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Krejčí V, Murínová I, Slanař O, Šíma M. Evidence for Therapeutic Drug Monitoring of Atypical Antipsychotics. Prague Med Rep 2024; 125:101-129. [PMID: 38761044 DOI: 10.14712/23362936.2024.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2024] Open
Abstract
Second-generation antipsychotics (SGAs), also known as atypical antipsychotics, are a newer class of antipsychotic drugs used to treat schizophrenia, bipolar disorder, and related psychiatric conditions. The plasma concentration of antipsychotic drugs is a valid measure of the drug at its primary target structure in the brain, and therefore determines the efficacy and safety of these drugs. However, despite the well-known high variability in pharmacokinetics of these substances, psychiatric medication is usually administered in uniform dosage schedules. Therapeutic drug monitoring (TDM), as the specific method that can help personalised medicine in dose adjustment according to the characteristics of the individual patient, minimizing the risk of toxicity, monitoring adherence, and increasing cost-effectiveness in the treatment, thus seems to be an elegant tool to solve this problem. Non-response to therapeutic doses, uncertain adherence to medication, suboptimal tolerability, or pharmacokinetic drug-drug interactions are typical indications for TDM of SGAs. This review aims to summarize an overview of the current knowledge and evidence of the possibilities to tailor the dosage of selected SGAs using TDM, including the necessary pharmacokinetic parameters for personalised pharmacotherapy.
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Affiliation(s)
- Veronika Krejčí
- Department of Clinical Pharmacy, Military University Hospital Prague, Prague, Czech Republic.
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.
| | - Irena Murínová
- Department of Applied Pharmacy, Faculty of Pharmacy, Masaryk University, Brno, Czech Republic
- Department of Clinical Pharmacy, Military University Hospital Prague, Prague, Czech Republic
| | - Ondřej Slanař
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Martin Šíma
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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Markowicz-Piasecka M, Kubisiak M, Asendrych-Wicik K, Kołodziejczyk M, Grzelińska J, Fabijańska M, Pietrzak T. Long-Acting Injectable Antipsychotics-A Review on Formulation and In Vitro Dissolution. Pharmaceutics 2023; 16:28. [PMID: 38258037 PMCID: PMC10820045 DOI: 10.3390/pharmaceutics16010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/08/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
Long-acting injectable (LAI) neuroleptics constitute an effective therapeutical alternative for individuals suffering from persistent mental illness. These injectable pharmaceuticals help patients manage their condition better and improve long-term outcomes by preventing relapses and improving compliance. This review aims to analyse the current formulation aspects of LAI neuroleptics, with particular emphasis on analysis of drug release profiles as a critical test to guarantee drug quality and relevant therapeutical activity. While there is no officially approved procedure for depot parenteral drug formulations, various dissolution tests which were developed by LAI manufacturers are described. In vitro dissolution tests also possess a critical function in the estimation of the in vivo performance of a drug formulation. For that reason, thorough inspection of the in vitro-in vivo correlation (IVIVC) is also discussed.
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Affiliation(s)
| | - Marcin Kubisiak
- Liquid Dosage Form Laboratory, Research and Development Department, Polfa Warszawa S.A., Karolkowa 22/24, 01-207 Warsaw, Poland; (M.K.); (K.A.-W.); (J.G.); (T.P.)
| | - Katarzyna Asendrych-Wicik
- Liquid Dosage Form Laboratory, Research and Development Department, Polfa Warszawa S.A., Karolkowa 22/24, 01-207 Warsaw, Poland; (M.K.); (K.A.-W.); (J.G.); (T.P.)
- Department of Pharmaceutical Chemistry, Drug Analysis and Radiopharmacy, Medical University of Lodz, ul. Muszynskiego 1, 90-151 Lodz, Poland
| | - Michał Kołodziejczyk
- Department of Drug Form Technology, Medical University of Lodz, ul. Muszynskiego 1, 90-151 Lodz, Poland;
| | - Joanna Grzelińska
- Liquid Dosage Form Laboratory, Research and Development Department, Polfa Warszawa S.A., Karolkowa 22/24, 01-207 Warsaw, Poland; (M.K.); (K.A.-W.); (J.G.); (T.P.)
| | - Małgorzata Fabijańska
- Department of Bioinorganic Chemistry, Medical University of Lodz, ul. Muszynskiego 1, 90-151 Lodz, Poland;
| | - Tomasz Pietrzak
- Liquid Dosage Form Laboratory, Research and Development Department, Polfa Warszawa S.A., Karolkowa 22/24, 01-207 Warsaw, Poland; (M.K.); (K.A.-W.); (J.G.); (T.P.)
