Pharmacogenetics of selective serotonin reuptake inhibitors and associated adverse drug reactions

Safety and risk assessment of psychedelic psychotherapy: A meta-analysis and systematic review

Psychotherapies assisted by psychedelic substances have shown promising results in the treatment of psychiatric disorders. The aim of this systematic review and meta-analysis was to evaluate safety data in human subjects. We carried out a search on MEDLINE, Embase and PsycINFO databases between 2000 and 2022. Standardized mean differences between different dose ranges and between acute and subacute phases were calculated for cardiovascular data after psychedelic administration. Risk differences were calculated for serious adverse events and common side effects. Thirty studies were included in this meta-analysis. There were only nine serious adverse events for over 1000 administrations of psychedelic substances (one during the acute phase and 8 during the post-acute phase). There were no suicide attempts during the acute phase and 3 participants engaged in self-harm during the post-acute phase. There was an increased risk for elevated heart rate, systolic and diastolic blood pressure for all dose range categories, as well as an increased risk of nausea during the acute phase. Other common side effects included headaches, anxiety, and decreased concentration or appetite. This meta-analysis demonstrates that psychedelics are well-tolerated, with a low risk of emerging serious adverse events in a controlled setting with appropriate inclusion criteria.

Comparative risk of Selective Serotonin Reuptake Inhibitors (SSRIs)-induced nausea among Chinese senile depression patients: A network meta-analysis of randomized-controlled trials

OBJECTIVES

To compare the therapeutic effect of 6 SSRIs among the Chinese senile depression patients. And drug-induced nausea leads to low compliance in elderly depression patients in China, it is urgent to assess the safety of 6 SSRIs with respect to induced-nausea among the Chinese senile depression patients.

METHOD

In the present study, a network of meta-analysis was conducted to assess the efficacy of 6 SSRIs among the Chinese senile depression patients, in addition, the safety of 6 SSRIs with respect to induced-nausea among the Chinese senile depression patients was also evaluated. PubMed, Embase databases, WanFang, CNKI, ChongqingWeiPu were searched for the related articles. The primary outcome of this study were the number of effective cases of SSRIs and the number of cases of nausea caused by SSRIs in Chinese elderly depressed patients. Odds ratios (ORs) and corresponding 95% confidence intervals(95%CIs) were calculated within pairwise and network meta-analysis.

RESULTS

Twenty eight trials were identified, including 2246 patients, the network meta-analysis indicated that Escitalopram was associated with a lower risk of nausea compared Paroxetine (odds ratios 0.49, 95%CI = 0.34-0.69) when they were used in Chinese elderly depressed patients. Escitalopram also exhibited distinct advantages compared other SSRIs.In terms of drug efficacy, Escitalopram was significantly superior to Paroxetine (OR = 2.26, 95%CI = 1.55-3.37).

CONCLUSION

The rank of SSRIs with respect to induced-nausea was: Combination of EP > Fluoxetine > Paroxetine > Citalopram > Sertraline > Fluvoxamine > Escitalopram, respectively.

The relationship between the serotonin 2A receptor gene -1438A/G and 102T/C polymorphisms and citalopram/sertraline-induced nausea in major depressed patients

OBJECTIVE

The aim of the present study was to determine the relationship between the polymorphisms of -1438A/G and 102T/C in the 5-HT2A receptor (HTR2A) gene and nausea/vomiting as a side effect induced by sertraline (SERT) or citalopram (CIT) in patients with major depressive disorder.

METHODS

A total of 128 patients were enrolled, 63 patients received CIT, whereas 65 patients were treated with SERT. Nausea/vomiting were assessed with the UKU Side-effects Rating Scale at baseline and at the end of the second and fourth weeks. Polymerase chain reaction-restriction fragment length polymorphism technique was employed to determine genetic differences.

RESULTS

We have found that, in the patients treated with CIT, there was a nominally significant difference in the genotypic distribution associated with -1438A/G polymorphism between patients with and without nausea (X²  = 6.15, p = 0.041). Moreover, logistic regression analysis revealed a significant association between nausea/vomiting as a side effect and -1438A/G polymorphism. That is, patients with the G allele were at a higher risk for developing nausea/vomiting (p = 0.044, odds ratio = 2.213). The 102T/C polymorphism in the HTR2A gene had no significant effect on the nausea/vomiting as a side effect among participants treated with either CIT or SERT.

