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Single-Nucleotide Polymorphisms as Biomarkers of Antipsychotic-Induced Akathisia: Systematic Review. Genes (Basel) 2023; 14:genes14030616. [PMID: 36980888 PMCID: PMC10048266 DOI: 10.3390/genes14030616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/05/2023] Open
Abstract
Antipsychotic-induced akathisia (AIA) is a movement disorder characterized by a subjective feeling of inner restlessness or nervousness with an irresistible urge to move, resulting in repetitive movements of the limbs and torso, while taking antipsychotics (APs). In recent years, there have been some associative genetic studies of the predisposition to the development of AIA. Objective: The goal of our study was to review the results of associative genetic and genome-wide studies and to systematize and update the knowledge on the genetic predictors of AIA in patients with schizophrenia (Sch). Methods: We searched full-text publications in PubMed, Web of Science, Springer, Google Scholar, and e-Library databases from 1977 to 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) quality scale was used for the critical selection of the studies. Results: We identified 37 articles, of which 3 were included in the review. Thus, the C allele of rs1800498 (59414 C>T) and the A allele of rs1800497 (17316 G>A) (TaqIA) from the DRD2 gene as well as the TT genotype rs13212041 (77461407 C>T) from the HTR1B gene were found to be associated with AIA. Conclusions: Uncovering the genetic biomarkers of AIA may provide a key to developing a strategy for the personalized prevention and treatment of this adverse neurological drug reaction of APs in patients with Sch in real clinical practice.
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Wang S, Cai X, Liu S, Zhou Q, Wang T, Du S, Wang D, Yang F, Wu Q, Han Y. A novel BCL11A polymorphism influences gene expression, therapeutic response and epilepsy risk: A multicenter study. Front Mol Neurosci 2022; 15:1010101. [PMID: 36568279 PMCID: PMC9780294 DOI: 10.3389/fnmol.2022.1010101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022] Open
Abstract
Background Genetic factors have been found to be associated with the efficacy and adverse reactions of antiseizure medications. BCL11A is an important regulator of the development of neuronal networks. However, the role of BCL11A in epilepsy remains unclear. This study aimed to evaluate the genetic association of BCL11A with the susceptibility to develop epileptic seizures and therapeutic response of patients with epilepsy in Han Chinese. Methods We matched 450 epilepsy cases with 550 healthy controls and 131 drug-resistant epilepsy patients with 319 drug-responsive epilepsy patients from two different centers. Genetic association analysis, genetic interaction analysis, expression quantitative trait loci analysis and protein-protein interaction analysis were conducted. Results Our results showed that rs2556375 not only increases susceptibility to develop epileptic seizures (OR = 2.700, 95% = 1.366-5.338, p = 0.004 and OR = 2.984, 95% = 1.401-6.356, p = 0.005, respectively), but also increases the risk of drug resistance(OR = 21.336, 95%CI =2.489-183.402, p = 0.005). The interaction between rs2556375 and rs12477097 results in increased risk for pharma coresistant. In addition, rs2556375 regulated BCL11A expression in human brain tissues (p = 0.0096 and p = 0.033, respectively). Furthermore, the protein encoded by BCL11A interacted with targets of approved antiepileptic drugs. Conclusion BCL11A may be a potential therapeutic target for epilepsy. Rs2556375 may increase the risks of epilepsy and drug resistance by regulating BCL11A expression in human brain tissues. Moreover, the interaction between rs2556375 and rs12477097 results in increased risk for drug resistance.
