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Lense XM, Hiemke C, Funk CSM, Havemann-Reinecke U, Hefner G, Menke A, Mössner R, Riemer TG, Scherf-Clavel M, Schoretsanitis G, Gründer G, Hart XM. Venlafaxine's therapeutic reference range in the treatment of depression revised: a systematic review and meta-analysis. Psychopharmacology (Berl) 2024; 241:275-289. [PMID: 37857898 PMCID: PMC10806172 DOI: 10.1007/s00213-023-06484-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION The selective serotonin and norepinephrine reuptake inhibitor venlafaxine is among the most prescribed antidepressant drugs worldwide and, according to guidelines, its dose titration should be guided by drug-level monitoring of its active moiety (AM) which consists of venlafaxine (VEN) plus active metabolite O-desmethylvenlafaxine (ODV). This indication of therapeutic drug monitoring (TDM), however, assumes a clear concentration/effect relationship for a drug, which for VEN has not been systematically explored yet. OBJECTIVES We performed a systematic review and meta-analysis to investigate the relationship between blood levels, efficacy, and adverse reactions in order to suggest an optimal target concentration range for VEN oral formulations for the treatment of depression. METHODS Four databases (MEDLINE (PubMed), PsycINFO, Web of Science Core Collection, and Cochrane Library) were systematically searched in March 2022 for relevant articles according to a previously published protocol. Reviewers independently screened references and performed data extraction and critical appraisal. RESULTS High-quality randomized controlled trials investigating concentration/efficacy relationships and studies using a placebo lead-in phase were not found. Sixty-eight articles, consisting mostly of naturalistic TDM studies or small noncontrolled studies, met the eligibility criteria. Of them, five cohort studies reported a positive correlation between blood levels and antidepressant effects after VEN treatment. Our meta-analyses showed (i) higher AM and (ii) higher ODV concentrations in patients responding to VEN treatment when compared to non-responders (n = 360, k = 5). AM concentration-dependent occurrence of tremor was reported in one study. We found a linear relationship between daily dose and AM concentration within guideline recommended doses (75-225 mg/day). The population-based concentration ranges (25-75% interquartile) among 11 studies (n = 3200) using flexible dosing were (i) 225-450 ng/ml for the AM and (ii) 144-302 ng/ml for ODV. One PET study reported an occupancy of 80% serotonin transporters for ODV serum levels above 85 ng/ml. Based on our findings, we propose a therapeutic reference range for AM of 140-600 ng/ml. CONCLUSION VEN TDM within a range of 140 to 600 ng/ml (AM) will increase the probability of response in nonresponders. A titration within the proposed reference range is recommended in case of non-response at lower drug concentrations as a consequence of VEN's dual mechanism of action via combined serotonin and norepinephrine reuptake inhibition. Drug titration towards higher concentrations will, however, increase the risk for ADRs, in particular with supratherapeutic drug concentrations.
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Affiliation(s)
- X M Lense
- Department of Molecular Neuroimaging, Medical Faculty Mannheim, Central Institute of Mental Health, University of Heidelberg, Heidelberg 68159 University J5, Mannheim, Germany.
| | - C Hiemke
- Clinic of Psychiatry and Psychotherapy, University of Mainz, Mainz, Germany
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP), Working Group "Therapeutic Drug Monitoring", Munich, Germany
| | - C S M Funk
- Institute of Clinical Pharmacology and Toxicology, Charité University, Berlin, Germany
| | - U Havemann-Reinecke
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP), Working Group "Therapeutic Drug Monitoring", Munich, Germany
- Clinic of Psychiatry and Psychotherapy, University of Göttingen, Göttingen, Germany
| | - G Hefner
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP), Working Group "Therapeutic Drug Monitoring", Munich, Germany
- Vitos Clinic of Forensic Psychiatry, Eltville, Germany
| | - A Menke
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP), Working Group "Therapeutic Drug Monitoring", Munich, Germany
- Psychosomatic Clinic Medical Park Chiemseeblick, Bernau a. Chiemsee, Germany
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - R Mössner
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP), Working Group "Therapeutic Drug Monitoring", Munich, Germany
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany
| | - T G Riemer
- Institute of Clinical Pharmacology and Toxicology, Charité University, Berlin, Germany
| | - M Scherf-Clavel
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP), Working Group "Therapeutic Drug Monitoring", Munich, Germany
- Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany
| | - G Schoretsanitis
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP), Working Group "Therapeutic Drug Monitoring", Munich, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Zürich, Zürich, Switzerland
| | - G Gründer
- Department of Molecular Neuroimaging, Medical Faculty Mannheim, Central Institute of Mental Health, University of Heidelberg, Heidelberg 68159 University J5, Mannheim, Germany
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP), Working Group "Therapeutic Drug Monitoring", Munich, Germany
| | - X M Hart
- Department of Molecular Neuroimaging, Medical Faculty Mannheim, Central Institute of Mental Health, University of Heidelberg, Heidelberg 68159 University J5, Mannheim, Germany
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP), Working Group "Therapeutic Drug Monitoring", Munich, Germany
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Hefner G, Wolff J, Toto S, Reißner P, Klimke A. Off-label use of antidepressants, antipsychotics, and mood-stabilizers in psychiatry. J Neural Transm (Vienna) 2022; 129:1353-1365. [PMID: 36070009 DOI: 10.1007/s00702-022-02542-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
Off-label drug prescribing in psychiatry is increasing. Many psychotropic drugs are approved for psychopathologic syndromes rather than based on international standard diagnostic classification systems which might facilitate the clinical decision for off-label prescriptions. The objective of this study was to analyze the prevalence and category of off-label use of psychotropic drugs. The study was conducted in 10 psychiatric hospitals in Germany over a period of 2 years. Prescription data of all patients were retrospectively analyzed after identification of antidepressants, antipsychotics, and mood-stabilizers, which were classified as off-label according to the German prescribing information and diagnostic classification according to ICD-10. In total, 53,909 patient cases (46% female) with a mean age of 46.8 (SD: 18) years were included in the study. 30.2% of the cases received at least one off-label prescription of a psychotropic drug during hospital stay. Off-label prevalence rates differed markedly between different diagnostic groups (ICD-10 F0/G3: 47%, F1: 33%, F2: 25%, F3: 21%, F4: 27%, F6: 46%, F7: 84%). The most often off-label prescribed drugs were quetiapine and mirtazapine for organic mental disorders (F0/G3), valproate and quetiapine in patients with disorders due to psychoactive substance use (F1), valproate in patients with psychotic disorders (F2), and risperidone and olanzapine in patients with affective disorders (F3). The prevalence rate of psychotropic off-label prescriptions is high if restricted to product description and ICD-10 diagnosis. Therefore, current psychiatric guidelines should drug-specifically issue this problem by defining psychiatric off-label indications based on a clear benefit-risk assessment.
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Affiliation(s)
- Gudrun Hefner
- Psychiatric Hospital, Vitos Clinic for Forensic Psychiatry, Kloster-Eberbach-Straße 4, 65346, Eltville, Germany.
| | - Jan Wolff
- Peter L. Reichertz Institute for Medical Informatics, Hannover Medical School, Hannover, Germany
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Pamela Reißner
- Department of Psychiatry and Psychotherapy, Vitos Klinikum Hochtaunus, Friedrichsdorf, Germany
| | - Ansgar Klimke
- Department of Psychiatry and Psychotherapy, Vitos Klinikum Hochtaunus, Friedrichsdorf, Germany.,Heinrich-Heine-University, Duesseldorf, Germany
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Lense X, Gründer G, Havemann-Reinecke U, Hefner G, Menke A, Mössner R, Scherf-Clavel M, Schoretsanitis G, Hiemke C, Hart X. Is it Time to Reevaluate the Therapeutic Reference Range for the
Antidepressant Drug Venlafaxine? PHARMACOPSYCHIATRY 2022. [DOI: 10.1055/s-0042-1747655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- X.M. Lense
- Central Institute of Mental Health Mannheim, Department of Molecular
Neuroimaging
| | - G. Gründer
- Central Institute of Mental Health Mannheim, Department of Molecular
Neuroimaging
| | | | - G. Hefner
- Vitos Clinic of Forensic Psychiatry, Eltville
| | - A. Menke
- Department of Psychosomatics Medical Park Chiemseeblick, Bernau a.