- Faculty of Chemistry, Warsaw University of Technology, Noakowskiego 3, 00-664 Warsaw, Poland
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3
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Smith-Diaz N, Stocker SL, Stamp LK, Dalbeth N, Phipps-Green AJ, Merriman TR, Wright DFB. An allopurinol adherence tool using plasma oxypurinol concentrations. Br J Clin Pharmacol 2022. [PMID: 36036094 DOI: 10.1111/bcp.15516] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 08/06/2022] [Accepted: 08/23/2022] [Indexed: 11/27/2022] Open
Abstract
AIMS This study aimed to develop and evaluate an allopurinol adherence tool based on steady-state oxypurinol plasma concentrations, allopurinol's active metabolite. METHODS Plasma oxypurinol concentration were simulated stochastically from an oxypurinol pharmacokinetic model for allopurinol doses of 100-800 mg daily, accounting for differences in renal function, diuretic use, and ethnicity. For each scenario, the 20th percentile for peak and trough concentrations defined the adherence threshold, below which imperfect adherence was assumed. Predictive performance was evaluated using both simulated low adherence and against data from 146 individuals with paired oxypurinol plasma concentrations and adherence measures. Sensitivity and specificity (S&S), negative and positive predictive values (NPV, PPV) and receiver operating characteristic (ROC) area under the curve (AUC) were determined. The predictive performance of the tool was evaluated externally using RESULTS: The allopurinol adherence tool produced S&S values for trough thresholds of 89-98% and 76-84%, respectively, and 90%-98% and 76-83% for peak thresholds. PPV and NPV were 79-84% and 88-94% respectively for trough and 80-85% and 89-98% for peak concentrations. The ROC AUC values ranged from 0.84-0.88 and 0.86-0.89 for trough and peak concentrations, respectively. S&S values for the external evaluation were found to be 75.8% and 86.5%, respectively, producing a ROC AUC of 0.8113. CONCLUSION A tool to identify people with gout who require additional support to maintain adherence using plasma oxypurinol concentrations was developed and evaluated. The predictive performance of the tool is suitable for adherence screening in clinical trials and may have utility in some clinical practice settings.
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Affiliation(s)
| | | | - Lisa K Stamp
- Department of Medicine, University of Otago - Christchurch, Christchurch, New Zealand
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | | | - Tony R Merriman
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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Haen E. Dose-Related Reference Range as a Tool in Therapeutic Drug Monitoring. Ther Drug Monit 2022; 44:475-493. [PMID: 35067666 DOI: 10.1097/ftd.0000000000000962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/01/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) aims to individualize drug therapy. This systematic review provides a state-of-the-art overview of the benefits of adding the dose-related reference range (DRR) as a second reference range to the set of tools used by TDM for measurement and evaluation. It discusses alternative pharmacokinetic approaches for individualization of drug therapy. METHODS Literature was searched in PubMed. Textbooks provided Bateman transformations for calculating expected drug concentrations at various times after drug application in "normal patients," that is, the population of phase II clinical trials. The review compiles conditions and prerequisites for these transformations to be valid. RESULTS Relating a measured drug concentration to the orienting therapeutic reference range provides pharmacodynamic information for improving the benefit-to-risk ratio of desired drug effects versus adverse drug effects. The discriminating DRR considers a patient's individual pharmacokinetic situation. DRR is statistically based on the pharmacokinetic parameters total clearance, time to reach maximal concentrations, and elimination half-life. Relating the measured drug concentration to a range rather than a particular value, DRR determines if individual patients do or do not belong to the population of "normal patients." Once a patient is identified to be outside the population of "normal patients," the clinical-pharmacological TDM report elaborates the cause. It consists of the measured value, the TDM 9-field-board, the elimination pathways table, and a medication recommendation taking into account clinical information. The internet-based platform KONBEST supports editing of the clinical-pharmacological TDM report. It is personally signed and send to the therapist. CONCLUSIONS The DRR embedded into a clinical-pharmacological TDM report allows adjusting a patient's medication to the patient's individual needs (individualization of drug therapy).