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Affiliation(s)
- Shitao Wang
- Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, China,Department of Neurology, Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang, China
| | - Xuemei Cai
- Department of Clinical Laboratory, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shiyong Liu
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Qixin Zhou
- Laboratory of Learning and Memory, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, China
| | - Ting Wang
- Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Sunbing Du
- Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Dan Wang
- Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Fei Yang
- Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Qian Wu
- Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yanbing Han
- Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, China,*Correspondence: Yanbing Han,
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The Gender-Specific Association of DRD2 Polymorphism with Metabolic Syndrome in Patients with Schizophrenia. Genes (Basel) 2022; 13:genes13081312. [PMID: 35893053 PMCID: PMC9331510 DOI: 10.3390/genes13081312] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/13/2022] [Accepted: 07/20/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Metabolic syndrome is widespread in patients with schizophrenia receiving long-term antipsychotic therapy. Dopamine D2 receptors play an important role in mediating both the therapeutic actions of antipsychotics and their side effects. The present study examined the association of two polymorphisms of the DRD2 gene with metabolic syndrome in patients with schizophrenia. Methods: We examined 517 patients from several regions of Siberia (Russia) with a clinical diagnosis of schizophrenia. Genotyping of two single nucleotide polymorphisms rs1799732 and rs4436578 of the dopamine D2 receptor gene (DRD2) was performed in a population of 471 patients. The results were analyzed using chi-square tests. Results: Functional polymorphism rs1799732 of the DRD2 gene is associated with drug-induced metabolic syndrome in women with schizophrenia. Conclusions: Our results show that the DRD2 gene may be involved in the pathogenesis of metabolic disorders in patients with schizophrenia. Further analysis of possible genetic markers will allow for personalized treatment with minimal side effects and optimal efficacy. This which seems relevant in light of the recent focus on improving the quality of life and ensuring a high level of social adaptation of patients with schizophrenia.
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Fedorenko OY, Paderina DZ, Kornetova EG, Poltavskaya EG, Pozhidaev IV, Goncharova AA, Freidin MB, Bocharova AV, Bokhan NA, Loonen AJM, Ivanova SA. Genes of the Glutamatergic System and Tardive Dyskinesia in Patients with Schizophrenia. Diagnostics (Basel) 2022; 12:diagnostics12071521. [PMID: 35885427 PMCID: PMC9322868 DOI: 10.3390/diagnostics12071521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Tardive dyskinesia (TD) is an extrapyramidal side effect of the long-term use of antipsychotics. In the present study, the role of glutamatergic system genes in the pathogenesis of total TD, as well as two phenotypic forms, orofacial TD and limb-truncal TD, was studied. Methods: A set of 46 SNPs of the glutamatergic system genes (GRIN2A, GRIN2B, GRIK4, GRM3, GRM7, GRM8, SLC1A2, SLC1A3, SLC17A7) was studied in a population of 704 Caucasian patients with schizophrenia. Genotyping was performed using the MassARRAY Analyzer 4 (Agena Bioscience™). Logistic regression analysis was performed to test for the association of TD with the SNPs while adjusting for confounders. Results: No statistically significant associations between the SNPs and TD were found after adjusting for multiple testing. Since three SNPs of the SLC1A2 gene demonstrated nominally significant associations, we carried out a haplotype analysis for these SNPs. This analysis identified a risk haplotype for TD comprising CAT alleles of the SLC1A2 gene SNPs rs1042113, rs10768121, and rs12361171. Nominally significant associations were identified for SLC1A3 rs2229894 and orofacial TD, as well as for GRIN2A rs7192557 and limb-truncal TD. Conclusions: Genes encoding for mGlu3, EAAT2, and EAAT1 may be involved in the development of TD in schizophrenia patients.
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Affiliation(s)
- Olga Yu. Fedorenko
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (O.Y.F.); (D.Z.P.); (E.G.K.); (E.G.P.); (I.V.P.); (A.A.G.); (N.A.B.); (S.A.I.)
| | - Diana Z. Paderina
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (O.Y.F.); (D.Z.P.); (E.G.K.); (E.G.P.); (I.V.P.); (A.A.G.); (N.A.B.); (S.A.I.)
| | - Elena G. Kornetova
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (O.Y.F.); (D.Z.P.); (E.G.K.); (E.G.P.); (I.V.P.); (A.A.G.); (N.A.B.); (S.A.I.)