Chiemsee
| | - R. Mössner
- University of Tübingen, Department of Psychiatry und
Psychotherapy
| | - M. Scherf-Clavel
- University of Würzburg, Department of Psychiatry,
Psychosomatics and Psychotherapy
| | - G. Schoretsanitis
- University of Zurich, Department of Psychiatry, Psychotherapy and
Psychosomatics, Zurich, Switzerland
| | - C. Hiemke
- University of Mainz, Department of Psychiatry and
Psychotherapy
| | - X.M. Hart
- Central Institute of Mental Health Mannheim, Department of Molecular
Neuroimaging
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Eichentopf L, Hiemke C, Conca A, Engelmann J, Gerlach M, Havemann-Reinecke U, Hefner G, Florio V, Kuzin M, Lieb K, Reis M, Riemer T, Seretti A, Schoretsanitis G, Zernig G, Gründer G, Hart XM. Escitalopram: Drug monitoring for dose titration? Systematic
literature review on the therapeutic and the dose-related reference
range. PHARMACOPSYCHIATRY 2022. [DOI: 10.1055/s-0042-1747647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- L. Eichentopf
- Central Institute of Mental Health, Department of Molecular
Neuroimaging, Medical Faculty Mannheim, Heidelberg University, Mannheim,
Germany
| | - C. Hiemke
- Institute of Clinical Chemistry and Laboratory Medicine- University
Medical Center of Mainz, Department of Psychiatry and Psychotherapy, Mainz,
Germany
| | - A. Conca
- Central Hospital- Sanitary Agency of South Tyrol, Department of
Psychiatry, Bolzano, Italy
| | - J. Engelmann
- Department of Psychiatry and Psychotherapy, Johannes Gutenberg
University Medical Center Mainz, Mainz, Germany
| | - M. Gerlach
- University Hospital Würzburg, Department of Child and
Adolescent Psychiatry- Psychosomatics and Psychotherapy, Würzburg,
Germany
| | - U. Havemann-Reinecke
- University of Göttingen, Department of Psychiatry and
Psychosomatics, Göttingen, Germany
| | - G. Hefner
- Vitos Clinic for Forensic Psychiatry, Forensic Psychiatry, Eltville,
Germany
| | - V. Florio
- Vitos Clinic for Forensic Psychiatry, Forensic Psychiatry, Eltville,
Germany
- Department of Psychiatry, Comprensorio Sanitario di Bolzano, Bolzano,
Italy
| | - M. Kuzin
- Clienia Schlössli AG- Academic Teaching Hospital of the
University of Zurich, Psychiatric and Psychotherapeutic Private Clinic, Oetwil
am See, Switzerland
| | - K. Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center
Mainz, Mainz, Germany
| | - M. Reis
- Department of Biomedical And Clinical Sciences, Linköping
University, Linköping, Sweden
- Department of Clinical Chemistry and Pharmacology, Skåne
University hospital, Lund, Sweden
| | - T.G. Riemer
- Berlin Institute of Health, Institute of Clinical Pharmacology and
Toxicology, Charité - Universitätsmedizin Berlin, Freie
Universität Berlin, Humboldt-Universität zu Berlin, Berlin,
Germany
| | - A. Seretti
- Department of Biomedical and Neuromotor Sciences, University of
Bologna, Bologna, Italy
| | - G. Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of
Psychiatry, University of Zurich, Zurich, Switzerland
| | - G. Zernig
- Medical University of Innsbruck, Department of Psychiatry, Innsbruck,
Austria
- Private Practice for Psychotherapy and Court-Certified Witness, Private
Practice for Psychotherapy and Court-Certified Witness, Hall in Tirol,
Austria
| | - G. Gründer
- Central Institute of Mental Health, Department of Molecular
Neuroimaging, Medical Faculty Mannheim, Heidelberg University, Mannheim,
Germany
| | - X. M. Hart
- Central Institute of Mental Health, Department of Molecular
Neuroimaging, Medical Faculty Mannheim, Heidelberg University, Mannheim,
Germany
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Eichentopf L, Hiemke C, Conca A, Engelmann J, Gerlach M, Havemann-Reinecke U, Hefner G, Florio V, Kuzin M, Lieb K, Reis M, Riemer TG, Serretti A, Schoretsanitis G, Zernig G, Gründer G, Hart XM. Systematic review and meta-analysis on the therapeutic reference range for escitalopram: Blood concentrations, clinical effects and serotonin transporter occupancy. Front Psychiatry 2022; 13:972141. [PMID: 36325531 PMCID: PMC9621321 DOI: 10.3389/fpsyt.2022.972141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/28/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION A titration within a certain therapeutic reference range presupposes a relationship between the blood concentration and the therapeutic effect of a drug. However, this has not been systematically investigated for escitalopram. Furthermore, the recommended reference range disagrees with mean steady state concentrations (11-21 ng/ml) that are expected under the approved dose range (10-20 mg/day). This work systematically investigated the relationships between escitalopram dose, blood levels, clinical effects, and serotonin transporter occupancy. METHODS Following our previously published methodology, relevant articles were systematically searched and reviewed for escitalopram. RESULTS Of 1,032 articles screened, a total of 30 studies met the eligibility criteria. The included studies investigated escitalopram blood levels in relationship to clinical effects (9 studies) or moderating factors on escitalopram metabolism (12 studies) or serotonin transporter occupancy (9 studies). Overall, the evidence for an escitalopram concentration/effect relationship is low (level C). CONCLUSION Based on our findings, we propose a target range of 20-40 ng/ml for antidepressant efficacy of escitalopram. In maintenance treatment, therapeutic response is expected, when titrating patients above the lower limit. The lower concentration threshold is strongly supported by findings from neuroimaging studies. The upper limit for escitalopram's reference range rather reflects a therapeutic maximum than a tolerability threshold, since the incidence of side effects in general is low. Concentrations above 40 ng/ml should not necessarily result in dose reductions in case of good clinical efficacy and tolerability. Dose-related escitalopram concentrations in different trials were more than twice the expected concentrations from guideline reports. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=215873], identifier [CRD42020215873].
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Affiliation(s)
- Luzie Eichentopf
- Department of Molecular Neuroimaging, Medical Faculty Mannheim, Central Institute of Mental Health, Heidelberg University, Mannheim, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Mainz, Germany.,Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany
| | - Andreas Conca
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany.,Department of Psychiatry, Central Hospital, Sanitary Agency of South Tyrol, Bolzano, Italy
| | - Jan Engelmann
- Department of Psychiatry and Psychotherapy, Johannes Gutenberg University Medical Center Mainz, Mainz, Germany
| | - Manfred Gerlach
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany.,Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Würzburg, Würzburg, Germany
| | - Ursula Havemann-Reinecke
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany.,Department of Psychiatry and Psychosomatics, University of Göttingen, Göttingen, Germany
| | - Gudrun Hefner
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany.,Vitos Clinic for Forensic Psychiatry, Forensic Psychiatry, Eltville, Germany
| | - Vincenzo Florio
- Department of Psychiatry, Comprensorio Sanitario di Bolzano, Bolzano, Italy
| | - Maxim Kuzin
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany.,Clienia Schlössli AG, Psychiatric and Psychotherapeutic Private Clinic, Academic Teaching Hospital of the University of Zurich, Oetwil am See, Switzerland
| | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Margareta Reis
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Clinical Chemistry and Pharmacology, Skåne University Hospital, Lund, Sweden
| | - Thomas G Riemer
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Alessandro Serretti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Georgios Schoretsanitis
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany.,Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland.,Department of Psychiatry, Behavioral Health Pavilion, Northwell Health, The Zucker Hillside Hospital, Glen Oaks, NY, United States.,Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, United States
| | - Gerald Zernig
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany.,Department of Pharmacology, Medical University of Innsbruck, Innsbruck, Austria.,Private Practice for Psychotherapy and Court-Certified Witness, Hall in Tirol, Austria
| | - Gerhard Gründer
- Department of Molecular Neuroimaging, Medical Faculty Mannheim, Central Institute of Mental Health, Heidelberg University, Mannheim, Germany.,Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany
| | - Xenia M Hart
- Department of Molecular Neuroimaging, Medical Faculty Mannheim, Central Institute of Mental Health, Heidelberg University, Mannheim, Germany.,Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany
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Wolff J, Reißner P, Hefner G, Normann C, Kaier K, Binder H, Hiemke C, Toto S, Domschke K, Marschollek M, Klimke A. Pharmacotherapy, drug-drug interactions and potentially inappropriate medication in depressive disorders. PLoS One 2021; 16:e0255192. [PMID: 34293068 PMCID: PMC8297778 DOI: 10.1371/journal.pone.0255192] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/11/2021] [Indexed: 12/24/2022] Open
Abstract
Introduction The aim of this study was to describe the number and type of drugs used to treat depressive disorders in inpatient psychiatry and to analyse the determinants of potential drug-drug interactions (pDDI) and potentially inappropriate medication (PIM). Methods Our study was part of a larger pharmacovigilance project funded by the German Innovation Funds. It included all inpatients with a main diagnosis in the group of depressive episodes (F32, ICD-10) or recurrent depressive disorders (F33) discharged from eight psychiatric hospitals in Germany between 1 October 2017 and 30 September 2018 or between 1 January and 31 December 2019. Results The study included 14,418 inpatient cases. The mean number of drugs per day was 3.7 (psychotropic drugs = 1.7; others = 2.0). Thirty-one percent of cases received at least five drugs simultaneously (polypharmacy). Almost one half of all cases received a combination of multiple antidepressant drugs (24.8%, 95% CI 24.1%–25.5%) or a treatment with antidepressant drugs augmented by antipsychotic drugs (21.9%, 95% CI 21.3%–22.6%). The most frequently used antidepressants were selective serotonin reuptake inhibitors, followed by serotonin and norepinephrine reuptake inhibitors and tetracyclic antidepressants. In multivariate analyses, cases with recurrent depressive disorders and cases with severe depression were more likely to receive a combination of multiple antidepressant drugs (Odds ratio recurrent depressive disorder: 1.56, 95% CI 1.41–1.70, severe depression 1.33, 95% CI 1.18–1.48). The risk of any pDDI and PIM in elderly patients increased substantially with each additional drug (Odds Ratio: pDDI 1.32, 95% CI: 1.27–1.38, PIM 1.18, 95% CI: 1.14–1.22) and severity of disease (Odds Ratio per point on CGI-Scale: pDDI 1.29, 95% CI: 1.11–1.46, PIM 1.27, 95% CI: 1.11–1.44), respectively. Conclusion This study identified potential sources and determinants of safety risks in pharmacotherapy of depressive disorders and provided additional data which were previously unavailable. Most inpatients with depressive disorders receive multiple psychotropic and non-psychotropic drugs and pDDI and PIM are relatively frequent. Patients with a high number of different drugs must be intensively monitored in the management of their individual drug-related risk-benefit profiles.
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Affiliation(s)
- Jan Wolff
- Peter L. Reichertz Institute for Medical Informatics of TU Braunschweig and Hannover Medical School, Hannover, Germany
- Faculty of Medicine, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
- Evangelical Foundation Neuerkerode, Braunschweig, Germany
- * E-mail: ,
| | | | - Gudrun Hefner
- Vitos Clinic for Forensic Psychiatry, Eltville, Germany
| | - Claus Normann
- Faculty of Medicine, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Faculty of Medicine, Institute of Medical Biometry and Statistics, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Harald Binder
- Faculty of Medicine, Institute of Medical Biometry and Statistics, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Katharina Domschke
- Faculty of Medicine, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Michael Marschollek
- Peter L. Reichertz Institute for Medical Informatics of TU Braunschweig and Hannover Medical School, Hannover, Germany
| | - Ansgar Klimke
- Vitos Hochtaunus, Friedrichsdorf, Germany
- Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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Wolff J, Hefner G, Normann C, Kaier K, Binder H, Hiemke C, Toto S, Domschke K, Marschollek M, Klimke A. Polypharmacy and the risk of drug-drug interactions and potentially inappropriate medications in hospital psychiatry. Pharmacoepidemiol Drug Saf 2021; 30:1258-1268. [PMID: 34146372 DOI: 10.1002/pds.5310] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/27/2021] [Accepted: 06/09/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE The aim of this study was to analyze the epidemiology of polypharmacy in hospital psychiatry. Another aim was to investigate predictors of the number of drugs taken and the associated risks of drug-drug interactions and potentially inappropriate medications in the elderly. METHODS Daily prescription data were obtained from a pharmacovigilance project sponsored by the Innovations Funds of the German Federal Joint Committee. RESULTS The study included 47 071 inpatient hospital cases from eight different study centers. The mean number of different drugs during the entire stay was 6.1 (psychotropic drugs = 2.7; others = 3.4). The mean number of drugs per day was 3.8 (psychotropic drugs = 1.6; others = 2.2). One third of cases received at least five different drugs per day on average during their hospital stay (polypharmacy). Fifty-one percent of patients received more than one psychotropic drug simultaneously. Hospital cases with polypharmacy were 18 years older (p < 0.001), more likely to be female (52% vs. 40%, p < 0.001) and had more comorbidities (5 vs. 2, p < 0.001) than hospital cases without polypharmacy. The risks of drug-drug interactions (OR = 3.7; 95% CI = 3.5-3.9) and potentially inappropriate medication use in the elderly (OR = 2.2; CI = 1.9-2.5) substantially increased in patients that received polypharmacy. CONCLUSION Polypharmacy is frequent in clinical care. The number of used drugs is a proven risk factor of adverse drug reactions due to drug-drug interactions and potentially inappropriate medication use in the elderly. The potential interactions and the specific pharmacokinetics and -dynamics of older patients should always be considered when multiple drugs are used.