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Affiliation(s)
- Ekkehard Haen
- Clinical Pharmacology, Institute AGATE gGmbH, Pentling, Germany ; and
- Departments of Pharmacology & Toxicology,
- Psychiatry & Psychotherapy, University of Regensburg, Regensburg, Germany
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Schoretsanitis G, Haen E, Piacentino D, Conca A, Endres K, Hiemke C, Gründer G, Paulzen M. Effects of body weight, smoking status, and sex on plasma concentrations of once-monthly paliperidone palmitate. Expert Rev Clin Pharmacol 2021; 15:243-249. [PMID: 34918984 DOI: 10.1080/17512433.2022.2020641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Knowledge about the impact of body composition features on pharmacokinetics of newer long-acting injectable antipsychotics is limited. METHODS We analyzed steady-state plasma concentrations of paliperidone in different body mass index (BMI), age, sex, and smoking status patient subgroups treated with once-monthly paliperidone palmitate (PP1M). Paliperidone plasma concentrations and dose-adjusted-plasma concentrations (C/D) from a therapeutic drug monitoring (TDM) database of PP1M-treated patients were compared among normal BMI, overweight, and obese patients as well as between females vs. males, elderly vs. non-elderly, and smokers vs. non-smokers using non-parametric tests. RESULTS In a total of 183 PP1M-treated patients, we found highly variable paliperidone plasma concentrations between individuals but no significant effect of PP1M dose or dosing intervals (p> 0.05). C/D ratios were similar in 54 obese, 82 overweight, and 47 normal BMI patients (p> 0.05). Females had 13.7% higher C/D ratios compared to males, yet this difference was not significant (p> 0.05). No differences were found between elderly vs. non-elderly patients or for smokers vs. non-smokers (p> 0.05). CONCLUSION Our findings suggest that age, sex, smoking, or body weight may not substantially affect pharmacokinetic indices of PP1M. The high interindividual variation of plasma concentrations implies that TDM may be helpful to enhance PP1M efficacy and tolerability.
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Affiliation(s)
- Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, NY, USA and Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
| | - Ekkehard Haen
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Daria Piacentino
- Psychiatric Service of the Health District of Bolzano, Bolzano, Italy.,Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, The National Institutes of Health, Bethesda, MD, USA
| | - Andreas Conca
- Psychiatric Service of the Health District of Bolzano, Bolzano, Italy
| | - Katharina Endres
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy and Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Mainz, Germany
| | - Gerhard Gründer
- Department of Molecular Neuroimaging, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Paulzen
- Alexianer Hospital Aachen, Aachen, Germany and Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, and Jara - Translational Brain Medicine, Aachen, Germany
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Schoretsanitis G, Haen E, Piacentino D, Conca A, Endres K, Hiemke C, Gründer G, Paulzen M. Clinical response in patients treated with once-monthly paliperidone palmitate: analysis of a therapeutic drug monitoring (TDM) database. Eur Arch Psychiatry Clin Neurosci 2021; 271:1437-1443. [PMID: 33821323 DOI: 10.1007/s00406-021-01257-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 03/30/2021] [Indexed: 12/01/2022]
Abstract
To investigate pharmacokinetic correlates of clinical response in patients treated with once-monthly paliperidone palmitate (PP1M) injections at steady state. Plasma concentrations and dose-adjusted-plasma concentrations (C/D) of paliperidone from a naturalistic therapeutic drug monitoring (TDM) database were compared between responders and non-responders using the Clinical Global Impressions-Improvement scale (CGI-I) ratings. Analyses were based on the non-parametric Mann-Whitney U test and the Pearson Chi-squared test (χ2) with a significance level of 0.05. Subgroup analyses were performed separately in patients with schizophrenia spectrum, schizoaffective disorders and bipolar disorders. Comparing 93 responders with 80 non-responders, we detected no significant differences in the proportion of females, age, and body mass index (p's ranging 0.18-0.83); there were more smokers in the group of non-responders (p = 0.04), which also included more patients with bipolar disorders (p = 0.014). Despite the lack of differences for prescribed PP1M doses and dose intervals (p = 0.42 and p = 0.11, respectively), non-responders had higher paliperidone plasma concentrations and C/D levels (p = 0.033 and p = 0.021, respectively). Subgroup analyses did not yield differences for paliperidone plasma and C/D levels between non-responders and responders with schizophrenia spectrum (p = 0.099 and p = 0.14, respectively) and bipolar disorders (p = 0.95 and p = 0.75, respectively); dose-adjusted plasma concentrations were higher in non-responders compared to responders with schizoaffective disorders (p = 0.039), while no differences were reported for plasma levels (p = 0. 15). Our results show that paliperidone plasma concentrations over injection doses may be associated with patterns of clinical response suggesting potential utility of TDM as part of PP1M-based maintenance treatment.