- Department of Psychiatry, Addictology and Psychotherapy, Siberian State Medical University, 634050 Tomsk, Russia
| | - Evgeniya G. Poltavskaya
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (O.Y.F.); (D.Z.P.); (E.G.K.); (E.G.P.); (I.V.P.); (A.A.G.); (N.A.B.); (S.A.I.)
| | - Ivan V. Pozhidaev
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (O.Y.F.); (D.Z.P.); (E.G.K.); (E.G.P.); (I.V.P.); (A.A.G.); (N.A.B.); (S.A.I.)
| | - Anastasiia A. Goncharova
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (O.Y.F.); (D.Z.P.); (E.G.K.); (E.G.P.); (I.V.P.); (A.A.G.); (N.A.B.); (S.A.I.)
| | - Maxim B. Freidin
- Research Institute of Medical Genetics, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634050 Tomsk, Russia; (M.B.F.); (A.V.B.)
- School of Biological and Behavioural Sciences, Queen Mary University of London, London E1 4NS, UK
| | - Anna V. Bocharova
- Research Institute of Medical Genetics, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634050 Tomsk, Russia; (M.B.F.); (A.V.B.)
| | - Nikolay A. Bokhan
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (O.Y.F.); (D.Z.P.); (E.G.K.); (E.G.P.); (I.V.P.); (A.A.G.); (N.A.B.); (S.A.I.)
- Department of Psychiatry, Addictology and Psychotherapy, Siberian State Medical University, 634050 Tomsk, Russia
| | - Anton J. M. Loonen
- Unit of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, University of Groningen, 9713 AV Groningen, The Netherlands
- Correspondence:
| | - Svetlana A. Ivanova
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (O.Y.F.); (D.Z.P.); (E.G.K.); (E.G.P.); (I.V.P.); (A.A.G.); (N.A.B.); (S.A.I.)
- Department of Psychiatry, Addictology and Psychotherapy, Siberian State Medical University, 634050 Tomsk, Russia
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Tsermpini EE, Redenšek S, Dolžan V. Genetic Factors Associated With Tardive Dyskinesia: From Pre-clinical Models to Clinical Studies. Front Pharmacol 2022; 12:834129. [PMID: 35140610 PMCID: PMC8819690 DOI: 10.3389/fphar.2021.834129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/31/2021] [Indexed: 01/14/2023] Open
Abstract
Tardive dyskinesia is a severe motor adverse event of antipsychotic medication, characterized by involuntary athetoid movements of the trunk, limbs, and/or orofacial areas. It affects two to ten patients under long-term administration of antipsychotics that do not subside for years even after the drug is stopped. Dopamine, serotonin, cannabinoid receptors, oxidative stress, plasticity factors, signaling cascades, as well as CYP isoenzymes and transporters have been associated with tardive dyskinesia (TD) occurrence in terms of genetic variability and metabolic capacity. Besides the factors related to the drug and the dose and patients’ clinical characteristics, a very crucial variable of TD development is individual susceptibility and genetic predisposition. This review summarizes the studies in experimental animal models and clinical studies focusing on the impact of genetic variations on TD occurrence. We identified eight genes emerging from preclinical findings that also reached statistical significance in at least one clinical study. The results of clinical studies are often conflicting and non-conclusive enough to support implementation in clinical practice.