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Affiliation(s)
- Jan Wolff
- Peter L. Reichertz Institute for Medical Informatics of TU Braunschweig and Hannover Medical School, Hannover, Germany.,Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Evangelical Foundation Neuerkerode, Braunschweig, Germany
| | - Gudrun Hefner
- Vitos Clinic for Forensic Psychiatry, Eltville, Germany
| | - Claus Normann
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Harald Binder
- Institute of Medical Biometry and Statistics, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center, Mainz, Germany
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Marschollek
- Peter L. Reichertz Institute for Medical Informatics of TU Braunschweig and Hannover Medical School, Hannover, Germany
| | - Ansgar Klimke
- Vitos Hochtaunus gemeinnutzige GmbH, Friedrichsdorf, Germany.,Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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8
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Moschny N, Hefner G, Grohmann R, Eckermann G, Maier HB, Seifert J, Heck J, Francis F, Bleich S, Toto S, Meissner C. Therapeutic Drug Monitoring of Second- and Third-Generation Antipsychotic Drugs-Influence of Smoking Behavior and Inflammation on Pharmacokinetics. Pharmaceuticals (Basel) 2021; 14:514. [PMID: 34071813 PMCID: PMC8230242 DOI: 10.3390/ph14060514&set/a 947965394+957477086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Both inflammation and smoking can influence a drug's pharmacokinetic properties, i.e., its liberation, absorption, distribution, metabolism, and elimination. Depending on, e.g., pharmacogenetics, these changes may alter treatment response or cause serious adverse drug reactions and are thus of clinical relevance. Antipsychotic drugs, used in the treatment of psychosis and schizophrenia, should be closely monitored due to multiple factors (e.g., the narrow therapeutic window of certain psychotropic drugs, the chronicity of most mental illnesses, and the common occurrence of polypharmacotherapy in psychiatry). Therapeutic drug monitoring (TDM) aids with drug titration by enabling the quantification of patients' drug levels. Recommendations on the use of TDM during treatment with psychotropic drugs are presented in the Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology; however, data on antipsychotic drug levels during inflammation or after changes in smoking behavior-both clinically relevant in psychiatry-that can aid clinical decision making are sparse. The following narrative review provides an overview of relevant literature regarding TDM in psychiatry, particularly in the context of second- and third-generation antipsychotic drugs, inflammation, and smoking behavior. It aims to spread awareness regarding TDM (most pronouncedly of clozapine and olanzapine) as a tool to optimize drug safety and provide patient-tailored treatment.
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Affiliation(s)
- Nicole Moschny
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
- Correspondence: ; Tel.: +49-511-532-3656
| | - Gudrun Hefner
- Department of Psychiatry and Psychotherapy, Vitos Clinic for Forensic Psychiatry, Kloster-Eberbach-Str. 4, 65346 Eltville, Germany;
| | - Renate Grohmann
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Nussbaum-Str. 7, 80336 Munich, Germany;
| | - Gabriel Eckermann
- Department of Forensic Psychiatry and Psychotherapy, Hospital Kaufbeuren, Kemnater-Str. 16, 87600 Kaufbeuren, Germany;
| | - Hannah B Maier
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Johanna Seifert
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Johannes Heck
- Institute for Clinical Pharmacology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany;
| | - Flverly Francis
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Catharina Meissner
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
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Wolff J, Hefner G, Normann C, Kaier K, Binder H, Domschke K, Hiemke C, Marschollek M, Klimke A. Predicting the risk of drug-drug interactions in psychiatric hospitals: a retrospective longitudinal pharmacovigilance study. BMJ Open 2021; 11:e045276. [PMID: 33837103 PMCID: PMC8043005 DOI: 10.1136/bmjopen-2020-045276] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES The aim was to use routine data available at a patient's admission to the hospital to predict polypharmacy and drug-drug interactions (DDI) and to evaluate the prediction performance with regard to its usefulness to support the efficient management of benefits and risks of drug prescriptions. DESIGN Retrospective, longitudinal study. SETTING We used data from a large multicentred pharmacovigilance project carried out in eight psychiatric hospitals in Hesse, Germany. PARTICIPANTS Inpatient episodes consecutively discharged between 1 October 2017 and 30 September 2018 (year 1) or 1 January 2019 and 31 December 2019 (year 2). OUTCOME MEASURES The proportion of rightly classified hospital episodes. METHODS We used gradient boosting to predict respective outcomes. We tested the performance of our final models in unseen patients from another calendar year and separated the study sites used for training from the study sites used for performance testing. RESULTS A total of 53 909 episodes were included in the study. The models' performance, as measured by the area under the receiver operating characteristic, was 'excellent' (0.83) and 'acceptable' (0.72) compared with common benchmarks for the prediction of polypharmacy and DDI, respectively. Both models were substantially better than a naive prediction based solely on basic diagnostic grouping. CONCLUSION This study has shown that polypharmacy and DDI can be predicted from routine data at patient admission. These predictions could support an efficient management of benefits and risks of hospital prescriptions, for instance by including pharmaceutical supervision early after admission for patients at risk before pharmacological treatment is established.
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Affiliation(s)
- Jan Wolff
- Peter L. Reichertz Institute for Medical Informatics, Hannover Medical School, Hannover, Germany
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Freiburg, Germany
| | - Gudrun Hefner
- Vitos Clinic for Forensic Psychiatry, Vitos Rheingau, Eltville, Germany
| | - Claus Normann
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics, Medical Center-University of Freiburg, Freiburg, Germany
| | - Harald Binder
- Institute for Medical Biometry and Statistics, Medical Center-University of Freiburg, Freiburg, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Freiburg, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Michael Marschollek
- Peter L. Reichertz Institute for Medical Informatics, Hannover Medical School, Hannover, Germany
| | - Ansgar Klimke
- Waldkrankenhaus Köppern, Vitos Hospital Hochtaunus, Friedrichsdorf, Germany
- Department of Psychiatry and Psychotherapy, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Wolff J, Hefner G, Normann C, Kaier K, Binder H, Domschke K, Marschollek M, Klimke A. Predicting the risk of drug-drug interactions in psychiatric hospitals. Eur Psychiatry 2021. [PMCID: PMC9471843 DOI: 10.1192/j.eurpsy.2021.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction The most common medical decision is the prescription of medicines. More than 130 different drugs with proven efficacy are currently available for the treatment of patients with mental disorders. Objectives The aim was to use routine data available at a patient’s admission to the hospital to predict polypharmacy and drug-drug interactions (DDI). Methods The study used data obtained from a large clinical pharmacovigilance study sponsored by the Innovations Funds of the German Federal Joint Committee. It included all inpatient episodes admitted to eight psychiatric hospitals in Hesse, Germany, over two years. We used gradient boosting to predict respective outcomes. We tested the performance of our final models in unseen patients from another calendar year and separated the study sites used for training from the study sites used for performance testing. Results A total of 53,909 episodes were included in the study. The models’ performance, as measured by the area under the ROC, was “excellent” (0.83) and “acceptable” (0.72) compared to common benchmarks for the prediction of polypharmacy and DDI, respectively. Both models were substantially better than a naive prediction based solely on basic diagnostic grouping. Conclusions This study has shown that polypharmacy and DDI at a psychiatric hospital can be predicted from routine data at patient admission. These predictions could support an efficient management of benefits and risks of hospital prescriptions, for instance by including pharmaceutical supervision early after admission for patients at risk before pharmacological treatment is established Disclosure This work was supported by the Innovations Funds of the German Federal Joint Committee (grant number: 01VSF16009). The funding body played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscrip
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Schoretsanitis G, Baumann P, Conca A, Dietmaier O, Giupponi G, Gründer G, Hahn M, Hart X, Havemann-Reinecke U, Hefner G, Kuzin M, Mössner R, Piacentino D, Steimer W, Zernig G, Hiemke C. Therapeutic Drug Monitoring of Long-Acting Injectable Antipsychotic Drugs. Ther Drug Monit 2021; 43:79-102. [PMID: 33196621 DOI: 10.1097/ftd.0000000000000830] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/28/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The use of therapeutic drug monitoring (TDM) to guide treatment with long-acting injectable (LAI) antipsychotics, which are increasingly prescribed, remains a matter of debate. The aim of this review was to provide a practical framework for the integration of TDM when switching from an oral formulation to the LAI counterpart, and in maintenance treatment. METHODS The authors critically reviewed 3 types of data: (1) positron emission tomography data evaluating dopamine (D2/D3) receptor occupancy related to antipsychotic concentrations in serum or plasma; D2/D3 receptors are embraced as target sites in the brain for antipsychotic efficacy and tolerability, (2) pharmacokinetic studies evaluating the switch from oral to LAI antipsychotics, and (3) pharmacokinetic data for LAI formulations. Based on these data, indications for TDM and therapeutic reference ranges were considered for LAI antipsychotics. RESULTS Antipsychotic concentrations in blood exhibited interindividual variability not only under oral but also under LAI formulations because these concentrations are affected by demographic characteristics such as age and sex, genetic peculiarities, and clinical variables, including comedications and comorbidities. Reported data combined with positron emission tomography evidence indicated a trend toward lower concentrations under LAI administration than under oral medications. However, the available evidence is insufficient to recommend LAI-specific therapeutic reference ranges. CONCLUSIONS Although TDM evidence for newer LAI formulations is limited, this review suggests the use of TDM when switching an antipsychotic from oral to its LAI formulation. The application of TDM practice is more accurate for dose selection than the use of dose equivalents as it accounts more precisely for individual characteristics.