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Affiliation(s)
- Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Behavioral Health Pavilion, 7559 263rd Street, Glen Oaks, NY, 11004, USA.
| | - Ekkehard Haen
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Daria Piacentino
- Psychiatric Service of the Health District of Bozen, Bozen, Italy.,Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, National Institute On Drug Abuse Intramural Research Program and National Institute On Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, The National Institutes of Health, Bethesda, MD, USA
| | - Andreas Conca
- Psychiatric Service of the Health District of Bozen, Bozen, Italy
| | - Katharina Endres
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy and Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Mainz, Germany
| | - Gerhard Gründer
- Department of Molecular Neuroimaging, Medical Faculty Mannheim, Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany
| | - Michael Paulzen
- Alexianer Hospital Aachen, Aachen, Germany.,Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, and JARA-Translational Brain Medicine, Aachen, Germany
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7
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Pharmacokinetic Correlates of Once-Monthly Paliperidone Palmitate-Related Adverse Drug Reactions. Clin Pharmacokinet 2021; 60:1583-1589. [PMID: 34142360 DOI: 10.1007/s40262-021-01044-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The objective of this study was to investigate associations between pharmacokinetic correlates and once-monthly paliperidone palmitate (PP1M)-related adverse drug reactions (ADRs). METHODS Plasma concentrations and dose-adjusted plasma concentrations ('concentration-by-dose' [C/D]) of paliperidone from a naturalistic therapeutic drug monitoring database of PP1M-treated patients were compared between patients with ADRs, classified according to the Udvalg for Kliniske Undersogelser side-effect rating scales categories, and patients without ADRs. Analyses included non-parametric tests and a logistic regression model with a significance level set at 0.05. RESULTS In 172 patients, we found no differences in sex, age, smoking, body mass index, PP1M dose, paliperidone plasma concentrations, and C/D values (p > 0.05) between 44 patients with and 128 patients without PP1M-related ADRs. We did not detect differences when specifying for different types of ADRs (p > 0.05). Injection intervals were shorter in patients with vs patients without ADRs (p = 0.03). The logistic regression did not report effects for sex, plasma concentrations, or C/D values (p > 0.05). Post hoc analyses in male patients receiving PP1M every 28 weeks reported higher paliperidone concentrations and C/D values in patients with vs without ADRs (p = 0.049 and p = 0.022). Within the group of male patients, we found an odds ratio of 3.07 for PP1M-associated ADRs in patients with C/D values above 7.7 (ng/mL)/(mg/day). CONCLUSIONS Our findings did not reveal distinct patterns of paliperidone concentrations in patients with PP1M-related ADRs. However, male patients receiving PP1M every 28 days with C/D values higher than 7.7 (ng/mL)/(mg/day) showed a higher risk for ADRs, implying that therapeutic drug monitoring may be useful in assessing the risk of PP1M-related ADRs.
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Koizumi T, Suzuki T, Pillai NS, Bies RR, Takeuchi H, Yoshimura K, Mimura M, Uchida H. Circadian patterns of hallucinatory experiences in patients with schizophrenia: Potentials for chrono-pharmacology. J Psychiatr Res 2019; 117:1-6. [PMID: 31254838 DOI: 10.1016/j.jpsychires.2019.06.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 11/15/2022]
Abstract
The objective of this study was to investigate possible circadian pattern of psychotic symptoms in patients with schizophrenia, which could be reflected on the dosing schedule/regimen, i.e. chrono-pharmacology. Patients with schizophrenia (ICD-10) who reported having auditory hallucination, receiving monotherapy with risperidone, olanzapine or paliperidone for at least two weeks were included. The subjects were provided a diary and asked to record the time and duration of auditory hallucinations during the eight time periods (i.e. 00:00-03:00, 03:00-06:00, 06:00-09:00, 09:00-12:00, 12:00-15:00, 15:00-18:00, 18:00-21:00, and 21:00-24:00). In the diary, times of medication doses and sleep were also recorded. Time and degree of peak and trough dopamine D2 receptor blockade with antipsychotics were estimated from 2 sparsely collected plasma drug concentrations. The prevalence and duration of auditory hallucinations were statistically examined among the eight time periods, respectively. Forty-nine patients participated in this study (mean ± SD age, 50.7 ± 14.8 years; 36 men (73.5%); 34 inpatients (69.4%)). Auditory hallucinations occurred most frequently and lasted for the longest duration in the period of 18:00-21:00 (75.5% (37/49) and 1.37 ± 1.67 h). This happened despite the fact that the difference in D2 receptor occupancy between the peak and trough was less than 2%, indicating a stable drug delivery. Since the dopamine D2 receptor blockade by antipsychotics was stable, the nocturnal circadian pattern found in this study may reflect intrinsic dopaminergic fluctuation or generally quieter environments at night. These circadian patterns may be considered to devise individualized treatment approach in the context of "chrono-pharmacology" for patients with schizophrenia.