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Paderina DZ, Boiko AS, Pozhidaev IV, Bocharova AV, Mednova IA, Fedorenko OY, Kornetova EG, Loonen AJ, Semke AV, Bokhan NA, Ivanova SA. Genetic Polymorphisms of 5-HT Receptors and Antipsychotic-Induced Metabolic Dysfunction in Patients with Schizophrenia. J Pers Med 2021; 11:jpm11030181. [PMID: 33807811 PMCID: PMC7999828 DOI: 10.3390/jpm11030181] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Antipsychotic-induced metabolic syndrome (MetS) is a multifactorial disease with a genetic predisposition. Serotonin and its receptors are involved in antipsychotic-drug-induced metabolic disorders. The present study investigated the association of nine polymorphisms in the four 5-hydroxytryptamine receptor (HTR) genes HTR1A, HTR2A, HTR3A, and HTR2C and the gene encoding for the serotonin transporter SLC6A4 with MetS in patients with schizophrenia. METHODS A set of nine single-nucleotide polymorphisms of genes of the serotonergic system was investigated in a population of 475 patients from several Siberian regions (Russia) with a clinical diagnosis of schizophrenia. Genotyping was performed and the results were analyzed using chi-square tests. RESULTS Polymorphic variant rs521018 (HTR2C) was associated with higher body mass index in patients receiving long-term antipsychotic therapy, but not with drug-induced metabolic syndrome. Rs1150226 (HTR3A) was also associated but did not meet Hardy-Weinberg equilibrium. CONCLUSIONS Our results indicate that allelic variants of HTR2C genes may have consequences on metabolic parameters. MetS may have too complex a mechanistic background to be studied without dissecting the syndrome into its individual (causal) components.
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Affiliation(s)
- Diana Z. Paderina
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (D.Z.P.); (A.S.B.); (I.V.P.); (I.A.M.); (O.Y.F.); (E.G.K.); (A.V.S.); (N.A.B.); (S.A.I.)
| | - Anastasiia S. Boiko
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (D.Z.P.); (A.S.B.); (I.V.P.); (I.A.M.); (O.Y.F.); (E.G.K.); (A.V.S.); (N.A.B.); (S.A.I.)
| | - Ivan V. Pozhidaev
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (D.Z.P.); (A.S.B.); (I.V.P.); (I.A.M.); (O.Y.F.); (E.G.K.); (A.V.S.); (N.A.B.); (S.A.I.)
| | - Anna V. Bocharova
- Research Institute of Medical Genetics, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634050 Tomsk, Russia;
| | - Irina A. Mednova
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (D.Z.P.); (A.S.B.); (I.V.P.); (I.A.M.); (O.Y.F.); (E.G.K.); (A.V.S.); (N.A.B.); (S.A.I.)
| | - Olga Yu. Fedorenko
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (D.Z.P.); (A.S.B.); (I.V.P.); (I.A.M.); (O.Y.F.); (E.G.K.); (A.V.S.); (N.A.B.); (S.A.I.)
| | - Elena G. Kornetova
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (D.Z.P.); (A.S.B.); (I.V.P.); (I.A.M.); (O.Y.F.); (E.G.K.); (A.V.S.); (N.A.B.); (S.A.I.)
- Siberian State Medical University, 634050 Tomsk, Russia
| | - Anton J.M. Loonen
- Unit of PharmacoTherapy, -Epidemiology & -Economics, Groningen Research Institute of Pharmacy, University of Groningen, 9713AV Groningen, The Netherlands
- Correspondence:
| | - Arkadiy V. Semke
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (D.Z.P.); (A.S.B.); (I.V.P.); (I.A.M.); (O.Y.F.); (E.G.K.); (A.V.S.); (N.A.B.); (S.A.I.)
| | - Nikolay A. Bokhan
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (D.Z.P.); (A.S.B.); (I.V.P.); (I.A.M.); (O.Y.F.); (E.G.K.); (A.V.S.); (N.A.B.); (S.A.I.)
- Siberian State Medical University, 634050 Tomsk, Russia
| | - Svetlana A. Ivanova
- Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, 634014 Tomsk, Russia; (D.Z.P.); (A.S.B.); (I.V.P.); (I.A.M.); (O.Y.F.); (E.G.K.); (A.V.S.); (N.A.B.); (S.A.I.)