CONCLUSION

The present study suggests the association of the HTR2A gene -1438A/G polymorphism with nausea/vomiting as a side effect related to CIT treatment.

Point-of-care companion diagnostic tests for personalizing psychiatric medications: fulfilling an unmet clinical need

Over the last decade stable isotope-labeled substrates have been used as probes for rapid, point-of-care, non-invasive and user-friendly phenotype breath tests to evaluate activity of drug metabolizing enzymes. These diagnostic breath tests can potentially be used as companion diagnostics by physicians to personalize medications, especially psychiatric drugs with narrow therapeutic windows, to monitor the progress of disease severity, medication efficacy and to study in vivo the pharmacokinetics of xenobiotics. Several genotype tests have been approved by the FDA over the last 15 years for both cytochrome P450 2D6 and 2C19 enzymes, however they have not been cleared for use in personalizing medications since they fall woefully short in identifying all non-responders to drugs, especially for the CYP450 enzymes. CYP2D6 and CYP2C19 are among the most extensively studied drug metabolizing enzymes, involved in the metabolism of approximately 30% of FDA-approved drugs in clinical use, associated with large individual differences in medication efficacy or tolerability essentially due to phenoconversion. The development and commercialization via FDA approval of the non-invasive, rapid (<60 min), in vivo, phenotype diagnostic breath tests to evaluate polymorphic CYP2D6 and CYP2C19 enzyme activity by measuring exhaled ¹³CO₂ as a biomarker in breath will effectively resolve the currently unmet clinical need for individualized psychiatric drug therapy. Clinicians could personalize treatment options for patients based on the CYP2D6 and CYP2C19 phenotype by selecting the optimal medication at the right initial and subsequent maintenance dose for the desired clinical outcome (i.e. greatest efficacy and minimal side effects).

Perinatal SSRI exposure permanently alters cerebral serotonin receptor mRNA in mice but does not impact adult behaviors

PURPOSE

Associations have been made between maternal selective serotonin reuptake inhibitor (SSRI) use during pregnancy and altered behavior in offspring, including an increased risk of autism. Given the important role serotonin plays in behavior, we hypothesized SSRI exposure in the perinatal period would alter central serotonin receptor expression and program adult behaviors in mice.

METHODS

Female mice were injected with sertraline or saline throughout pregnancy. Offspring continued to receive injections on postnatal days 1-14, a time period in mice similar to the third trimester in human pregnancy. Adult offspring underwent behavioral testing, and serotonin receptor mRNA levels were quantified.

RESULTS

Compared to controls, SSRI exposed mice did not have a reduction in social interactions, spatial learning, or exploratory behavior. As adults, sertraline exposed mice had significantly increased mRNA levels of multiple 5-HT receptors, serotonin transporter (5-HTT), and tryptophan hydroxylase isoform 2 in the cerebral cortex.

CONCLUSION

Although no behavioral phenotype was observed, SSRI exposure in the perinatal period permanently alters cerebral receptor mRNA levels. We speculate these shifts in mRNA expression provide important compensation during SSRI exposure. Further pre-clinical and clinical investigation into additional serotonin-regulated phenotypes is necessary to further assess the long-term implications of perinatal SSRI exposure.

Changes in depression subtypes for women during treatment with citalopram: a latent transition analysis

The aim of this study was to characterize latent subtypes of major depression and changes in these subtypes among women receiving citalopram in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. Latent transition analysis was applied to data from 755 women who completed baseline and week 12 study visits in level 1 of STAR*D. Items from the self-report version of the Quick Inventory of Depressive Symptomatology were used as indicators of latent depression subtype. Four subtypes were identified at baseline and week 12. The baseline subtypes were Mild (21 %), Moderate (30 %), Severe with Increased Appetite (16 %), and Severe with Decreased Appetite (34 %). The subtypes at week 12 were Symptom Resolution (65 %), Mild (23 %), Moderate (9 %), and Severe with Psychomotor Disturbances (3 %). Women in the Moderate subtype at baseline had the greatest chance of moving to Symptom Resolution (87 %). Women in the Severe with Decreased Appetite subtype had the lowest chance of transitioning to Symptom Resolution (46 %). Depression severity and appetite distinguished depression subtypes for women before treatment with citalopram. Depression severity and psychomotor disturbances characterized the subtypes after treatment. This work highlights the need to consider how depression treatment changes different symptoms instead of relying exclusively on summary rating scores.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov , NCT00021528.