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Affiliation(s)
| | - Pierre Baumann
- Department of Psychiatry, University of Lausanne, Prilly-Lausanne, Switzerland
| | - Andreas Conca
- Department of Psychiatry, Central Hospital, Sanitary Agency of South Tyrol, Bolzano, Italy
| | - Otto Dietmaier
- Psychiatric Hospital, Klinikum am Weissenhof, Weinsberg, Germany
| | - Giancarlo Giupponi
- Department of Psychiatry, Central Hospital, Sanitary Agency of South Tyrol, Bolzano, Italy
| | - Gerhard Gründer
- Department of Molecular Neuroimaging, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Martina Hahn
- Department of Psychiatry and Psychotherapy, University of Frankfurt, Frankfurt, Germany
| | - Xenia Hart
- Department of Molecular Neuroimaging, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Gudrun Hefner
- Forensic Psychiatric Hospital, Vitos Klinik, Eichberg, Eltville, Germany
| | - Maxim Kuzin
- Psychiatric and Psychotherapeutic Private Clinic Clienia Schlössli, Academic Teaching Hospital of the University of Zurich, Oetwil am See, Switzerland
| | - Rainald Mössner
- Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - Daria Piacentino
- Department of Psychiatry, Central Hospital, Sanitary Agency of South Tyrol, Bolzano, Italy
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, National Institute on Drug Abuse Intramural Research Program, National Institute on Alcohol Abuse and Alcoholism, Division of Intramural Clinical and Biological Research, National Institutes of Health, Bethesda, MD
| | - Werner Steimer
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich, Munich, Germany
| | - Gerald Zernig
- Department of Psychiatry, Medical University of Innsbruck, Innsbruck, Austria
- Private Practice for Psychotherapy and Court-Certified Witness, Hall in Tirol, Austria ; and
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Mainz, Germany
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Toto S, Hefner G, Hahn M, Hiemke C, Roll SC, Wolff J, Klimke A. Current use of anticholinergic medications in a large naturalistic sample of psychiatric patients. J Neural Transm (Vienna) 2021; 128:263-272. [PMID: 33439364 DOI: 10.1007/s00702-020-02298-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/27/2020] [Indexed: 12/19/2022]
Abstract
Due to the high number of psychotropic drugs with anticholinergic potential, patients taking psychotropic drugs are at high risk for anticholinergic adverse drug reactions (ADRs). The aim of this study was to analyze the prevalence and type of pharmacodynamic anticholinergic drug-drug interactions in psychiatric patients. The retrospective longitudinal analysis used data from a large pharmacovigilance study conducted in ten German psychiatric hospitals. Anticholinergic burden of drugs was defined as "strong" or "moderate" based on current literature. Number and type of anticholinergic drugs were assessed. In total, 27,396 patient cases (45.6% female) with a mean age of 47.3 ± 18.3 years were included. 17.4% (n = 4760) of patients were ≥ 64 years. 35.4% of the patients received between one and four anticholinergic drugs simultaneously. A combination of drugs with anticholinergic potential was detected in 1738 cases (6.3%). Most prescribed drugs were promethazine (n = 2996), olanzapine (n = 2561), biperiden (n = 1074), and doxepin (n = 963). Patients receiving anticholinergic combinations were younger (45.7 vs. 47.4 years, p < 0.01) and had a longer inpatient stay (median 18 vs. 26.5 days, p < 0.001). The prevalence of anticholinergic drug use in psychiatry is high. Further efforts need to focus on reducing the rate of anticholinergics and inappropriate medication especially in the elderly. Anticholinergic ADRs can be prevented by avoiding high-risk drug combinations. Replacing tricyclic antidepressants and first-generation antihistamines with drugs with lower anticholinergic potential and avoiding biperiden could reduce 59.3% of anticholinergic drug application.
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Affiliation(s)
- Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany.
| | - Gudrun Hefner
- Department of Psychiatry and Psychotherapy, Vitos Klinikum Hochtaunus, Friedrichsdorf, Germany
| | - Martina Hahn
- Psychiatric Hospital, Vitos Klinik Eichberg, Eltville, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Mainz, Germany
| | - Sibylle C Roll
- Psychiatric Hospital, Vitos Klinik Eichberg, Eltville, Germany
| | - Jan Wolff
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Evangelical Foundation Neuerkerode, Braunschweig, Germany
| | - Ansgar Klimke
- Department of Psychiatry and Psychotherapy, Vitos Klinikum Hochtaunus, Friedrichsdorf, Germany.,Heinrich-Heine-University, Duesseldorf, Germany
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13
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Hefner G, Hahn M, Hiemke C, Toto S, Wolff J, Roll SC, Klimke A. Pharmacodynamic Drug-Drug interactions of QT-prolonging drugs in hospitalized psychiatric patients. J Neural Transm (Vienna) 2021; 128:243-252. [PMID: 33417009 DOI: 10.1007/s00702-020-02291-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/14/2020] [Indexed: 12/30/2022]
Abstract
At least 170 approved drugs are linked to QT prolongation, which can lead to serious adverse drug reactions (ADRs), such as Torsade de Pointes (TdP). The aim of this study was to analyze the prevalence and type of pharmacodynamic drug-drug interactions (DDIs) between QT-prolonging drugs in psychiatry. The present retrospective analysis used data from a large pharmacovigilance study, conducted in 10 psychiatric hospitals in Germany. Patients medication lists were screened for QT-prolonging drugs, classified according to the Arizona Center for Education and Research on Therapeutics (AZCERT). In total, 27,396 patient cases (46% female) with a mean (± standard deviation) age of 47 ± 18 years were included in the study. Altogether, 83% of the cases received at least one and up to eight QT-prolonging drugs at the same time. Combination of drugs with a known or possible risk for TdP (according to the AZCERT) was detected in 13,670 cases (50%). Most frequently prescribed psychotropic high-risk drugs (n = 48,995) were the antipsychotics pipamperone (n = 6202), quetiapine (n = 5718), prothipendyl (n = 4298), and risperidone (n = 4265). The replacement of high-risk drugs such as tricyclic antidepressants, levomepromazine, melperone, and promethazine with more tolerable drugs could avoid 11% of QT-prolonging drugs and increase the tolerability of psychopharmacological treatment. More than 80% of psychiatric patients receive at least one QT-prolonging drug during their hospital stay, and almost 50% of these drugs are combined in clinical practice. For the prevention of cardiac ADRs, the physician should evaluate the risk for QT prolongation for each drug and patient-specific risk factors before prescribing these drugs or drug combinations.
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Affiliation(s)
- Gudrun Hefner
- Department of Psychiatry and Psychotherapy, Vitos Klinikum Hochtaunus, Emil-Sioli-Weg 1-3, 61081, Friedrichsdorf, Germany.
| | - Martina Hahn
- Psychiatric Hospital, Vitos Klinik Eichberg, Eltville, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Mainz, Germany
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Jan Wolff
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Evangelical Foundation Neuerkerode, Braunschweig, Germany
| | - Sibylle C Roll
- Psychiatric Hospital, Vitos Klinik Eichberg, Eltville, Germany
| | - Ansgar Klimke
- Department of Psychiatry and Psychotherapy, Vitos Klinikum Hochtaunus, Emil-Sioli-Weg 1-3, 61081, Friedrichsdorf, Germany.,Heinrich-Heine-University, Duesseldorf, Germany
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Hefner G. 11 Psychopharmacotherapy in geriatric patients. PHARMACOPSYCHIATRY 2020. [DOI: 10.1055/s-0040-1710119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- G Hefner
- Vitos clinic for forensic psychiatry
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Unterecker S, Hefner G. [Correction of the level of recommendation for TDM]. Nervenarzt 2020; 91:75-76. [PMID: 31297573 DOI: 10.1007/s00115-019-0764-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Stefan Unterecker
- Klinik für Psychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Margarete-Höppel-Platz 1, 97080, Würzburg, Deutschland.
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Unterecker S, Hefner G, Baumann P, Gründer G, Bergemann N, Clement HW, Conca A, Deckert J, Domschke K, Eckermann G, Egberts K, Gerlach M, Greiner C, Haen E, Havemann-Reinecke U, Helmer R, Janssen G, Jaquenoud E, Laux G, Messer T, Mössner R, Müller MJ, Paulzen M, Pfuhlmann B, Riederer P, Saria A, Schoppek B, Schoretsanitis G, Schwarz M, Gracia MS, Stegmann B, Steimer W, Stingl JC, Uhr M, Ulrich S, Waschgler R, Zernig G, Zurek G, Hiemke C. [Erratum to: Therapeutic drug monitoring in neuropsychopharmacology : Summary of the consensus guidelines 2017 of the TDM task force of the AGNP]. Nervenarzt 2019; 90:958-960. [PMID: 31309271 DOI: 10.1007/s00115-019-0766-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Stefan Unterecker
- Klinik für Psychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Margarete-Höppel-Platz 1, 97080, Würzburg, Deutschland.