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Affiliation(s)
- Teruki Koizumi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Department of Psychiatry National Hospital Organization Shimofusa Psychiatric Medical Center, Chiba, Japan
| | - Takefumi Suzuki
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Department of Neuropsychiatry and Clinical Ethics. University of Yamanashi, Yamanashi, Japan
| | - Nikhil Sasidharan Pillai
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Computational and Data Enabled Sciences Program, University at Buffalo, Buffalo, NY, USA
| | - Robert R Bies
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Computational and Data Enabled Sciences Program, University at Buffalo, Buffalo, NY, USA
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Kimio Yoshimura
- Department of Health Policy and Management, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Geriatric Mental Health Program, Centre for Addiction and Mental Health, Toronto, ON, Canada.
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Pérez-Ruixo C, Remmerie B, Peréz-Ruixo JJ, Vermeulen A. A Receiver Operating Characteristic Framework for Non-adherence Detection Using Drug Concentration Thresholds-Application to Simulated Risperidone Data in Schizophrenic Patients. AAPS JOURNAL 2019; 21:40. [PMID: 30874997 DOI: 10.1208/s12248-019-0299-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 01/12/2019] [Indexed: 01/10/2023]
Abstract
Non-adherence to antipsychotic medication is a primary factor in disease relapse in schizophrenic patients. We sought to evaluate if plasma concentrations of the antipsychotic risperidone can be used as a predictor of treatment adherence and to identify the optimal plasma concentration threshold to reliably distinguish between adherent and non-adherent patients. A population pharmacokinetic model was used to simulate plasma risperidone steady-state trough concentrations in 1000 virtual patients, where 60% of the patients were 100% adherent to their medication, while 40% of the patients were non-adherent to their medication. The probability of adherence was assessed by receiver operating characteristic (ROC) analysis on Ctrough. The area under the ROC curve (AUCROC) was used to identify the optimal Ctrough threshold. Single vs multiple Ctrough at steady state was also evaluated. After a single risperidone Ctrough measurement, the AUCROC (95% CI) was estimated to be 0.71 (0.69-0.72) and the optimal Ctrough threshold accounting for the lowest number of adherent and non-adherent misclassifications was estimated to be 11.9 ng/mL. After multiple Ctrough measurements, the AUCROC (95% CI) increased up to 0.85 (0.84-0.87) for three Ctrough measurements. The optimal probability threshold to reliably discriminate between adherent and non-adherent patients was estimated to be 0.51. Using this model which is reflective of typical adherence to antipsychotic medication, we found that three consecutive steady-state Ctrough measurements are needed for an accurate and precise diagnostic test to discriminate between patients who are adherent or non-adherent to treatment.
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Affiliation(s)
- Carlos Pérez-Ruixo
- Janssen Research & Development, Clinical Pharmacology & Pharmacometrics, Beerse, Belgium.
| | - Bart Remmerie
- Janssen Research & Development, Clinical Pharmacology & Pharmacometrics, Beerse, Belgium
| | - Juan José Peréz-Ruixo
- Janssen Research & Development, Clinical Pharmacology & Pharmacometrics, Beerse, Belgium
| | - An Vermeulen
- Janssen Research & Development, Quantitative Sciences Consulting, Beerse, Belgium
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10
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Melkote R, Singh A, Vermeulen A, Remmerie B, Savitz A. Relationship between antipsychotic blood levels and treatment failure during the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study. Schizophr Res 2018; 201:324-328. [PMID: 29804929 DOI: 10.1016/j.schres.2018.05.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 04/13/2018] [Accepted: 05/14/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Antipsychotic blood levels (ABLs) may help identify patients at risk for treatment failure. Reference ranges (RR) for plasma concentrations of ABLs that account for between-patient variability were developed for risperidone and olanzapine based on population pharmacokinetic models. The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) collected clinical outcomes and ABLs, allowing testing of the relationship of ABLs with outcomes. METHODS ABLs from 694 patients who were randomized to olanzapine or risperidone were compared to the 80% RRs and were assessed as below or within/above the RR. Treatment failure was defined per any of these criteria: (1) emergency room visit for psychiatric reasons, (2) hospitalization for psychiatric reasons, (3) adverse event of completed suicide, suicidal ideation, or suicide attempt, (4) assaultive behavior, (5) arrested or jailed, (6) 2-point increase from baseline in Clinical Global Impression-Severity score, (7) 25% increase in Positive and Negative Syndrome Scale total score. Patients assessed with treatment failure within 100 days of drug concentration measurement were analyzed. RESULTS Treatment failure occurred in 126 of 323 patients. The proportion of patients with ABLs below RR was 18.3% (59/323) compared to 10% expected in a fully adherent population. Among the 59 with ABLs below RR, 50.8% had treatment failure (compared to 36.4% for the 264 with ABLs within/above RR). The difference between groups was significant (odds ratio = 1.810; 95% CI = 1.025, 3.197; p = 0.0408). CONCLUSIONS Analysis of CATIE data showed that ABLs within the context of RRs may identify patients with higher risk of relapse.