Acute dystonia due to citalopram treatment: a case series

INTRODUCTION

Abnormal movements such as acute dystonia, dyskinesia, parkinsonism, exacerbation of Parkinson disease, akathisia and possibly neuroleptic malignant syndrome may be associated with the use of selective serotonin reuptake inhibitors (SSRIs) rarely. Citalopram, a typical SSRI, used in serotonergic dysfunction related disorders, potentially can cause extrapyramidal symptoms such as acute dystonia.

METHODS

In a retrospective survey on patients referred to psychiatric clinic between February 2010 and February 2011 who were prescribed citalopram by the psychiatrist. The data about Demographic, history of drug and alcohol abuse or dependence, diagnosis and citalopram consumption length collected. The daily dose of citalopram was also recorded. Acute dystonia was identified by a validated chart review and precise neurological examination.

RESULTS

Nine patients were included. Citalopram was initiated at a 20 mg and titrated to a mean dose of 27 mg. The median length of acute dystonia after citalopram therapy was nine days. Other common adverse events included somnolence, gastric upset and nightmare in the cases.

CONCLUSIONS

This case series was an effort to show the citalopram potential to trigger acute dystonia. Clinician needs to be aware of possible dystonia, as early recognition is necessary to prevent major adverse outcomes.

Use of translational pharmacodynamic biomarkers in early-phase clinical studies for schizophrenia

Schizophrenia is a severe mental disorder characterized by cognitive deficits, and positive and negative symptoms. The development of effective pharmacological compounds for the treatment of schizophrenia has proven challenging and costly, with many compounds failing during clinical trials. Many failures occur due to disease heterogeneity and lack of predictive preclinical models and biomarkers that readily translate to humans during early characterization of novel antipsychotic compounds. Traditional early-phase trials consist of single- or multiple-dose designs aimed at determining the safety and tolerability of an investigational compound in healthy volunteers. However, by incorporating a translational approach employing methodologies derived from preclinical studies, such as EEG measures and imaging, into the traditional Phase I program, critical information regarding a compound's dose-response effects on pharmacodynamic biomarkers can be acquired. Furthermore, combined with the use of patients with stable schizophrenia in early-phase clinical trials, significant 'de-risking' and more confident 'go/no-go' decisions are possible.

Looking beyond 5-HT(3) receptors: a review of the wider role of serotonin in the pharmacology of nausea and vomiting

The concept that 5-hydroxytryptamine (5-HT; serotonin) is involved in the emetic reflex was revealed using drugs that interfere with its synthesis, storage, release and metabolism ahead of the discovery of selective tools to modulate specific subtypes of receptors. This review comprehensively examines the fundamental role of serotonin in emesis control and highlights data indicating association of 5-HT1-4 receptors in the emetic reflex, whilst leaving open the possibility that 5-HT5-7 receptors may also be involved. The fact that each receptor subtype may mediate both emetic and anti-emetic effects is discussed in detail for the first time. These discussions are made in light of known species differences in emesis control, which has sometimes affected the perception of the translational value of data in regard to the development of novel anti-emetic for use in man.

Personalized medicine in Alzheimer's disease and depression

Latest research in the mental health field brings new hope to patients and promises to revolutionize the field of psychiatry. Personalized pharmacogenetic tests that aid in diagnosis and treatment choice are now becoming available for clinical practice. Amyloid beta peptide biomarkers in the cerebrospinal fluid of patients with Alzheimer's disease are now available. For the first time, radiologists are able to visualize amyloid plaques specific to Alzheimer's disease in live patients using Positron Emission Tomography-based tests approved by the FDA. A novel blood-based assay has been developed to aid in the diagnosis of depression based on activation of the HPA axis, metabolic, inflammatory and neurochemical pathways. Serotonin reuptake inhibitors have shown increased remission rates in specific ethnic subgroups and Cytochrome P450 gene polymorphisms can predict antidepressant tolerability. The latest research will help to eradicate "trial and error" prescription, ushering in the most personalized medicine to date. Like all major medical breakthroughs, integration of new algorithms and technologies requires sound science and time. But for many mentally ill patients, diagnosis and effective therapy cannot happen fast enough. This review will describe the newest diagnostic tests, treatments and clinical studies for the diagnosis and treatment of Alzheimer's disease and unipolar, major depressive disorder.

