japan.,Department of Disaster Psychiatry, International Research Institute of Disaster Science, Tohoku University, Sendai, Miyagi, Japan
| | - Takeshi Kondo
- Department of Cellular and Molecular Anatomy, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan.,International Mass Imaging Center, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yasuto Kunii
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Fukushima, Japan.,Department of Disaster Psychiatry, International Research Institute of Disaster Science, Tohoku University, Sendai, Miyagi, Japan
| | - Junya Matsumoto
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Fukushima, Japan
| | - Akira Wada
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Fukushima, Japan
| | - Shin-Ichi Niwa
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Fukushima, Japan.,Department of Psychiatry, Aizu Medical Center, School of Medicine, Fukushima Medical University, Aizuwakamatsu, Fukushima, Japan
| | - Mitsutoshi Setou
- Department of Cellular and Molecular Anatomy, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan.,International Mass Imaging Center, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan.,Preeminent Medical Photonics Education and Research Center, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Hirooki Yabe
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Fukushima, Japan
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Clozapine: An Updated Overview of Pharmacogenetic Biomarkers, Risks, and Safety-Particularities in the Context of COVID-19. Brain Sci 2020; 10:brainsci10110840. [PMID: 33187329 PMCID: PMC7697202 DOI: 10.3390/brainsci10110840] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 12/11/2022] Open
Abstract
Background: clozapine (CLZ) use is precarious due to its neurological, cardiovascular, and hematological side effects; however, it is the gold standard in therapy-resistant schizophrenia (TRS) in adults and is underused. Objective: to examine the most recent CLZ data on (a) side effects concerning (b) recent pharmacological mechanisms, (c) therapy benefits, and (d) the particularities of the COVID-19 pandemic. Data sources: a search was performed in two databases (PubMed and Web of Science) using the specific keywords “clozapine” and “schizophrenia”, “side effects”, “agranulocytosis”, “TRS”, or “bipolar affective disorder (BAF)” for the last ten years. Study eligibility criteria: clinical trials on adults with acute symptoms of schizophrenia or related disorders. Results: we selected 37 studies, randomized controlled trials (RCTs), and clinical case series (CCS), centered on six main topics in the search area: (a) CLZ in schizophrenia, (b) CLZ in bipolar disorder, (c) side effects during the clozapine therapy, (d) CLZ in pregnancy, (e) CLZ in early-onset schizophrenia, and (f) CLZ therapy and COVID-19 infection. Limitations: we considered RCTs and CCS from two databases, limited to the search topics. Conclusions and implications of key findings: (a) clozapine doses should be personalized for each patient based on pharmacogenetics testing when available; the genetic vulnerability postulates predictors of adverse reactions’ severity; patients with a lower genetic risk could have less frequent hematological monitoring; (b) a CLZ-associated risk of pulmonary embolism imposes prophylactic measures for venous thromboembolism; (c) convulsive episodes are not an indication for stopping treatment; the plasma concentration of clozapine is a better side effect predictor than the dosage; (d) COVID-19 infection may enhance clozapine toxicity, generating an increased risk of pneumonia. Therapy must be continued with the proper monitoring of the white blood count, and the clozapine dose decreased by half until three days after the fever breaks; psychiatrists and healthcare providers must act together.
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Sangüesa E, Cirujeda C, Concha J, Padilla PP, Ribate MP, García CB. Implementation of pharmacogenetics in a clozapine treatment resistant patient: a case report. Pharmacogenomics 2019; 20:871-877. [DOI: 10.2217/pgs-2019-0074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
We report the case of a young Caucasian male with disorganized chronic schizophrenia, an active smoker and nonresponder to 400 mg of clozapine/day. Therapeutic clozapine monitoring was analyzed revealing a low clozapine:norclozapine ratio. An additional pharmacogenetic test was carried out showing that the patient carried *1F variant ( CYP1A2 gene), which has been associated with nonresponse to clozapine in smoker patients. A genetic variation in the SLC6A4 gene was also found, which could be related to the poor response to clozapine. The remainder of the genes analyzed ( CYP2D6, ABCB1 and HTR2A) were not directly associated with the patient’s phenotype. The dose of clozapine was increased to 600 mg/day, reaching the therapeutic range. This case shows how pharmacogenetics can help in understanding the value of plasma levels to provide clinical improvement.
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Affiliation(s)
- Estela Sangüesa
- Pharmacy Degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego- Zaragoza, Spain
| | - Christine Cirujeda
- Centro Neuropsiquiátrico Nuestra Señora del Carmen. Hermanas Hospitalarias, Zaragoza, Spain
| | - Julia Concha
- Pharmacy Degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego- Zaragoza, Spain
| | - Pedro Pablo Padilla
- Centro Neuropsiquiátrico Nuestra Señora del Carmen. Hermanas Hospitalarias, Zaragoza, Spain
| | - María Pilar Ribate
- Pharmacy Degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego- Zaragoza, Spain
| | - Cristina Belén García
- Pharmacy Degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego- Zaragoza, Spain
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Abstract
PURPOSE OF REVIEW To examine recent literature regarding the pharmacogenomics of clozapine (CLZ) efficacy, pharmacokinetics, and agranulocytosis. RECENT FINDINGS Several genetic loci (FKBP5, NR3C1, BDNF, NTRK2) along the hypothalamic pituitary adrenal axis have been investigated as targets for CLZ response. Homozygous FKBP5-rs1360780, homozygous NTRK2-rs1778929, and homozygous NTRK2-rs10465180 conferred significant risks for CLZ nonresponse - 2.11x risk [95% confidence interval (CI) 1.22-3.64], 1.7x risk (95% CI 1.13-2.59), and 2.15x risk (95% CI 1.3-3.55), respectively. BDNF and NR3C1 had no significant associations with CLZ response. Candidate genes within neurotransmitter pathways continue to be explored including dopaminergic (DRD1-4, COMT) and glutamatergic pathways (GRIN2B, SLC1A2, SLC6A9, GRIA1, GAD1). Despite promising trending data, no significant associations between CLZ response and glutamatergic system variants have been found. Synergistic effect of catecholamine O-methyltransferase (COMT) Met and dopamine receptor-4 (DRD4) single 120 bp duplicate associated with improved CLZ response odds ratio (OR) 0.15 (95% CI 0.03-0.62) while COMT Val/Val confer a risk of CLZ nonresponse OR 4.34 (95% CI 0.98-23.9). Diagnostic performance testing continues through human leukocyte antigen (HLA) and other genetic loci but have yet to find statistically or clinically meaningful results. SUMMARY Current landscape of pharmacogenomic research in CLZ continues to be limited by small sample sizes and low power. However, many promising candidate genes have been discovered and should be further investigated with larger cohorts.
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Genetics and Antipsychotic Response in Schizophrenia: an Update. Curr Behav Neurosci Rep 2017. [DOI: 10.1007/s40473-017-0119-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nakazawa T, Kikuchi M, Ishikawa M, Yamamori H, Nagayasu K, Matsumoto T, Fujimoto M, Yasuda Y, Fujiwara M, Okada S, Matsumura K, Kasai A, Hayata-Takano A, Shintani N, Numata S, Takuma K, Akamatsu W, Okano H, Nakaya A, Hashimoto H, Hashimoto R. Differential gene expression profiles in neurons generated from lymphoblastoid B-cell line-derived iPS cells from monozygotic twin cases with treatment-resistant schizophrenia and discordant responses to clozapine. Schizophr Res 2017; 181:75-82. [PMID: 28277309 DOI: 10.1016/j.schres.2016.10.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 09/30/2016] [Accepted: 10/06/2016] [Indexed: 01/25/2023]
Abstract
Schizophrenia is a chronic psychiatric disorder with complex genetic and environmental origins. While many antipsychotics have been demonstrated as effective in the treatment of schizophrenia, a substantial number of schizophrenia patients are partially or fully unresponsive to the treatment. Clozapine is the most effective antipsychotic drug for treatment-resistant schizophrenia; however, clozapine has rare but serious side-effects. Furthermore, there is inter-individual variability in the drug response to clozapine treatment. Therefore, the identification of the molecular mechanisms underlying the action of clozapine and drug response predictors is imperative. In the present study, we focused on a pair of monozygotic twin cases with treatment-resistant schizophrenia, in which one twin responded well to clozapine treatment and the other twin did not. Using induced pluripotent stem (iPS) cell-based technology, we generated neurons from iPS cells derived from these patients and subsequently performed RNA-sequencing to compare the transcriptome profiles of the mock or clozapine-treated neurons. Although, these iPS cells similarly differentiated into neurons, several genes encoding homophilic cell adhesion molecules, such as protocadherin genes, showed differential expression patterns between these two patients. These results, which contribute to the current understanding of the molecular mechanisms of clozapine action, establish a new strategy for the use of monozygotic twin studies in schizophrenia research.
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Affiliation(s)
- Takanobu Nakazawa
- Department of Pharmacology, Graduate School of Dentistry, Osaka University, 1-8 Yamadaoka, Suita, Osaka 565-0871, Japan; Laboratory of Molecular Neuropharmacology, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6 Yamadaoka, Suita, Osaka 565-0871, Japan; iPS Cell-Based Research Project on Brain Neuropharmacology and Toxicology, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Masataka Kikuchi
- Department of Genome Informatics, Graduate School of Medicine, Osaka University, 2-2, Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Mitsuru Ishikawa
- Department of Physiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Hidenaga Yamamori
- Department of Psychiatry, Osaka University Graduate School of Medicine, D3, 2-2, Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Kazuki Nagayasu
- Laboratory of Molecular Neuropharmacology, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6 Yamadaoka, Suita, Osaka 565-0871, Japan; iPS Cell-Based Research Project on Brain Neuropharmacology and Toxicology, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Takuya Matsumoto
- Department of Physiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; Institute for Innovation, Ajinomoto Co., Inc., 1-1 Suzukicho, Kawasaki-ku, Kawasaki, Kanagawa 210-8681, Japan
| | - Michiko Fujimoto
- Department of Psychiatry, Osaka University Graduate School of Medicine, D3, 2-2, Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Yuka Yasuda
- Department of Psychiatry, Osaka University Graduate School of Medicine, D3, 2-2, Yamadaoka, Suita, Osaka 565-0871, Japan; Oncology Center, Osaka University Hospital, 2-15, Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Mikiya Fujiwara
- Laboratory of Molecular Neuropharmacology, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Shota Okada
- Laboratory of Molecular Neuropharmacology, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Kensuke Matsumura
- Laboratory of Molecular Neuropharmacology, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Atsushi Kasai
- Laboratory of Molecular Neuropharmacology, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Atsuko Hayata-Takano
- Laboratory of Molecular Neuropharmacology, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Norihito Shintani
- Laboratory of Molecular Neuropharmacology, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Shusuke Numata
- Department of Psychiatry, Course of Integrated Brain Sciences, School of Medicine, University of Tokushima, 2-50-1 Kuramotocho, Tokushima, Tokushima 770-8503, Japan
| | - Kazuhiro Takuma
- Department of Pharmacology, Graduate School of Dentistry, Osaka University, 1-8 Yamadaoka, Suita, Osaka 565-0871, Japan; Molecular Research Center for Children's Mental Development, United Graduate School of Child Development, Osaka University, D3, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Wado Akamatsu
- Department of Physiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; Center for Genomic and Regenerative Medicine, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Hideyuki Okano
- Department of Physiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Akihiro Nakaya
- Department of Genome Informatics, Graduate School of Medicine, Osaka University, 2-2, Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Hitoshi Hashimoto
- Laboratory of Molecular Neuropharmacology, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6 Yamadaoka, Suita, Osaka 565-0871, Japan; iPS Cell-Based Research Project on Brain Neuropharmacology and Toxicology, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6 Yamadaoka, Suita, Osaka 565-0871, Japan; Molecular Research Center for Children's Mental Development, United Graduate School of Child Development, Osaka University, D3, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan; Division of Bioscience, Institute for Datability Science, Osaka University, 1-1 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Ryota Hashimoto
- Department of Psychiatry, Osaka University Graduate School of Medicine, D3, 2-2, Yamadaoka, Suita, Osaka 565-0871, Japan; Molecular Research Center for Children's Mental Development, United Graduate School of Child Development, Osaka University, D3, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan.
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Lally J, Gaughran F, Timms P, Curran SR. Treatment-resistant schizophrenia: current insights on the pharmacogenomics of antipsychotics. Pharmgenomics Pers Med 2016; 9:117-129. [PMID: 27853387 PMCID: PMC5106233 DOI: 10.2147/pgpm.s115741] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Up to 30% of people with schizophrenia do not respond to two (or more) trials of dopaminergic antipsychotics. They are said to have treatment-resistant schizophrenia (TRS). Clozapine is still the only effective treatment for TRS, although it is underused in clinical practice. Initial use is delayed, it can be hard for patients to tolerate, and clinicians can be uncertain as to when to use it. What if, at the start of treatment, we could identify those patients likely to respond to clozapine - and those likely to suffer adverse effects? It is likely that clinicians would feel less inhibited about using it, allowing clozapine to be used earlier and more appropriately. Genetic testing holds out the tantalizing possibility of being able to do just this, and hence the vital importance of pharmacogenomic studies. These can potentially identify genetic markers for both tolerance of and vulnerability to clozapine. We aim to summarize progress so far, possible clinical applications, limitations to the evidence, and problems in applying these findings to the management of TRS. Pharmacogenomic studies of clozapine response and tolerability have produced conflicting results. These are due, at least in part, to significant differences in the patient groups studied. The use of clinical pharmacogenomic testing - to personalize clozapine treatment and identify patients at high risk of treatment failure or of adverse events - has moved closer over the last 20 years. However, to develop such testing that could be used clinically will require larger, multicenter, prospective studies.
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Affiliation(s)
- John Lally
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Department of Psychiatry, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
- National Psychosis Service
| | - Fiona Gaughran
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- National Psychosis Service
| | - Philip Timms
- START Team, South London and Maudsley NHS Foundation Trust
- King’s College London
| | - Sarah R Curran
- King’s College London
- South West London and St George’s Mental Health NHS Foundation Trust
- St George’s University of London, London, UK
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Taylor DL, Tiwari AK, Lieberman JA, Potkin SG, Meltzer HY, Knight J, Remington G, Müller DJ, Kennedy JL. Pharmacogenetic Analysis of Functional Glutamate System Gene Variants and Clinical Response to Clozapine. MOLECULAR NEUROPSYCHIATRY 2016; 2:185-197. [PMID: 28277565 DOI: 10.1159/000449224] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 08/17/2016] [Indexed: 01/16/2023]
Abstract
Altered glutamate neurotransmission is implicated in the etiology of schizophrenia (SCZ) and the pharmacogenetics of response to clozapine (CLZ), which is the drug of choice for treatment-resistant SCZ. Response to antipsychotic therapy is highly variable, although twin studies suggest a genetic component. We investigated the association of 10 glutamate system gene variants with CLZ response using standard genotyping procedures. GRM2 (rs4067 and rs2518461), SLC1A2 (rs4354668, rs4534557, and rs2901534), SLC6A9 (rs12037805, rs1978195, and rs16831558), GRIA1 (rs2195450), and GAD1 (rs3749034) were typed in 163 European SCZ/schizoaffective disorder patients deemed resistant or intolerant to previous pharmacotherapy. Response was assessed following 6 months of CLZ monotherapy using change in Brief Psychiatric Rating Scale (BPRS) scores. Categorical and continuous response variables were analyzed using χ2 tests and analysis of covariance, respectively. We report no significant associations following correction for multiple testing. Prior to correction, nominally significant associations were observed for SLC6A9, SLC1A2, GRM2, and GRIA1. Most notably, CC homozygotes of rs16831558 located in the glycine transporter 1 gene (SLC6A9) exhibited an allele dose-dependent improvement in positive symptoms compared to T allele carriers (puncorrected = 0.008, pcorrected = 0.08). To clarify the role of SLC6A9 in clinical response to antipsychotic medication, and CLZ in particular, this finding warrants further investigation in larger well-characterized samples.
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Affiliation(s)
- Danielle L Taylor
- Neuroscience Research Department, Campbell Family Research Institute, Toronto, Ont., Canada; Institute of Medical Science, Toronto, Ont., Canada
| | - Arun K Tiwari
- Neuroscience Research Department, Campbell Family Research Institute, Toronto, Ont., Canada
| | - Jeffrey A Lieberman
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University and the New York State Psychiatric Institute, New York, N.Y, USA
| | - Steven G Potkin
- Department of Psychiatry, University of California, Irvine, Calif, USA
| | - Herbert Y Meltzer
- Northwestern University Feinberg School of Medicine, Chicago, Ill., USA
| | - Joanne Knight
- Neuroscience Research Department, Campbell Family Research Institute, Toronto, Ont., Canada; Institute of Medical Science, Toronto, Ont., Canada; Department of Psychiatry, University of Toronto, Toronto, Ont., Canada; Lancaster Medical School and Data Science Institute, Lancaster University, Lancaster, UK
| | - Gary Remington
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, Ont., Canada; Department of Psychiatry, University of Toronto, Toronto, Ont., Canada
| | - Daniel J Müller
- Neuroscience Research Department, Campbell Family Research Institute, Toronto, Ont., Canada; Institute of Medical Science, Toronto, Ont., Canada; Department of Psychiatry, University of Toronto, Toronto, Ont., Canada
| | - James L Kennedy
- Neuroscience Research Department, Campbell Family Research Institute, Toronto, Ont., Canada; Institute of Medical Science, Toronto, Ont., Canada; Department of Psychiatry, University of Toronto, Toronto, Ont., Canada
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12
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Abstract
Although treatment-resistant schizophrenia (TRS) was described 50 years ago and has a gold standard treatment with clozapine based on well-defined criteria, there is still a matter of great interest and controversy. In terms of the underlying mechanisms of the development of TRS, progress has been made for the elucidation of the neurochemical mechanisms. Structural neuroimaging studies have shown that patients with TRS have significant reduction of the prefrontal cortex volume when compared with non- TRS. This article updates and enhances our previous review with new evidence mainly derived from new studies, clinical trials, systematic reviews, and meta-analyses.
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Affiliation(s)
- Helio Elkis
- Instituto de Psiquiatria HC- FMUSP, Rua Ovidio Pires de Campos 785-São Paulo, SP-05403-010, Brazil.
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13
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Taylor DL, Tiwari AK, Lieberman JA, Potkin SG, Meltzer HY, Knight J, Remington G, Müller DJ, Kennedy JL. Genetic association analysis of N-methyl-D-aspartate receptor subunit gene GRIN2B and clinical response to clozapine. Hum Psychopharmacol 2016; 31:121-34. [PMID: 26876050 DOI: 10.1002/hup.2519] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 11/20/2015] [Accepted: 12/15/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Approximately 30% of patients with schizophrenia fail to respond to antipsychotic therapy and are classified as having treatment-resistant schizophrenia. Clozapine is the most efficacious drug for treatment-resistant schizophrenia and may deliver superior therapeutic effects partly by modulating glutamate neurotransmission. Response to clozapine is highly variable and may depend on genetic factors as indicated by twin studies. We investigated eight polymorphisms in the N-methyl-D-aspartate glutamate receptor subunit gene GRIN2B with response to clozapine. METHODS GRIN2B variants were genotyped using standard TaqMan procedures in 175 European patients with schizophrenia deemed resistant or intolerant to treatment. Response was assessed using change in Brief Psychiatric Rating Scale scores following six months of clozapine therapy. Categorical and continuous response was assessed using chi-squared test and analysis of covariance, respectively. RESULTS No associations were observed between the variants and response to clozapine. A-allele carriers of rs1072388 responded marginally better to clozapine therapy than GG-homozygotes; however, the difference was not statistically significant (p = 0.067, uncorrected). CONCLUSIONS Our findings do not support a role for these GRIN2B variants in altering response to clozapine in our sample. Investigation of additional glutamate variants in clozapine response is warranted.
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Affiliation(s)
- Danielle L Taylor
- Neurogenetics Section, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Arun K Tiwari
- Neurogenetics Section, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Jeffrey A Lieberman
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University and the New York State Psychiatric Institute, New York City, New York, USA
| | - Steven G Potkin
- Department of Psychiatry, University of California, Irvine, Irvine, California, USA
| | - Herbert Y Meltzer
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jo Knight
- Neurogenetics Section, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Gary Remington
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Daniel J Müller
- Neurogenetics Section, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - James L Kennedy
- Neurogenetics Section, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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14
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Pharmacogenetics of clozapine response and induced weight gain: A comprehensive review and meta-analysis. Eur Neuropsychopharmacol 2016; 26:163-185. [PMID: 26792444 DOI: 10.1016/j.euroneuro.2015.12.035] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Revised: 10/06/2015] [Accepted: 12/20/2015] [Indexed: 12/22/2022]
Abstract
Clozapine (CLZ) is the prototype atypical antipsychotic and it has many advantages over other antipsychotic drugs. Several data suggest that both CLZ response and induced weight gain are strongly determined by genetic variability. However, results remain mainly inconclusive. We aim to review the literature data about pharmacogenetics studies on CLZ efficacy, focusing on pharmacodynamic genes. Further, we performed meta-analyses on response when at least three studies for each polymorphism were available. Sensitivity analyses were conducted on Caucasian population when feasible. Electronic literature search was performed to identify pertinent studies published until May 2014 using PubMed, ISI Web of Knowledge and PsycINFO databases. For meta-analyses, data were entered and analyzed through RevMan version 5.2 using a random-effect model. Our literature search yielded 9266 articles on CLZ; among these, we identified 59 pertinent pharmacogenetic studies. Genotype data were retrieved for 14 polymorphisms in 9 genes. Among these, we had available data from at least three independent samples for 8 SNPs in 6 genes to perform meta-analyses: DRD2 rs1799732, DRD3 rs6280, HTR2A rs6313, rs6311, rs6314, HTR2C rs6318, HTR3A rs1062613, TNFa rs1800629. Although literature review provided conflicting results, in meta-analyses three genetic variants within serotonin genes resulted associated to CLZ response: rs6313 and rs6314 within HTR2A gene and rs1062613 within HT3A gene. On the other hand, no clear finding emerged for CLZ-induced weight gain. Our results suggest a possible serotonergic modulation of CLZ clinical response.
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15
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Sriretnakumar V, Huang E, Müller DJ. Pharmacogenetics of clozapine treatment response and side-effects in schizophrenia: an update. Expert Opin Drug Metab Toxicol 2015; 11:1709-31. [PMID: 26364648 DOI: 10.1517/17425255.2015.1075003] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Clozapine (CLZ) is the most effective treatment for treatment-resistant schizophrenia (SCZ) patients, with potential added benefits of reduction in suicide risk and aggression. However, CLZ is also mainly underused due to its high risk for the potentially lethal side-effect of agranulocytosis as well as weight gain and related metabolic dysregulation. Pharmacogenetics promises to enable the prediction of patient treatment response and risk of adverse effects based on patients' genetics, paving the way toward individualized treatment. AREA COVERED This article reviews pharmacogenetics studies of CLZ response and side-effects with a focus on articles from January 2012 to February 2015, as an update to the previous reviews. Pharmacokinetic genes explored primarily include CYP1A2, while pharmacodynamic genes consisted of traditional pharmacogenetic targets such as brain-derived neurotrophic factor as well novel mitochondrial genes, NDUFS-1 and translocator protein. EXPERT OPINION Pharmacogenetics is a promising avenue for individualized medication of CLZ in SCZ, with several consistently replicated gene variants predicting CLZ response and side-effects. However, a large proportion of studies have yielded mixed results. Large-scale Genome-wide association studies (e.g., CRESTAR) and targeted gene studies with standardized designs (response measurements, treatment durations, plasma level monitoring) are required for further progress toward clinical translation. Additionally, in order to improve study quality, we recommend accounting for important confounders, including polypharmacy, baseline measurements, treatment duration, gender, and age at onset.
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Affiliation(s)
- Venuja Sriretnakumar
- a 1 Campbell Family Research Institute, Pharmacogenetics Research Clinic, Centre for Addiction and Mental Health , Toronto, Ontario, Canada +1 416 535 8501 ; +1 416 979 4666 ; .,b 2 University of Toronto, Department of Laboratory Medicine and Pathobiology , Ontario, Canada
| | - Eric Huang
- a 1 Campbell Family Research Institute, Pharmacogenetics Research Clinic, Centre for Addiction and Mental Health , Toronto, Ontario, Canada +1 416 535 8501 ; +1 416 979 4666 ; .,c 3 University of Toronto, Institute of Medical Sciences , Ontario, Canada
| | - Daniel J Müller
- a 1 Campbell Family Research Institute, Pharmacogenetics Research Clinic, Centre for Addiction and Mental Health , Toronto, Ontario, Canada +1 416 535 8501 ; +1 416 979 4666 ; .,c 3 University of Toronto, Institute of Medical Sciences , Ontario, Canada.,d 4 University of Toronto, Department of Psychiatry , Ontario, Canada
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16
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»Treatment Resistance« Enigma Resolved by Pharmacogenomics - A Case Study of Clozapine Therapy in Schizophrenia. J Med Biochem 2015; 34:223-227. [PMID: 28356835 PMCID: PMC4922322 DOI: 10.2478/jomb-2014-0041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 04/07/2014] [Indexed: 01/31/2023] Open
Abstract
The introduction of antipsychotic medication in the 1950s forever changed the outlook on the treatment of schizophrenia, although there is still a large proportion of patients who do not reach functional recovery. At least 30% of patients do not respond to clozapine, the tricyclic dibenzodiazepine with complex pharmacological actions, which was proven to be more effective than any other antipsychotic in the treatment of schizophrenia. According to most of the therapeutic guidelines for schizophrenia, clozapine is the third line therapy for patients who did not respond to other antipsychotics. Large inter-individual variability exists for clozapine bioavailability and plasma steady-state concentrations and clearance. Clozapine is metabolized by the cytochrome P450 oxidase enzyme family (CYP450). Cytochrome P450 1A2 (CYP1A2), which is polymorphically expressed in humans, is the main enzyme of clozapine metabolism. This case report addresses the influence of CYP1A2*1F genetic polymorphism on clozapine metabolism, explains the primary non-response of a young patient with schizophrenia due to increased gene expression in homozygous genotype *1F/*1F (increased metabolism of clozapine) and underlies the importance of personalizing schizophrenia treatment by means of genetic and other molecular tools, at least in the cases of »treatment resistance«.
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17
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Abstract
This review considers pharmacogenetics of the so called 'second-generation' antipsychotics. Findings for polymorphisms replicating in more than one study are emphasized and compared and contrasted with larger-scale candidate gene studies and genome-wide association study analyses. Variants in three types of genes are discussed: pharmacokinetic genes associated with drug metabolism and disposition, pharmacodynamic genes encoding drug targets, and pharmacotypic genes impacting disease presentation and subtype. Among pharmacokinetic markers, CYP2D6 metabolizer phenotype has clear clinical significance, as it impacts dosing considerations for aripiprazole, iloperidone and risperidone, and variants of the ABCB1 gene hold promise as biomarkers for dosing for olanzapine and clozapine. Among pharmacodynamic variants, the TaqIA1 allele of the DRD2 gene, the DRD3 (Ser9Gly) polymorphism, and the HTR2C -759C/T polymorphism have emerged as potential biomarkers for response and/or side effects. However, large-scale candidate gene studies and genome-wide association studies indicate that pharmacotypic genes may ultimately prove to be the richest source of biomarkers for response and side effect profiles for second-generation antipsychotics.
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Affiliation(s)
- Mark D Brennan
- Department of Biochemistry & Molecular Biology, School of Medicine, University of Louisville, Louisville, KY 40292, USA.
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18
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Bergen SE. Genetic Modifiers and Subtypes in Schizophrenia. Curr Behav Neurosci Rep 2014. [DOI: 10.1007/s40473-014-0025-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Tovilla-Zárate CA, Vargas I, Hernández S, Fresán A, Aguilar A, Escamilla R, Saracco R, Palacios J, Camarena B. Association study between the MDR1 gene and clinical characteristics in schizophrenia. REVISTA BRASILEIRA DE PSIQUIATRIA 2014; 36:227-32. [DOI: 10.1590/1516-4446-2013-1270] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 12/23/2013] [Indexed: 01/23/2023]
Affiliation(s)
| | - Iván Vargas
- Instituto Nacional de Psiquiatría Ramón de la Fuente Muãiz, Mexico
| | - Sandra Hernández
- Instituto Nacional de Psiquiatría Ramón de la Fuente Muãiz, Mexico
| | - Ana Fresán
- Instituto Nacional de Psiquiatría Ramón de la Fuente Muãiz, Mexico
| | | | - Raúl Escamilla
- Instituto Nacional de Psiquiatría Ramón de la Fuente Muãiz, Mexico
| | - Ricardo Saracco
- Instituto Nacional de Psiquiatría Ramón de la Fuente Muãiz, Mexico
| | - Jorge Palacios
- Instituto Nacional de Psiquiatría Ramón de la Fuente Muãiz, Mexico
| | - Beatriz Camarena
- Instituto Nacional de Psiquiatría Ramón de la Fuente Muãiz, Mexico
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20
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Abstract
PURPOSE OF REVIEW This review outlines the positive and negative aspects of DNA testing and provides an account of the issues particularly relevant to schizophrenia. RECENT FINDINGS Modern technology has changed the field of medicine so rapidly that patients and their families have become much more independent in their healthcare decisions than in the previous decade. Simply by finding information on the Internet, they gain knowledge about disease diagnosis, treatment options and their side-effects. No medical field likely has been more affected and more controversial than that of genetics. It is now possible to sequence the individual human genome and detect single nucleotide variations, microdeletions and duplications within it. Commercial companies have sprung up in a similar manner to the software or electronic industries and have begun to market direct-to-consumer DNA testing. Much of this may be performed to satisfy curiosity about one's ancestry; but commercially available results that appear incidentally can also be distributed to the consumer. SUMMARY Ethicists, genetics researchers, clinicians and government agencies are currently in discussion about concerns raised about commercially available DNA testing, while at the same time recognizing its value in some instances to be able to predict very serious disabilities.
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