- Siberian State Medical University, 634050 Tomsk, Russia
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Forster J, Duis J, Butler MG. Pharmacodynamic Gene Testing in Prader-Willi Syndrome. Front Genet 2020; 11:579609. [PMID: 33329716 PMCID: PMC7715001 DOI: 10.3389/fgene.2020.579609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/20/2020] [Indexed: 01/14/2023] Open
Abstract
Prader-Willi syndrome (PWS) is a rare genetic disorder with a complex neurobehavioral phenotype associated with considerable psychiatric co-morbidity. This clinical case series, for the first time, describes the distribution and frequency of polymorphisms of pharmacodynamic genes (serotonin transporter, serotonin 2A and 2C receptors, catechol-o-methyltransferase, adrenergic receptor 2A, methylene tetrahydrofolate reductase, and human leucocytic antigens) across the two major molecular classes of PWS in a cohort of 33 referred patients who met medical criteria for testing. When results were pooled across PWS genetic subtypes, genotypic and allelic frequencies did not differ from normative population data. However, when the genetic subtype of PWS was examined, there were differences observed across all genes tested that may affect response to psychotropic medication. Due to small sample size, no statistical significance was found, but results suggest that pharmacodynamic gene testing should be considered before initiating pharmacotherapy in PWS. Larger scale studies are warranted.
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Affiliation(s)
| | - Jessica Duis
- Section of Genetics and Inherited Metabolic Disease, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Merlin G Butler
- Division of Research and Genetics, Department of Psychiatry and Behavioral Sciences and Pediatrics, University of Kansas Medical Center, Kansas City, KS, United States
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Arranz MJ, Salazar J, Hernández MH. Pharmacogenetics of antipsychotics: Clinical utility and implementation. Behav Brain Res 2020; 401:113058. [PMID: 33316324 DOI: 10.1016/j.bbr.2020.113058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/23/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023]
Abstract
Decades of research have produced extensive evidence of the contribution of genetic factors to the efficacy and toxicity of antipsychotics. Numerous genetic variants in genes controlling drug availability or involved in antipsychotic processes have been linked to treatment variability. The complex mechanism of action and multitarget profile of most antipsychotic drugs hinder the identification of pharmacogenetic markers of clinical value. Nevertheless, the validity of associations between variants in CYP1A2, CYP2D6, CYP2C19, ABCB1, DRD2, DRD3, HTR2A, HTR2C, BDNF, COMT, MC4R genes and antipsychotic response has been confirmed in independent candidate gene studies. Genome wide pharmacogenomic studies have proven the role of the glutamatergic pathway in mediating antipsychotic activity and have reported novel associations with antipsychotic response. However, only a limited number of the findings, mainly functional variants of CYP metabolic enzymes, have been shown to be of clinical utility and translated into useful pharmacogenetic markers. Based on the currently available information, actionable pharmacogenetics should be reduced to antipsychotics' dose adjustment according to the genetically predicted metabolic status (CYPs' profile) of the patient. Growing evidence suggests that such interventions will reduce antipsychotics' side-effects and increase treatment safety. Despite this evidence, the use of pharmacogenetics in psychiatric wards is minimal. Hopefully, further evidence on the clinical and economic benefits, the development of clinical protocols based on pharmacogenetic information, and improved and cheaper genetic testing will increase the implementation of pharmacogenetic guided prescription in clinical settings.
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Affiliation(s)
- Maria J Arranz
- Fundació Docència i Recerca Mútua Terrassa, Spain; Centro de investigación en Red de Salud Mental, CIBERSAM, Madrid, Spain; PHAGEX Research Group, Universitat Ramon LLull, Spain.
| | - Juliana Salazar
- Translational Medical Oncology Laboratory, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona, Spain; U705, ISCIII Center for Biomedical Research on Rare Diseases (CIBERER), Barcelona, Spain; PHAGEX Research Group, Universitat Ramon LLull, Spain
| | - Marta H Hernández
- PHAGEX Research Group, Universitat Ramon LLull, Spain; School of Health Sciences Blanquerna. University Ramon Llull, Barcelona, Spain
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