Genome-wide association study of SSRI/SNRI-induced sexual dysfunction in a Japanese cohort with major depression

Sexual dysfunction is a major side effect of selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs). We conducted a genome-wide association study to identify the genetic factors contributing to the risk of SSRI/SNRI-induced sexual dysfunction by testing 186 320 single nucleotide polymorphism (SNP) markers in a cohort of 201 Japanese major depression patients including 36 with sexual dysfunction induced by SSRI (paroxetine or fluvoxamine) or SNRI (milnacipran). The Cochran-Armitage trend test showed that 11 SNPs, tightly clustered in a distinct region on chromosome 14q21.3, were associated with SSRI/SNRI-induced sexual dysfunction at a genome-wide significance level after false discovery rate (FDR) correction, and the strongest SNP association was with rs1160351 (P=3.04 × 10(-7), risk ratio=2.92, 95% confidence interval (CI)=1.79-4.76). These SNPs mapped to the intronic region of the MDGA2 gene. A Manhattan plot showed that the strong association peak remained in MDGA2 after adjustment for sex and age in a multivariable logistic regression analysis although P values increased slightly and became non-significant. Replication studies with larger sample sizes are required to validate this exploratory study, but our findings may provide insights into the genetic basis of sexual dysfunction induced by SSRI/SNRI.

Serotonin as a homeostatic regulator of lactation

Serotonin (5-HT), a neurotransmitter produced in mammary epithelial cells (MECs), acts via autocrine-paracrine mechanisms on MECs to regulate milk secretion in a variety of species. Recent studies in dairy cows reported that 5-HT ligands affect milk yield and composition. We determined the mRNA expression of bovine 5-HT receptor (5-HTR) subtypes in bovine mammary tissue (BMT) and cultured bovine MECs. We then used pharmacologic agents to evaluate functional activities of 5-HTR subtypes. The mRNAs for five receptor isoforms (5-HTR1B, 5-HTR2A, 5-HTR2B, 5-HTR4, and 5-HTR7) were identified by conventional reverse transcription PCR, real-time PCR, and in situ hybridization in BMT. In addition to luminal MEC expression, 5-HTR4 was expressed in myoepithelium, and 5-HTR1B, HTR2A, and HTR2B were expressed in small mammary blood vessels. Studies to date report that there are multiple 5-HTR isoforms in mammary tissue of rodents, humans, and cattle. Inhibition of the 5-HT reuptake transporter with selective 5-HT reuptake inhibitors (SSRIs) disrupted tight junctions and decreased milk protein mRNA expression in mouse, human, and bovine mammary cells. Selective 5-HT reuptake inhibitors act to increase the cellular exposure to 5-HT by preventing reuptake of 5-HT by the cell and eventual degradation. Increasing 5-HT concentration in milk via inhibiting its reuptake (SSRI), or by increasing the precursor for 5-HT synthesis 5-hydroxytryptophan, accelerated decline in milk synthesis at dry-off. We conclude that the 5-HT system in mammary tissue acts as a homeostatic regulator of lactation.

Antidepressants, metoprolol and the risk of bradycardia

Case reports and pharmacologic theory suggest that some antidepressants can interfere with the hepatic metabolism of metoprolol by cytochrome P450 2D6 (CYP2D6), potentially increasing the risk of bradycardia. The objective of this study was to characterize the clinical consequences of this potential drug interaction at the population level. We conducted a population-based, nested case-control study of Ontario residents 66 years of age or older receiving metoprolol. Cases hospitalized for bradycardia were compared with matched controls (4:1) to explore the odds ratio for initiation of antidepressants that inhibit CYP2D6 (fluoxetine and paroxetine) and those that do not inhibit CYP2D6 (fluvoxamine, citalopram, venlafaxine, and sertraline) 30 days before hospitalization. From April 1997 to March 2009, we identified 332,254 older patients continuously receiving metoprolol, of whom 8232 (2.5%) were treated in hospital for bradycardia. The adjusted odds ratio for exposure to fluoxetine or paroxetine compared with other antidepressants 30 days prior to hospitalization for bradycardia was 0.76 (95% confidence interval 0.42-1.37). Among older patients receiving metoprolol, the initiation of antidepressants that inhibit CYP2D6 was not associated with a significant increase in the risk of bradycardia compared with antidepressants that do not inhibit CYP2D6.