| | - Gudrun Hefner
- Waldkrankenhaus Köppern, Vitos Klinik Hochtaunus, Friedrichsdorf, Deutschland
| | - Pierre Baumann
- Klinik für Psychiatrie, Universität Lausanne, Prilly-Lausanne, Schweiz
| | - Gerd Gründer
- Abteilung Molekulares Neuroimaging, Medizinische Fakultät Mannheim, Zentralinstitut für Seelische Gesundheit, Mannheim, Deutschland
| | - Niels Bergemann
- Klinik für Psychosomatik und Psychotherapie, Kitzberg-Kliniken, Bad Mergentheim, Deutschland
| | - Hans-Willi Clement
- Klinik für Kinder- und Jugendpsychiatrie, Universität Freiburg, Freiburg, Deutschland
| | - Andreas Conca
- Servizio Psichiatrico del Comprensorio Sanitario di Bolzano, Bolzano, Italien
| | - Jürgen Deckert
- Klinik für Psychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Margarete-Höppel-Platz 1, 97080, Würzburg, Deutschland
| | - Katharina Domschke
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Freiburg, Deutschland
- Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland
| | | | - Karin Egberts
- Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Manfred Gerlach
- Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Christine Greiner
- Bundesinstitut für Arzneimittel und Medizinprodukte (BfArM), Bonn, Deutschland
| | - Ekkehard Haen
- Klinische Pharmakologie, Institut AGATE, Pentling, und Klinische Pharmakologie am Lehrstuhl für Pharmakologie und Toxikologie, Universität Regensburg, Regensburg, Deutschland
| | | | | | - Ger Janssen
- Medizinisches Labor Stein, Limbach Group, Mönchengladbach, Deutschland
| | | | - Gerd Laux
- Institut für Psychologische Medizin und Zentrum für Neuropsychiatrie, Soyen und Waldkraiburg, Deutschland
| | - Thomas Messer
- Psychiatrische Klinik, Danuviuskliniken, Pfaffenhofen, Deutschland
| | - Rainald Mössner
- Klinik für Psychiatrie und Psychotherapie, Universität Tübingen, Tübingen, Deutschland
| | - Matthias J Müller
- Psychiatrische Klinik Oberberggruppe und Justus-Liebig-Universität Gießen, Berlin und Gießen, Deutschland
| | - Michael Paulzen
- Alexianer Krankenhaus, Aachen, Deutschland
- Klinik für Psychiatrie, Psychotherapie und Psychosomatik, Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland
| | | | - Peter Riederer
- Klinik für Psychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Margarete-Höppel-Platz 1, 97080, Würzburg, Deutschland
| | - Alois Saria
- Department für Psychiatrie, Psychotherapie und Psychosomatik, 1, Abteilung für Experimentelle Psychiatrie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Bernd Schoppek
- Psychiatrische Klinik, kbo-Isar-Amper Klinikum München-Ost, München-Haar, Deutschland
| | | | - Markus Schwarz
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig Maximilian Universität, München, Deutschland
| | - Margarethe Silva Gracia
- Klinische Pharmakologie, Institut AGATE, Pentling, und Klinische Pharmakologie am Lehrstuhl für Pharmakologie und Toxikologie, Universität Regensburg, Regensburg, Deutschland
| | - Benedikt Stegmann
- Klinische Pharmakologie, Institut AGATE, Pentling, und Klinische Pharmakologie am Lehrstuhl für Pharmakologie und Toxikologie, Universität Regensburg, Regensburg, Deutschland
| | - Werner Steimer
- Institut für klinische Chemie und Pathobiochemie, Technische Universität München, München, Deutschland
| | - Julia C Stingl
- Bundesinstitut für Arzneimittel und Medizinprodukte (BfArM), Bonn, Deutschland
| | - Manfred Uhr
- Max Planck Institut für Psychiatrie, München, Deutschland
| | | | | | - Gerald Zernig
- Department für Psychiatrie, Psychotherapie und Psychosomatik, 1, Abteilung für Experimentelle Psychiatrie, Medizinische Universität Innsbruck, Innsbruck, Österreich
- Gerichtssachverständiger und Psychotherapeut, Hall in Tirol, Österreich
| | | | - Christoph Hiemke
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Mainz, Mainz, Deutschland
- Institut für klinische Chemie und Laboratoriumsmedizin, Universitätsklinikum Mainz, Mainz, Deutschland
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Schoretsanitis G, Paulzen M, Unterecker S, Schwarz M, Conca A, Zernig G, Gründer G, Haen E, Baumann P, Bergemann N, Clement HW, Domschke K, Eckermann G, Egberts K, Gerlach M, Greiner C, Havemann-Reinecke U, Hefner G, Helmer R, Janssen G, Jaquenoud-Sirot E, Laux G, Messer T, Mössner R, Müller MJ, Pfuhlmann B, Riederer P, Saria A, Schoppek B, Silva Gracia M, Stegmann B, Steimer W, Stingl JC, Uhr M, Ulrich S, Waschgler R, Zurek G, Hiemke C. TDM in psychiatry and neurology: A comprehensive summary of the consensus guidelines for therapeutic drug monitoring in neuropsychopharmacology, update 2017; a tool for clinicians<sup/>. World J Biol Psychiatry 2018; 19:162-174. [PMID: 29493375 DOI: 10.1080/15622975.2018.1439595] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Therapeutic drug monitoring (TDM) combines the quantification of drug concentrations in blood, pharmacological interpretation and treatment guidance. TDM introduces a precision medicine tool in times of increasing awareness of the need for personalized treatment. In neurology and psychiatry, TDM can guide pharmacotherapy for patient subgroups such as children, adolescents, pregnant women, elderly patients, patients with intellectual disabilities, patients with substance use disorders, individuals with pharmacokinetic peculiarities and forensic patients. Clear indications for TDM include lack of clinical response in the therapeutic dose range, assessment of drug adherence, tolerability issues and drug-drug interactions. METHODS Based upon existing literature, recommended therapeutic reference ranges, laboratory alert levels, and levels of recommendation to use TDM for dosage optimization without specific indications, conversion factors, factors for calculation of dose-related drug concentrations and metabolite-to-parent ratios were calculated. RESULTS This summary of the updated consensus guidelines by the TDM task force of the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie offers the practical and theoretical knowledge for the integration of TDM as part of pharmacotherapy with neuropsychiatric agents into clinical routine. CONCLUSIONS The present guidelines for TDM application for neuropsychiatric agents aim to assist clinicians in enhancing safety and efficacy of treatment.
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Affiliation(s)
- Georgios Schoretsanitis
- a Department of Psychiatry , University of Bern , Bern , Switzerland.,b Department of Psychiatry, Psychotherapy and Psychosomatics , RWTH Aachen University, JARA - Translational Brain Medicine , Aachen , Germany
| | - Michael Paulzen
- b Department of Psychiatry, Psychotherapy and Psychosomatics , RWTH Aachen University, JARA - Translational Brain Medicine , Aachen , Germany.,c Alexianer Hospital Aachen , Aachen , Germany
| | - Stefan Unterecker
- d Department of Psychiatry, Psychosomatics and Psychotherapy , University Hospital of Würzburg , Germany
| | - Markus Schwarz
- e Department of Laboratory Medicine , Ludwig Maximilian University , Munich , Germany
| | - Andreas Conca
- f Servizio Psichiatrico del Comprensorio Sanitario di Bolzano , Bolzano , Italy
| | - Gerald Zernig
- g Experimental Psychiatry Unit, Department of Psychiatry and Psychotherapy , Medical University of Innsbruck , Innsbruck , Austria.,h Private Practice for Psychotherapy and Court-Certified Witness , Hall in Tirol , Austria
| | - Gerhard Gründer
- i Department of Molecular Neuroimaging , Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg , Mannheim , Germany
| | - Ekkerhard Haen
- j Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology , University of Regensburg , Regensburg , Germany
| | - Pierre Baumann
- k Department of Psychiatry , University of Lausanne , Lausanne , Switzerland
| | - Niels Bergemann
- l Kitzberg Hospitals, Center for Psychosomatic Medicine and Psychotherapy , Bad Mergentheim , Germany
| | - Hans Willi Clement
- m Department of Child and Adolescent Psychiatry , University of Freiburg , Freiburg , Germany
| | - Katharina Domschke
- n Department of Psychiatry and Psychotherapy , Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg , Freiburg , Germany
| | | | - Karin Egberts
- p Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy , Center of Mental Health, University Hospital of Würzburg , Germany
| | - Manfred Gerlach
- p Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy , Center of Mental Health, University Hospital of Würzburg , Germany
| | - Christine Greiner
- q Federal Institute for Drugs and Medical Devices (BfArM) , Bonn , Germany
| | | | - Gudrun Hefner
- s Psychiatric Hospital, Vitos Klinik Hochtaunus , Friedrichsdorf , Germany
| | | | - Ger Janssen
- u Medical Laboratory Stein , Limbach Group , Mönchengladbach , Germany
| | | | - Gerd Laux
- w Institute of Psychological Medicine , Haag in Oberbayern , Germany
| | - Thomas Messer
- x Danuviuskliniken, Psychiatric Hospital , Pfaffenhofen , Germany
| | - Rainald Mössner
- y Department of Psychiatry and Psychotherapy , University of Tübingen , Tübingen , Germany
| | | | | | - Peter Riederer
- d Department of Psychiatry, Psychosomatics and Psychotherapy , University Hospital of Würzburg , Germany
| | - Alois Saria
- g Experimental Psychiatry Unit, Department of Psychiatry and Psychotherapy , Medical University of Innsbruck , Innsbruck , Austria
| | - Bernd Schoppek
- ab kbo-Isar-Amper Klinikum München-Ost, Psychiatric Hospital , Munich , Germany
| | - Margarete Silva Gracia
- j Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology , University of Regensburg , Regensburg , Germany
| | - Benedikt Stegmann
- j Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology , University of Regensburg , Regensburg , Germany
| | - Werner Steimer
- ac Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich , Munich , Germany
| | - Julia C Stingl
- q Federal Institute for Drugs and Medical Devices (BfArM) , Bonn , Germany
| | - Manfred Uhr
- ad Max Planck Institute of Psychiatry , Munich , Germany
| | | | | | | | - Christoph Hiemke
- ah Department of Psychiatry and Psychotherapy , University Medical Center of Mainz , Mainz , Germany.,ai Institute of Clinical Chemistry and Laboratory Medicine , University Medical Center of Mainz , Mainz , Germany
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Hefner G, Hahn M, Hohner M, Roll SC, Klimke A, Hiemke C. QTc Time Correlates with Amitriptyline and Venlafaxine Serum Levels in Elderly Psychiatric Inpatients. Pharmacopsychiatry 2018; 52:38-43. [PMID: 29466824 DOI: 10.1055/s-0044-102009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Many antidepressants cause QT prolongation but the classification of cardiac risk of these drugs varies markedly in different published lists. This retrospective study analyzed the correlation of QTc time with amitriptyline and venlafaxine serum level in elderly psychiatric inpatients. METHODS Elderly inpatients aged≥65 years for whom venlafaxine or amitriptyline serum level had been measured were selected retrospectively from a therapeutic drug monitoring database and screened for an electrocardiogram measurement at the time of blood withdrawal. The correlation of amitriptyline or venlafaxine serum levels with QTc time was examined by using Pearson's correlation analysis. RESULTS Amitriptyline serum levels (n=11) correlated significantly with QTc time (r=0.918, p<0.001, CI 95%). Venlafaxine serum levels (n=27) also correlated significantly with QTc time (r=0.382, p<0.05, CI 95%). DISCUSSION Amitriptyline and venlafaxine induce QT prolongation depending on drug concentrations in blood. Its extent, however, is very low when drug serum levels are within the therapeutic range. Future pharmacokinetic studies that correlate drug serum level and QT time should classify the cardiac risk of drugs based on the grade of the regression line in relation to the therapeutic range.
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Affiliation(s)
- Gudrun Hefner
- Psychiatric Hospital, Vitos Klinik Hochtaunus, Friedrichsdorf, Germany
| | - Martina Hahn
- Psychiatric Hospital, Vitos Klinik Eichberg, Eltville, Germany
| | - Matthias Hohner
- Department of Psychiatry and Psychotherapy, University of Würzburg, Würzburg, Germany
| | - Sybille C Roll
- Psychiatric Hospital, Vitos Klinik Eichberg, Eltville, Germany
| | - Ansgar Klimke
- Psychiatric Hospital, Vitos Klinik Hochtaunus, Friedrichsdorf, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Germany
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19
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Hiemke C, Bergemann N, Clement HW, Conca A, Deckert J, Domschke K, Eckermann G, Egberts K, Gerlach M, Greiner C, Gründer G, Haen E, Havemann-Reinecke U, Hefner G, Helmer R, Janssen G, Jaquenoud E, Laux G, Messer T, Mössner R, Müller MJ, Paulzen M, Pfuhlmann B, Riederer P, Saria A, Schoppek B, Schoretsanitis G, Schwarz M, Gracia MS, Stegmann B, Steimer W, Stingl JC, Uhr M, Ulrich S, Unterecker S, Waschgler R, Zernig G, Zurek G, Baumann P. Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology: Update 2017. Pharmacopsychiatry 2018; 51:e1. [PMID: 29390205 DOI: 10.1055/s-0037-1600991] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- C Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Mainz, Germany.,Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Mainz, Germany
| | - N Bergemann
- Kitzberg Hospitals, Center for Psychosomatic Medicine and Psychotherapy, Bad Mergentheim, Germany
| | - H W Clement
- Department of Child and Adolescent Psychiatry, University of Freiburg, Freiburg, Germany
| | - A Conca
- Servizio Psichiatrico del Comprensorio Sanitario di Bolzano, Bolzano, Italy
| | - J Deckert
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Würzburg, Germany
| | - K Domschke
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - K Egberts
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Germany
| | - M Gerlach
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Germany
| | - C Greiner
- Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany
| | - G Gründer
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, and JARA - Translational Brain Medicine, Aachen, Germany
| | - E Haen
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - U Havemann-Reinecke
- Department of Psychiatry and Psychosomatics, University of Göttingen, Göttingen, Germany
| | - G Hefner
- Psychiatric Hospital, Vitos Klinik, Eichberg, Eltville, Germany
| | - R Helmer
- Center of Epilepsy, Bielefeld, Germany
| | - G Janssen
- Medical Laboratory Stein, Limbach Group, Mönchengladbach, Germany
| | - E Jaquenoud
- Psychiatric Hospital, Königsfelden, Brugg, Aargau, Switzerland
| | - G Laux
- Institute of Psychological Medicine, Haag in Oberbayern, Germany
| | - T Messer
- Danuviuskliniken, Psychiatric Hospital, Pfaffenhofen, Germany
| | - R Mössner
- Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - M J Müller
- Psychiatric Hospitals Oberberggruppe, Berlin, Germany
| | - M Paulzen
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, and JARA - Translational Brain Medicine, Aachen, Germany
| | - B Pfuhlmann
- Psychiatric Hospital Weisser Hirsch, Dresden, Germany
| | - P Riederer
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Würzburg, Germany
| | - A Saria
- Experimental Psychiatry Unit, Department of Psychiatry 1, Medical University of Innsbruck, Innsbruck, Austria
| | - B Schoppek
- kbo-Isar-Amper Klinikum München-Ost, Psychiatric Hospital, Munich-Haar, Germany
| | | | - M Schwarz
- Department of Laboratory Medicine, Ludwig Maximilian University, Munich, Germany
| | - M Silva Gracia
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - B Stegmann
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - W Steimer
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich, Munich, Germany
| | - J C Stingl
- Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany
| | - M Uhr
- Max Planck Institute of Psychiatry, Munich, Germany
| | - S Ulrich
- Aristo Pharma GmbH, Berlin, Germany
| | - S Unterecker
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Würzburg, Germany
| | | | - G Zernig
- Experimental Psychiatry Unit, Department of Psychiatry 1, Medical University of Innsbruck, Innsbruck, Austria.,Private Practice for Psychotherapy and Court-Certified Witness, Hall in Tirol, Austria
| | - G Zurek
- Medical Laboratory Bremen, Bremen, Germany
| | - P Baumann
- Department of Psychiatry, University of Lausanne, Prilly-Lausanne, Switzerland
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20
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Hiemke C, Bergemann N, Clement HW, Conca A, Deckert J, Domschke K, Eckermann G, Egberts K, Gerlach M, Greiner C, Gründer G, Haen E, Havemann-Reinecke U, Hefner G, Helmer R, Janssen G, Jaquenoud E, Laux G, Messer T, Mössner R, Müller MJ, Paulzen M, Pfuhlmann B, Riederer P, Saria A, Schoppek B, Schoretsanitis G, Schwarz M, Gracia MS, Stegmann B, Steimer W, Stingl JC, Uhr M, Ulrich S, Unterecker S, Waschgler R, Zernig G, Zurek G, Baumann P. Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology: Update 2017. Pharmacopsychiatry 2017; 51:9-62. [PMID: 28910830 DOI: 10.1055/s-0043-116492] [Citation(s) in RCA: 533] [Impact Index Per Article: 76.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Therapeutic drug monitoring (TDM) is the quantification and interpretation of drug concentrations in blood to optimize pharmacotherapy. It considers the interindividual variability of pharmacokinetics and thus enables personalized pharmacotherapy. In psychiatry and neurology, patient populations that may particularly benefit from TDM are children and adolescents, pregnant women, elderly patients, individuals with intellectual disabilities, patients with substance abuse disorders, forensic psychiatric patients or patients with known or suspected pharmacokinetic abnormalities. Non-response at therapeutic doses, uncertain drug adherence, suboptimal tolerability, or pharmacokinetic drug-drug interactions are typical indications for TDM. However, the potential benefits of TDM to optimize pharmacotherapy can only be obtained if the method is adequately integrated in the clinical treatment process. To supply treating physicians and laboratories with valid information on TDM, the TDM task force of the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) issued their first guidelines for TDM in psychiatry in 2004. After an update in 2011, it was time for the next update. Following the new guidelines holds the potential to improve neuropsychopharmacotherapy, accelerate the recovery of many patients, and reduce health care costs.
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Affiliation(s)
- C Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Mainz, Germany.,Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Mainz, Germany
| | - N Bergemann
- Kitzberg Hospitals, Center for Psychosomatic Medicine and Psychotherapy, Bad Mergentheim, Germany
| | - H W Clement
- Department of Child and Adolescent Psychiatry, University of Freiburg, Freiburg, Germany
| | - A Conca
- Servizio Psichiatrico del Comprensorio Sanitario di Bolzano, Bolzano, Italy
| | - J Deckert
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Würzburg, Germany
| | - K Domschke
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - K Egberts
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Germany
| | - M Gerlach
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Germany
| | - C Greiner
- Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany
| | - G Gründer
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, and JARA - Translational Brain Medicine, Aachen, Germany
| | - E Haen
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - U Havemann-Reinecke
- Department of Psychiatry and Psychosomatics, University of Göttingen, Göttingen, Germany
| | - G Hefner
- Psychiatric Hospital, Vitos Klinik, Eichberg, Eltville, Germany
| | - R Helmer
- Center of Epilepsy, Bielefeld, Germany
| | - G Janssen
- Medical Laboratory Stein, Limbach Group, Mönchengladbach, Germany
| | - E Jaquenoud
- Psychiatric Hospital, Königsfelden, Brugg, Aargau, Switzerland
| | - G Laux
- Institute of Psychological Medicine, Haag in Oberbayern, Germany
| | - T Messer
- Danuviuskliniken, Psychiatric Hospital, Pfaffenhofen, Germany
| | - R Mössner
- Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - M J Müller
- Psychiatric Hospitals Oberberggruppe, Berlin, Germany
| | - M Paulzen
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, and JARA - Translational Brain Medicine, Aachen, Germany
| | - B Pfuhlmann
- Psychiatric Hospital Weisser Hirsch, Dresden, Germany
| | - P Riederer
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Würzburg, Germany
| | - A Saria
- Experimental Psychiatry Unit, Department of Psychiatry 1, Medical University of Innsbruck, Innsbruck, Austria
| | - B Schoppek
- kbo-Isar-Amper Klinikum München-Ost, Psychiatric Hospital, Munich-Haar, Germany
| | | | - M Schwarz
- Department of Laboratory Medicine, Ludwig Maximilian University, Munich, Germany
| | - M Silva Gracia
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - B Stegmann
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - W Steimer
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich, Munich, Germany
| | - J C Stingl
- Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany
| | - M Uhr
- Max Planck Institute of Psychiatry, Munich, Germany
| | - S Ulrich
- Aristo Pharma GmbH, Berlin, Germany
| | - S Unterecker
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Würzburg, Germany
| | | | - G Zernig
- Experimental Psychiatry Unit, Department of Psychiatry 1, Medical University of Innsbruck, Innsbruck, Austria.,Private Practice for Psychotherapy and Court-Certified Witness, Hall in Tirol, Austria
| | - G Zurek
- Medical Laboratory Bremen, Bremen, Germany
| | - P Baumann
- Department of Psychiatry, University of Lausanne, Prilly-Lausanne, Switzerland
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Falter T, Schmitt V, Herold S, Weyer V, von Auer C, Wagner S, Hefner G, Beutel M, Lackner K, Lämmle B, Scharrer I. Depression and cognitive deficits as long-term consequences of thrombotic thrombocytopenic purpura. Transfusion 2017; 57:1152-1162. [DOI: 10.1111/trf.14060] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/16/2016] [Accepted: 12/21/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Tanja Falter
- Institute of Clinical Chemistry and Laboratory Medicine
- Center for Thrombosis and Hemostasis (CTH)
| | | | | | - Veronika Weyer
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI)
| | | | | | - Gudrun Hefner
- Institute of Clinical Chemistry and Laboratory Medicine
- Department of Psychiatry and Psychotherapy
| | - Manfred Beutel
- Department of Psychosomatic Medicine and Psychotherapy; University Medical Center of the Johannes Gutenberg University; Mainz Germany
| | - Karl Lackner
- Institute of Clinical Chemistry and Laboratory Medicine
| | - Bernhard Lämmle
- Center for Thrombosis and Hemostasis (CTH)
- University Clinic of Hematology & Central Hematology Laboratory, Bern University Hospital and the University of Bern, Inselspital; Bern Switzerland
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Hefner G, Shams MEE, Unterecker S, Falter T, Hiemke C. Inflammation and psychotropic drugs: the relationship between C-reactive protein and antipsychotic drug levels. Psychopharmacology (Berl) 2016; 233:1695-705. [PMID: 26032842 DOI: 10.1007/s00213-015-3976-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 05/19/2015] [Indexed: 12/12/2022]
Abstract
RATIONALE In psychiatric clinical practice, there is a need to identify psychotropic drugs whose metabolisms are prone to be altered with increased inflammatory activity in an individual patient. OBJECTIVES The aim of this study was to find out whether elevated serum levels (≥5 mg/l) of C-reactive protein (CRP), an established laboratory marker of infection and inflammation, are associated with increased serum concentrations of the atypical antipsychotic drugs clozapine, quetiapine, and risperidone. METHODS Therapeutic drug monitoring request forms of patients whose antipsychotic drug concentrations had been measured under conditions of normal (<5 mg/l) and pathological (>5 mg/l) levels of C-reactive protein were retrospectively screened. The serum concentrations in relation to the daily doses [concentration per dose (C/D) (ng/mL/mg)] and the metabolic ratios [ratio of concentrations (metabolite/drug)] were compared intraindividually by the Wilcoxon signed rank test. To the study effects of the intensity of infections on drug concentrations, C-reactive protein and C/D levels were submitted to Spearman's correlation analysis. RESULTS Elevated levels of C-reactive protein were found in 105 patients. They were significantly associated with elevated values in C/D for clozapine (n = 33, P < 0.01) and risperidone (n = 40, P < 0.01). A trend for an increase was found for quetiapine (n = 32, P = 0.05). Median increases were 48.0 % (clozapine), 11.9 % (quetiapine), and 24.2 % (active moiety of risperidone), respectively. CONCLUSIONS In patients who exhibit signs of inflammation or infection with increased C-reactive protein values during psychopharmacological treatment, especially under clozapine and risperidone, therapeutic drug monitoring is recommendable in order to minimize the risk of intoxications due to elevated drug concentrations.
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Affiliation(s)
- Gudrun Hefner
- Department of Psychiatry and Psychotherapy, University Medical Centre, Mainz, Germany. .,Institute of Clinical Chemistry and Laboratory Medicine, University Medical Centre, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Mohamed E E Shams
- Department of Pharmaceutics, Faculty of Pharmacy, University of Mansoura, Mansoura, Egypt.,Department of Pharmacy Practice, College of Health Sciences, Ministry of Health, Muscat, Oman
| | - Stefan Unterecker
- Department of Psychiatry, Psychosomatics, and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany
| | - Tanja Falter
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Centre, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Centre, Mainz, Germany
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Abstract
Inflammation-mediated changes in drug metabolism may lead to alterations in the absorption, distribution, and clearance of psychotropic drugs and thus elevate drug levels in blood and lead to intoxications. We report about two patients who developed an up to threefold increase of dose-related serum concentrations of risperidone's active moiety (risperidone plus 9-hydroxyrisperidone) during acute inflammation indicated by elevated C-reactive protein. The two female patients (aged 56 and 38 years, respectively) had the diagnoses of paranoid schizophrenia and schizoaffective disorder. For both patients, there was a close time-dependent parallel fluctuation of drug levels and C-reactive protein. Since elevated drug levels could not be attributed to prescribed comedications, it seemed likely that high-serum concentrations of risperidone were due to inflammation. It is concluded that elevated C-reactive protein should be considered as an indication to control blood levels of risperidone and possibly dose adaption.
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Affiliation(s)
- Gudrun Hefner
- Department of Psychiatry and Psychotherapy, University Medical Center, Mainz, Germany Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center, Mainz, Germany
| | - Tanja Falter
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center, Mainz, Germany
| | - Kai Bruns
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center, Mainz, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center, Mainz, Germany
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Falter T, Schmitt V, Boeschen S, Herold S, Hefner G, Weyer V, Auer CV, Lämmle B, Rossmann H, Scharrer I, Lackner K. Prevalence of Depression in patients with diagnosis of thrombotic thrombocytopenic purpura (TTP). Pharmacopsychiatry 2015. [DOI: 10.1055/s-0035-1557951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Falter T, Schmitt V, Boeschen S, Herold S, Hefner G, Weyer V, Auer CV, Lämmle B, Rossmann H, Scharrer I, Lackner K. Prevalence of depression in patients with diagnosis of thrombotic thrombocytopenic purpura (TTP). Pharmacopsychiatry 2015. [DOI: 10.1055/s-0035-1558011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Hefner G, Shams MEE, Unterecker S, Falter T, Hiemke C. Retrospective pilot study for analysis of antidepressant serum concentrations of citalopram and venlafaxine during inflammation. Pharmacopsychiatry 2015; 48:215-8. [PMID: 26335759 DOI: 10.1055/s-0035-1559666] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Inflammation-mediated changes in drug metabolism may increase drug levels in blood and lead to intoxications. The objective of this study was to find out whether elevated serum levels of C-reactive protein (CRP) are associated with increased serum concentrations of the antidepressants citalopram and venlafaxine. METHODS Therapeutic drug monitoring request forms of psychiatric patients were screened retrospectively. The serum concentrations in relation to the daily doses [(C/D) (ng/ml/mg)] and the metabolic ratios (metabolite/drug) were compared intraindividually under normal (<5 mg/l) and pathological (>5 mg/l) condition by the Wilcoxon signed-rank test. RESULTS Elevated levels of CRP were not associated with a significant (P>0.05) increase in C/D for citalopram (2.4 ng/ml/mg vs. 2.85 ng/ml/mg, N=15) or in C/D for the active moiety of venlafaxine (1.76 ng/ml/mg vs. 1.68 ng/ml/mg, N=39), compared with normal CRP serum levels. No significant difference in the metabolic ratio was observed in both groups. DISCUSSION There was no major effect of inflammation on the metabolism of citalopram and venlafaxine. Because of the broad therapeutic indices of these 2 drugs, the drugs seem to be a good choice for the treatment of depression, even if an infection occurs.
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Affiliation(s)
- G Hefner
- Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Germany
| | - M E E Shams
- Faculty of Pharmacy, Department of Pharmaceutics, University of Mansoura, Egypt
| | - S Unterecker
- Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Germany
| | - T Falter
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Centre Mainz, Germany
| | - C Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Germany
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Hefner G, Unterecker S, Shams MEE, Wolf M, Falter T, Haen E, Hiemke C. Melperone but not bisoprolol or metoprolol is a clinically relevant inhibitor of CYP2D6: evidence from a therapeutic drug monitoring survey. J Neural Transm (Vienna) 2015; 122:1609-17. [DOI: 10.1007/s00702-015-1403-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
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Hefner G, Unterecker S, Ben-Omar N, Wolf M, Falter T, Hiemke C, Haen E. Prevalence and type of potential pharmacokinetic drug-drug interactions in old aged psychiatric patients. ACTA ACUST UNITED AC 2015. [DOI: 10.15761/cbhc.1000103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Hefner G, Stieffenhofer V, Gabriel S, Palmer G, Müller KM, Röschke J, Hiemke C. Side effects related to potentially inappropriate medications in elderly psychiatric patients under everyday pharmacotherapy. Eur J Clin Pharmacol 2014; 71:165-72. [PMID: 25529227 DOI: 10.1007/s00228-014-1796-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 12/15/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Potentially inappropriate medication (PIM) is suggested to give rise to adverse drug events. To study this suggestion for elderly psychiatric patients, an observational analysis related prescription of PRISCUS PIMs and drug-induced side effects in old aged (≥65 years) psychiatric inpatients and outpatients under conditions of everyday pharmacotherapy. METHODS Request forms from a therapeutic drug monitoring (TDM) survey and medical files were screened for medication to identify PIMs of the PRISCUS list and assessed using the Udvalg for Kliniske Undersøgelser (UKU) side effect rating scale. RESULTS From 914 TDM request forms, data were available for 168 patients (64.3 % female). Patients (mean ± SD age 73.0 ± 5.5 years) received by mean 6.4 ± 3.9 drugs per day. More than half of them (53.0 %, n = 89) had at least one PIM, inpatients 0.9 ± 0.8 and outpatients 0.5 ± 0.7. Predominant PIMs were hypnotic drugs (69 %) in inpatients and antipsychotic drugs (35.6 %) in outpatients. The number of PIMs correlated with the total number of drugs administered per day (Spearman correlation coefficient 0.225, p < 0.01, CI 95 %). Side effects were documented for 106 patients (63 %). Severity of side effects did not correlate significantly (p > 0.05) with number of PIMs. However, only 6 of 77 patients who took no PRISCUS PIMs but 2 of 3 patients who took 3 PRISCUS PIMs exhibited severe side effects. CONCLUSIONS Though the prevalence for PIMs and side effects was high in old aged psychiatric inpatients and outpatients, PIMs could not be identified as major determinants of overall unwanted side effects. Nevertheless, prescription of PIMs should be minimized, especially of hypnotic drugs, to improve safety.
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Affiliation(s)
- Gudrun Hefner
- Department of Psychiatry and Psychotherapy, University Medical Center, Mainz, Germany,
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Sigurdsson HP, Hefner G, Ben-Omar N, Köstlbacher A, Wenzel-Seifert K, Hiemke C, Haen E. Steady-state serum concentrations of venlafaxine in patients with late-life depression. Impact of age, sex and BMI. J Neural Transm (Vienna) 2014; 122:721-9. [DOI: 10.1007/s00702-014-1317-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 09/20/2014] [Indexed: 11/29/2022]
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Hefner G, Hiemke C. Therapeutic drug monitoring for improved psychopharmacotherapy in elderly patients. Pharmacopsychiatry 2014. [DOI: 10.1055/s-0034-1386834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Hefner G, Sigurdsson H, Wolf M, Hiemke C, Haen E. Melperone but not metoprolol is a clinically relevant inhibitor of CYP2D6. Pharmacopsychiatry 2014. [DOI: 10.1055/s-0034-1386840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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33
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Hefner G, Falter T, Bruns K, Hiemke C. Alteration of risperidone elimination during acute inflammation, two cases. Pharmacopsychiatry 2014. [DOI: 10.1055/s-0034-1386839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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34
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Hefner G, Hiemke C. Therapeutic drug monitoring for improved psychopharmacotherapy in elderly patients. Pharmacopsychiatry 2014. [DOI: 10.1055/s-0034-1386807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Freese C, Reinhardt S, Hefner G, Unger RE, Kirkpatrick CJ, Endres K. A novel blood-brain barrier co-culture system for drug targeting of Alzheimer's disease: establishment by using acitretin as a model drug. PLoS One 2014; 9:e91003. [PMID: 24608847 PMCID: PMC3946622 DOI: 10.1371/journal.pone.0091003] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 02/07/2014] [Indexed: 11/18/2022] Open
Abstract
In the pathogenesis of Alzheimer’s disease (AD) the homeostasis of amyloid precursor protein (APP) processing in the brain is impaired. The expression of the competing proteases ADAM10 (a disintegrin and metalloproteinase 10) and BACE-1 (beta site APP cleaving enzyme 1) is shifted in favor of the A-beta generating enzyme BACE-1. Acitretin–a synthetic retinoid–e.g., has been shown to increase ADAM10 gene expression, resulting in a decreased level of A-beta peptides within the brain of AD model mice and thus is of possible value for AD therapy. A striking challenge in evaluating novel therapeutically applicable drugs is the analysis of their potential to overcome the blood-brain barrier (BBB) for central nervous system targeting. In this study, we established a novel cell-based bio-assay model to test ADAM10-inducing drugs for their ability to cross the BBB. We therefore used primary porcine brain endothelial cells (PBECs) and human neuroblastoma cells (SH-SY5Y) transfected with an ADAM10-promoter luciferase reporter vector in an indirect co-culture system. Acitretin served as a model substance that crosses the BBB and induces ADAM10 expression. We ensured that ADAM10-dependent constitutive APP metabolism in the neuronal cells was unaffected under co-cultivation conditions. Barrier properties established by PBECs were augmented by co-cultivation with SH-SY5Y cells and they remained stable during the treatment with acitretin as demonstrated by electrical resistance measurement and permeability-coefficient determination. As a consequence of transcellular acitretin transport measured by HPLC, the activity of the ADAM10-promoter reporter gene was significantly increased in co-cultured neuronal cells as compared to vehicle-treated controls. In the present study, we provide a new bio-assay system relevant for the study of drug targeting of AD. This bio-assay can easily be adapted to analyze other Alzheimer- or CNS disease-relevant targets in neuronal cells, as their therapeutical potential also depends on the ability to penetrate the BBB.
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Affiliation(s)
- Christian Freese
- REPAIR-lab, Institute of Pathology, University Medical Center of the Johannes Gutenberg University Mainz and European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Mainz, Germany
- * E-mail:
| | - Sven Reinhardt
- Department of Psychiatry and Psychotherapy, Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Gudrun Hefner
- Department of Psychiatry and Psychotherapy, Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ronald E. Unger
- REPAIR-lab, Institute of Pathology, University Medical Center of the Johannes Gutenberg University Mainz and European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Mainz, Germany
| | - C. James Kirkpatrick
- REPAIR-lab, Institute of Pathology, University Medical Center of the Johannes Gutenberg University Mainz and European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Mainz, Germany
| | - Kristina Endres
- Department of Psychiatry and Psychotherapy, Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Hefner G, Laib AK, Sigurdsson H, Hohner M, Hiemke C. The value of drug and metabolite concentration in blood as a biomarker of psychopharmacological therapy. Int Rev Psychiatry 2013; 25:494-508. [PMID: 24151798 DOI: 10.3109/09540261.2013.836475] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Desirable and undesirable effects of a drug are related to its concentration at various sites of actions. For many psychotropic drugs, it has been shown that drug concentration in brain correlates with concentration in blood. The latter is also an available estimate of clearance and bioavailability. Its monitoring enables identification of multiple factors that have an impact on clinical outcomes, especially uncertain compliance and pharmacokinetic peculiarities. For this review we analysed for antidepressants if drug concentration in blood can be used as biomarker for psychopharmacological treatment. Systematic review of the literature revealed for new and old antidepressant drugs that drug and metabolite concentrations in blood are measures of the pharmacokinetic phenotype and related differentially to occupancy of primary target structures, therapeutic effects and unwanted anticholinergic, cardiac and other side effects. Drug concentration in blood can therefore be used as biomarker in clinical practice to guide psychopharmacological treatment with established antidepressant drugs. Monitoring of drug concentration is suitable to improve efficacy and safety of the pharmacotherapy, especially in elderly patients who require complex pharmacological therapies.
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Affiliation(s)
- Gudrun Hefner
- Department of Psychiatry and Psychotherapy, University Medical Centre Mainz , Germany
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Hefner G, Hohner M, Wenzel-Seifert K, Hiemke C, Haen E. Evaluation of a risk-scale for drug-induced QT-prolongation in elderly psychiatric inpatients. Pharmacopsychiatry 2013. [DOI: 10.1055/s-0033-1353306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Sigurdsson H, Ben Omar N, Hefner G, Hiemke C, Haen E. Influence of the body mass index on serum levels of venlafaxine and its active metabolite O-desmethylvenlafaxine. Analysis of a large therapeutic drug monitoring database. Pharmacopsychiatry 2013. [DOI: 10.1055/s-0033-1353319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Ben Omar N, Wenzel-Seifert K, Hefner G, Hiemke C, Haen E. Age-dependency of psychotropic drug-induced anticholinergic adverse reactions: Analysis of reports to the pharmacovigilance system AGATE. Pharmacopsychiatry 2013. [DOI: 10.1055/s-0033-1353267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Hefner G, Brueckner A, Geschke K, Hiemke C, Fellgiebel A. Therapeutic Drug Monitoring (TDM) of donepezil in patients with Alzheimers dementia. Pharmacopsychiatry 2013. [DOI: 10.1055/s-0033-1353303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Hefner G, Fellgiebel A, Hiemke C. Evaluation of a risk-scale for anticholinergic side-effects in elderly psychiatric inpatients. Pharmacopsychiatry 2012. [DOI: 10.1055/s-0032-1326752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Kurthen M, Lukas M, Hufnagel A, Linke DB, Hefner G, Elger CE, Schramm J. Correlations between verbal memory performance and electrocorticographically determined suppression of electrical brain activity in intracarotid amobarbital tests. Electroencephalogr Clin Neurophysiol 1992; 83:70-6. [PMID: 1376668 DOI: 10.1016/0013-4694(92)90134-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
As a part of presurgical evaluation, bilateral intracarotid amobarbital procedures (IAPs) were performed in 42 patients (84 tests) with long-standing, medically intractable complex-partial seizures. During the IAPs, electrocorticographic (ECoG) recording was carried out via bilaterally implanted subdural electrodes. Five distinct patterns of suppression of electrical brain activity were observed: (1) an isoelectric line; (2) a burst-suppression pattern; (3) polyphasic waves; (4) high-voltage beta; and (5) low-voltage beta activity. Further, two types of specific reactions of the epileptic focus were detectable: (1) spike-burst-suppression patterns (SBS; 11 left; 7 right; 6 in both IAPs) and amobarbital-induced spikes (7 left; 4 right). ECoG suppression patterns as well as SBS and spike induction showed great variability in duration and overall occurrence. To determine the influence of these amobarbital-induced ECoG changes on results of IAP memory testing, performance in a verbal learning task was analyzed according to the ECoG patterns predominant during encoding. In left IAPs, it was found that SBS at the beginning of or during encoding had a significant negative effect on verbal memory. In right IAPs, verbal memory performance improved significantly with the decline of ECoG suppression. Hence, verbal memory performance in IAPs is significantly affected by specific ECoG suppression patterns and activation of the epileptic focus.
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Affiliation(s)
- M Kurthen
- Neurosurgical Clinic, University Hospital of Bonn, F.R.G
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Abstract
A short anesthesia was provided by methohexital for painless percutaneous removal of subdural electrodes in 27 patients with medically intractable, complex partial seizures who had undergone invasive preoperative evaluation. Electrocorticographic(ECoG) recordings performed before and during the narcosis were submitted to visual (n = 27) and computerized (n = 3) analysis to obtain additional information about the location of the epileptic focus (or foci). The following observations were made: focal epileptiform potentials were induced in 24 of 27 patients (89%); (b) in 20 of these 24, the induced spikes appeared amid or were followed by isoelectric or subdelta activity. These spikes were characterized by high amplitude as well as rhythmic and synchronized appearance over a circumscribed focal area (or areas) known to be spontaneously epileptogenic. This phenomenon, termed spike-burst-suppression (SBS) pattern, allowed identification of the primary epileptic focus in many patients with temporal lobe epilepsy. Furthermore, it indicated a good outcome of epilepsy surgery. Computerized analysis of the induced synchronized spikes (n = 3) allowed further delineation of the primary site of epileptogenicity and quantitative comparison of multiple epileptic generators. ECoG recording during deep methohexital-induced narcosis is a valuable tool for lateralization and delineation of the primary epileptogenic focus.
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Affiliation(s)
- A Hufnagel
- Department of Epileptology, University of Bonn, Germany
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Funcke AM, Hefner G, Brams V, Günthner W, Brouscheck H. [Preceptorship from the viewpoint of the medical practitioner]. ZFA (Stuttgart) 1980; 56:1419-1423. [PMID: 7467731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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