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Affiliation(s)
- Rama Melkote
- Quantitative Sciences, 920 Rt. 202, Janssen Research & Development, Raritan, NJ 08869, United States.
| | - Arun Singh
- Neurosciences, Janssen Research & Development, 1800 American Boulevard, Pennington, NJ, 08534, United States
| | - An Vermeulen
- Quantitative Sciences, Janssen Research & Development, A Division of Janssen Pharmaceutica NV, Beerse, Belgium
| | - Bart Remmerie
- Quantitative Sciences, Janssen Research & Development, A Division of Janssen Pharmaceutica NV, Beerse, Belgium
| | - Adam Savitz
- Neurosciences, Janssen Research & Development, 1800 American Boulevard, Pennington, NJ, 08534, United States
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Mauri MC, Paletta S, Di Pace C, Reggiori A, Cirnigliaro G, Valli I, Altamura AC. Clinical Pharmacokinetics of Atypical Antipsychotics: An Update. Clin Pharmacokinet 2018; 57:1493-1528. [DOI: 10.1007/s40262-018-0664-3] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Korell J, Green B, Rae A, Remmerie B, Vermeulen A. Determination of plasma concentration reference ranges for oral aripiprazole, olanzapine, and quetiapine. Eur J Clin Pharmacol 2018; 74:593-599. [PMID: 29392351 DOI: 10.1007/s00228-018-2419-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 01/12/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Schizophrenia is a common disease which is commonly managed using antipsychotic medications (APS). Inadequate response and lack of adherence often prevent optimal therapeutic effectiveness. Monitoring APS concentrations can be useful to help improve outcomes for the patient. AIMS The aim of this study was to develop "reference ranges" for oral aripiprazole, olanzapine, and quetiapine to allow clinicians to understand expected variability in patients treated with APS. The reference ranges were constructed to account for different oral doses, sampling times, and variability both between, and within, subjects. METHODS Population pharmacokinetic models were used to simulate plasma concentrations over time under different doses and population demographics. The references were validated against external data both numerically and graphically. RESULTS Reference ranges for oral aripiprazole, olanzapine, and quetiapine were derived and successfully validated against the external data. The 80% reference range for aripiprazole following a 2-mg oral dose was 14.7-41.6 ng/mL 0-4 h post dose and 10.6-37.1 ng/mL 20-24 h post dose. These ranges increased to 221-624 ng/mL 0-4 h post dose following administration of a 30-mg dose, and 159-557 ng/mL 20-24 h post dose. The 80% reference range 0-4 h post dose was 22.5-67.1 ng/mL following a 15-mg dose once daily of oral olanzapine, and 179-768 ng/mL following a 150-mg dose once daily of oral quetiapine. CONCLUSIONS Comparing individual patients' APS levels with reference ranges, along with a full clinical assessment, could provide important insights to help a clinician optimize APS therapy.
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Affiliation(s)
- Julia Korell
- Model Answers Pty Ltd, Level 5, 99 Creek Street, Brisbane, QLD, 4000, Australia
| | - Bruce Green
- Model Answers Pty Ltd, Level 5, 99 Creek Street, Brisbane, QLD, 4000, Australia.
| | - Allan Rae
- Model Answers Pty Ltd, Level 5, 99 Creek Street, Brisbane, QLD, 4000, Australia
| | - Bart Remmerie
- Janssen R&D, Janssen Pharmaceutica NV, Beerse, Belgium
| | - An Vermeulen
- Janssen R&D, Janssen Pharmaceutica NV, Beerse, Belgium
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