Understanding the molecular pharmacology of the serotonergic system: using fluoxetine as a model

OBJECTIVES

Serotonin is a monoamine neurotransmitter that is widely distributed in the body and plays an important role in a variety of psychological and other body functions such as mood, sexual desire and function, appetite, sleep, memory and learning, temperature regulation and social behaviour. This review will assess the use of fluoxetine, one of the most commonly used selective serotonin reuptake inhibitors, as a model for understanding the molecular pharmacology of the serotoninergic system.

KEY FINDINGS

Seven serotonin receptor families have been discovered to date. All serotonin receptors, except 5-HT(3), are G-protein coupled, seven transmembrane receptors that activate an intracellular second messenger cascade. The 5-HT(3) receptor is a ligand-gated ion channel. Furthermore, 5-HT(1A) receptors are known as autoreceptors since their stimulation inhibits the release serotonin in nerve terminals. A transporter protein found in the plasma membrane of serotonergic neurones is responsible for the reuptake of this neurotransmitter. Selective serotonin reuptake inhibitors, such as fluoxetine, act primarily at the serotonin transporter protein and have limited, if any, reaction with other neurotransmitter systems. Selective serotonin reuptake inhibitors appear to bind with the serotonin transporter with different rates of occupancy, duration and potency.

SUMMARY

The following review focuses on the interaction of serotonin with this membrane transporter in the body and assesses the use of fluoxetine as a reference drug in the understanding of this interaction.

A consensus statement for safety monitoring guidelines of treatments for major depressive disorder

OBJECTIVE

This paper aims to present an overview of screening and safety considerations for the treatment of clinical depressive disorders and make recommendations for safety monitoring.

METHOD

Data were sourced by a literature search using MEDLINE and a manual search of scientific journals to identify relevant articles. Draft guidelines were prepared and serially revised in an iterative manner until all co-authors gave final approval of content.

RESULTS

Screening and monitoring can detect medical causes of depression. Specific adverse effects associated with antidepressant treatments may be reduced or identified earlier by baseline screening and agent-specific monitoring after commencing treatment.

CONCLUSION

The adoption of safety monitoring guidelines when treating clinical depression is likely to improve overall physical health status and treatment outcome. It is important to implement these guidelines in the routine management of clinical depression.

Long-term outcome following selective serotonin reuptake inhibitor induced neonatal abstinence syndrome

OBJECTIVE

To assess the long-term neurodevelopment of children exposed in utero to selective serotonin reuptake inhibitors (SSRIs) that developed a neonatal abstinence syndrome (NAS).

STUDY DESIGN

Neurodevelopmental evaluation was performed at the age of 2 to 6 years. Children who developed NAS were compared with those who did not using univariate and logistic regression analyses.

RESULT

Thirty children with NAS and 52 without NAS participated in the study. Both groups were similar in mean cognitive ability (106.9±14.0 vs 100.5±14.6, P=0.12) and developmental scores (98.9±11.4 vs 95.7±9.9, P=0.21). However, there was a trend towards small head circumference in the NAS group (20 vs 6%, P=0.068). NAS was associated with an increased risk of social-behavior abnormalities (odds ratio (OR) 3.03, 95% confidence interval (CI) 1.07 to 8.60, P=0.04) and advanced maternal age (OR 1.12, 95% CI 1.00 to 1.25, P=0.04).

CONCLUSION

Infants who developed NAS had normal cognitive ability, but were at an increased risk for social-behavioral abnormalities. Follow-up evaluation of symptomatic neonates should be considered.

Pharmacogenetics and personal genomes

While pharmacogenetics - the correlation of genotype and response to medicines - currently has a small but measurable impact on the prescribing practice of clinicians, the advent of the ;personal genome' is likely to change this significantly. Advances in high-throughput technologies aimed at characterizing human genetic variation, including chip-based genotyping and next-generation sequencing, are poised to provide a flood of information that will affect both pharmacogenetic discovery and pharmacogenetic application in clinical practice. In order for this flood of information to not overwhelm both researchers and clinicians alike, a variety of new and expanded information management tools will be needed, including electronic medical records, bioinformatic algorithms for analyzing sequence data, information management systems for storing, retrieving and interpreting whole-genome sequence data, and pharmacogenetic decision tools for prescribers.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly.