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Campos MG, China M, Cláudio M, Capinha M, Torres R, Oliveira S, Fortuna A. Drug-Cannabinoid Interactions in Selected Therapeutics for Symptoms Associated with Epilepsy, Autism Spectrum Disorder, Cancer, Multiple Sclerosis, and Pain. Pharmaceuticals (Basel) 2024; 17:613. [PMID: 38794183 PMCID: PMC11124308 DOI: 10.3390/ph17050613] [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: 02/06/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/26/2024] Open
Abstract
Clinical practice entails a translation of research that assists in the use of scientific data and therapeutic evidence for the benefit of the patient. This review critically summarizes the potential impact of cannabinoids in conjunction with other drugs when associated with treatments for epilepsy, autism spectrum disorder, cancer, multiple sclerosis, and chronic pain. In these associations, potential drug interactions may occur and alter the predicted clinical results. Therefore, the potential for drug interactions must always be assessed to avoid therapeutic failures and/or increased side effects. Some effects may be additive, synergistic, or antagonistic, but changes in absorption, distribution, metabolism, particularly through cytochrome P450 (CYP) isoenzymes (e.g., CYP2C9 and CYP3A4), and excretion may also occur. For example, the combination of cannabis-derived compounds and the antifungal drug ketoconazole, a CYP3A4 inhibitor, increases the plasma concentration of Δ-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). In contrast, rifampicin, a CYP3A4 inducer, stands out for reducing plasma THC levels by approximately 20-40% and 50% to 60% for CBD. Other CYP3A4 inhibitors and inducers are likely to have a similar effect on plasma concentrations if co-administered. Pharmacokinetic interactions with anticonvulsant medications have also been reported, as have pharmacodynamic interactions between cannabinoids and medications with sympathomimetic effects (e.g., tachycardia, hypertension), central nervous system depressants (e.g., drowsiness, ataxia), and anticholinergics (e.g., tachycardia and somnolence). Although further studies are still pending, there is currently clinical evidence supporting drug interactions with cannabinoids, requiring doctors to evaluate the risk of drug combinations with cannabinoids and vice versa. The tables provided here were designed to facilitate the identification of biorelevant interactions that may compromise therapeutic efficacy and toxicity.
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Affiliation(s)
- Maria G. Campos
- Observatory of Drug-Herb Interactions, Faculty of Pharmacy, University of Coimbra, Health Science Campus, Azinhaga Santa Comba, 3000-548 Coimbra, Portugal; (M.C.); (S.O.)
- Coimbra Chemistry Centre (CQC, FCT Unit 313) (FCTUC), University of Coimbra, Rua Larga, 3004-531 Coimbra, Portugal
| | - Maria China
- Observatory of Drug-Herb Interactions, Faculty of Pharmacy, University of Coimbra, Health Science Campus, Azinhaga Santa Comba, 3000-548 Coimbra, Portugal; (M.C.); (S.O.)
| | - Mariana Cláudio
- Observatory of Drug-Herb Interactions, Faculty of Pharmacy, University of Coimbra, Health Science Campus, Azinhaga Santa Comba, 3000-548 Coimbra, Portugal; (M.C.); (S.O.)
| | - Miguel Capinha
- Observatory of Drug-Herb Interactions, Faculty of Pharmacy, University of Coimbra, Health Science Campus, Azinhaga Santa Comba, 3000-548 Coimbra, Portugal; (M.C.); (S.O.)
| | - Rita Torres
- Observatory of Drug-Herb Interactions, Faculty of Pharmacy, University of Coimbra, Health Science Campus, Azinhaga Santa Comba, 3000-548 Coimbra, Portugal; (M.C.); (S.O.)
| | - Simão Oliveira
- Observatory of Drug-Herb Interactions, Faculty of Pharmacy, University of Coimbra, Health Science Campus, Azinhaga Santa Comba, 3000-548 Coimbra, Portugal; (M.C.); (S.O.)
| | - Ana Fortuna
- Observatory of Drug-Herb Interactions, Faculty of Pharmacy, University of Coimbra, Health Science Campus, Azinhaga Santa Comba, 3000-548 Coimbra, Portugal; (M.C.); (S.O.)
- Laboratory of Pharmacology and Pharmaceutical Care, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- CIBIT—Coimbra Institute for Biomedical Imaging and Translational Research, ICNAS, University of Coimbra, 3000-548 Coimbra, Portugal
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Murata T, Uno K, Nagamine T. Guanfacine Used With Antipsychotics May Cause Bradycardia to Become Apparent After Discontinuation of Antipsychotics. Am J Ther 2024:00045391-990000000-00170. [PMID: 38241083 DOI: 10.1097/mjt.0000000000001654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
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Pagán AF, Huizar YP, Short TR, Gotcher Z, Schmidt AT. Adult Attention-Deficit/Hyperactivity Disorder: a Narrative Review of Biological Mechanisms, Treatments, and Outcomes. Curr Neurol Neurosci Rep 2023:10.1007/s11910-023-01280-4. [PMID: 37335460 DOI: 10.1007/s11910-023-01280-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE OF REVIEW Attention-deficit/hyperactivity disorder (ADHD) is a heterogeneous and complex neurodevelopmental disorder related to disruptions in various neuronal structures and pathways, dopamine (DA) transporter, and receptor genes, resulting in cognitive and regulation deficits. This article reviews recent research on the biological mechanisms and markers, clinical manifestations, treatments, and outcomes of adult ADHD as well as current controversies within the field. RECENT FINDINGS New research identifies white matter disruptions in multiple cortical pathways in adults with ADHD. New treatments for ADHD in adults such as viloxazine ER have shown preliminary effectiveness in addition to research showing transcranial direct current stimulation can be an effective treatment for adults with ADHD. Although questions exist about the effectiveness of current assessments of and treatments for adult ADHD, recent findings represent a step towards improving the quality of life and outcomes for individuals experiencing this life-long, chronic health condition.
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Affiliation(s)
- Antonio F Pagán
- Department of Psychological Sciences, Texas Tech University, Psychological Sciences Building, 2700 18th St, Lubbock, TX, 79410, USA.
| | - Yazmine P Huizar
- Department of Psychological Sciences, Texas Tech University, Psychological Sciences Building, 2700 18th St, Lubbock, TX, 79410, USA
| | - Tucker R Short
- Department of Psychological Sciences, Texas Tech University, Psychological Sciences Building, 2700 18th St, Lubbock, TX, 79410, USA
| | - Zoe Gotcher
- Department of Psychological Sciences, Texas Tech University, Psychological Sciences Building, 2700 18th St, Lubbock, TX, 79410, USA
| | - Adam T Schmidt
- Department of Psychological Sciences, Texas Tech University, Psychological Sciences Building, 2700 18th St, Lubbock, TX, 79410, USA
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Topriceanu CC, Moon JC, Captur G, Perera B. The use of attention-deficit hyperactivity disorder medications in cardiac disease. Front Neurosci 2022; 16:1020961. [PMID: 36340760 PMCID: PMC9626759 DOI: 10.3389/fnins.2022.1020961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/03/2022] [Indexed: 09/02/2023] Open
Abstract
Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder with onset usually in childhood characterized by inattention, impulsivity, and hyperactivity causing a functional impairment. Untreated ADHD, or treatment delay is associated with adverse outcomes and poor quality of life. Although conservative management strategies such as behavioral and psychological interventions are important, pharmacological treatment has a strong evidence base with improved outcomes. ADHD medications are broadly divided into stimulant and non-stimulant medications. Stimulant medications are generally more effective than non-stimulants. Cardiovascular safety of ADHD medication has been a matter of debate for decades. Treatment guidelines advise the careful consideration of risks and benefits in people with cardiovascular diseases such as congenital heart disease or cardiomyopathy. Although stimulants can increase systemic blood pressure and heart rate, no significant associations were found between their use and serious cardiovascular events. Concerns regarding QT effects and attendant sudden cardiac death risks deter clinicians from initiating much-needed ADHD medications in patients with heart disease. This overly cautious approach is potentially depriving low-risk individuals from significant benefits associated with timely ADHD drug treatment. This review discusses the cardiovascular risks reportedly associated with ADHD medications, the evidence base for their safe usage in persons with established cardiovascular disease, and highlights future research directions.
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Affiliation(s)
- Constantin-Cristian Topriceanu
- Barnet, Enfield and Haringey Mental Health Trust, London, United Kingdom
- UCL Institute of Cardiovascular Science, University College London, London, United Kingdom
- UCL MRC Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
- Cardiac MRI Unit, Barts Heart Centre, London, United Kingdom
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, United Kingdom
| | - James C. Moon
- UCL Institute of Cardiovascular Science, University College London, London, United Kingdom
- Cardiac MRI Unit, Barts Heart Centre, London, United Kingdom
| | - Gabriella Captur
- UCL Institute of Cardiovascular Science, University College London, London, United Kingdom
- UCL MRC Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
- Department of Cardiology, Centre for Inherited Heart Muscle Conditions, The Royal Free Hospital, London, United Kingdom
| | - Bhathika Perera
- Barnet, Enfield and Haringey Mental Health Trust, London, United Kingdom
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Law R, Lewis D, Hain D, Daut R, DelBello MP, Frazier JA, Newcorn JH, Nurmi E, Cogan ES, Wagner S, Johnson H, Lanchbury J. Characterisation of seven medications approved for attention-deficit/hyperactivity disorder using in vitro models of hepatic metabolism. Xenobiotica 2022; 52:676-686. [PMID: 36317558 DOI: 10.1080/00498254.2022.2141151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The metabolism of most medications approved for the treatment of attention deficit/hyperactivity disorder (ADHD) is not fully understood.In vitro studies using cryopreserved, plated human hepatocytes (cPHHs) and pooled human liver microsomes (HLMs) were performed to more thoroughly characterise the metabolism of several ADHD medications.The use of enzyme-specific chemical inhibitors indicated a role for CYP2D6 in atomoxetine (ATX) metabolism, and roles for CYP3A4/5 in guanfacine (GUA) metabolism.The 4-hydroxy-atomoxetine and N-desmethyl-atomoxetine pathways represented 98.4% and 1.5% of ATX metabolism in cPHHs, respectively. The 3-OH-guanfacine pathway represented at least 2.6% of GUA metabolism in cPHHs, and 71% in HLMs.The major metabolising enzyme for methylphenidate (MPH) and dexmethylphenidate (dMPH) could not be identified using these methods because these compounds were too unstable. Hydrolysis of these medications was spontaneous and did not require the presence of protein to occur.Clonidine (CLD), amphetamine (AMPH), and dextroamphetamine (dAMPH) did not deplete substantially in cPHHs nor HLMs, suggesting that these compounds may not undergo considerable hepatic metabolism. The major circulating metabolites of AMPH and dAMPH (benzoic acid and hippuric acid) were not observed in either system, and therefore could not be characterised. Additionally, inhibition experiments suggested a very minimal role for CYP2D6 in CLD and AMPH metabolism.
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Affiliation(s)
| | | | | | | | - Melissa P DelBello
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Jean A Frazier
- Eunice Kennedy Shriver Center, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | - Erika Nurmi
- Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, Los Angeles, CA, USA
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Nonstimulant Treatments for ADHD. Child Adolesc Psychiatr Clin N Am 2022; 31:417-435. [PMID: 35697393 DOI: 10.1016/j.chc.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Nonstimulants have an important role when response or tolerability to psychostimulants is poor, when certain comorbid disorders are present, or if patients prefer nonstimulants. Here, we discuss monotherapy and combined treatment of ADHD and review mechanism of action, pharmacokinetics, efficacy, tolerability, and safety of approved, off-label, and pipeline nonstimulants. We present detailed information regarding the 4 FDA-approved nonstimulant medications-the norepinephrine reuptake inhibitors, atomoxetine and viloxazine extended release, and the α-2 adrenergic agonists, clonidine XR and guanfacine XR. We additionally review evidence regarding the off-label use of a variety of other medications. Variability across and within drug classes in nature of response, approach to titration, and temporal characteristics of treatment allow a nuanced treatment approach for individuals with comorbid disorders and complicated clinical presentations. Availability of nonstimulant medications enhances our opportunity to offer personalized treatment of ADHD across the lifespan.
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Monteith S, Glenn T. Comparison of potential psychiatric drug interactions in six drug interaction database programs: A replication study after 2 years of updates. Hum Psychopharmacol 2021; 36:e2802. [PMID: 34228368 DOI: 10.1002/hup.2802] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Drug interaction database programs are a fundamental clinical tool. In 2018, we compared the category of potential drug-drug interaction (DDI) provided by six drug interaction database programs for 100 drug interaction pairs including psychiatric drugs, and found the category often differed. This study replicated the comparison in 2020 after 2 years of updates to all six drug interaction database programs. METHODS The 100 drug pairs included 94 different drugs: 67 pairs with a psychiatric and non-psychiatric drug, and 33 pairs with two psychiatric drugs. The assigned category of potential DDI for the drug pairs was compared using percent agreement and Fleiss kappa statistic of interrater reliability. RESULTS Despite 67 updates involving 46 of the 100 drug pairs, differences remained. The overall percent agreement among the six drug interaction database programs for the category of potential DDI was 67%. The interrater agreement results did not change. The Fleiss kappa overall interrater agreement was fair. The kappa agreement for a drug pair with any severe category rating was substantial, and the kappa agreement for a drug pair with any major category rating was fair. CONCLUSIONS Physicians should be aware of the inconsistency among drug interaction database programs in the category of potential DDI for drug pairs including psychiatric drugs. Additionally, the category of potential DDI for a drug pair may change over time. This study highlights the importance of ongoing international efforts to standardize methods used to define and classify potential DDI.
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Affiliation(s)
- Scott Monteith
- Michigan State University College of Human Medicine, Department of Psychiatry, Traverse City Campus, Traverse City, Michigan, USA
| | - Tasha Glenn
- ChronoRecord Association, Fullerton, California, USA
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Jaeschke RR, Sujkowska E, Sowa-Kućma M. Methylphenidate for attention-deficit/hyperactivity disorder in adults: a narrative review. Psychopharmacology (Berl) 2021; 238:2667-2691. [PMID: 34436651 PMCID: PMC8455398 DOI: 10.1007/s00213-021-05946-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/31/2021] [Indexed: 12/12/2022]
Abstract
RATIONALE Psychostimulants, including methylphenidate (MPH), are the mainstay of pharmacotherapy for attention-deficit/hyperactivity disorder (ADHD) in adults. Even though MPH is the most commonly used medication for ADHD these days, there are relatively few resources available that provide comprehensive insight into the pharmacological and clinical features of the compound. OBJECTIVE The aim of this paper is to provide an up-to-date outline of the pharmacology and clinical utility of MPH for ADHD in adult patients. METHODS While conducting the narrative review, we applied structured search strategies covering the two major online databases (MEDLINE and Cochrane Central Register of Controlled Trials). In addition, we performed handsearching of reference lists of relevant papers. RESULTS Methylphenidate exhibits multimodal mechanism of action, working primarily as a dopamine and noradrenaline reuptake inhibitor. It also protects the dopaminergic system against the ongoing 'wearing off' (by securing a substantial reserve pool of the neurotransmitter, stored in the presynaptic vesicles). In placebo-controlled trials, MPH was shown to be moderately effective both against the core ADHD symptoms (standardized mean difference [SMD], 0.49; 95% confidence interval [CI], 0.35-0.64), and the accompanying emotion regulation deficits (SMD, 0.34; 95% CI, 0.23-0.45). The most common adverse events related to long-term treatment with MPH are decreased appetite (~ 20%), dry mouth (15%), heart palpitations (13%), gastrointestinal infections (~ 10%), and agitation/feeling restless (~ 10%). CONCLUSIONS There is substantial body of evidence to suggest that MPH is an effective and safe treatment option for adults with ADHD.
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Affiliation(s)
- Rafał R Jaeschke
- Section of Affective Disorders, Department of Psychiatry, Jagiellonian University Medical College, ul. Kopernika 21a, 31-501, Kraków, Poland.
| | - Ewelina Sujkowska
- Department of Human Physiology, Institute of Medical Sciences, Medical College of Rzeszów University, ul. Kopisto 2a, 35-315, Rzeszów, Poland
| | - Magdalena Sowa-Kućma
- Department of Human Physiology, Institute of Medical Sciences, Medical College of Rzeszów University, ul. Kopisto 2a, 35-315, Rzeszów, Poland
- Centre for Innovative Research in Medical and Natural Sciences, Medical College of Rzeszów University, ul. Warzywna 1a, 35-310, Rzeszów, Poland
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Lapato DM, Moore AA, Findling R, Brown RC, Roberson-Nay R. An Update on Precision Medicine Advances In Neurodevelopmental Disorders. Psychiatr Ann 2021; 51:175-184. [PMID: 37609560 PMCID: PMC10443929 DOI: 10.3928/00485713-20210309-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Neurodevelopmental disorders, including autism spectrum disorder (ASD) and attention-deficit/hyper-activity disorder (ADHD), represent a group of conditions that manifest early in child development and produce impairments across multiple domains of functioning. Although a number of pharmacological and psychosocial treatments exist to improve the symptoms associated with these syndromes, treatment advances have lagged. The Precision Medicine Initiative was launched with the goal of revolutionizing medicine by progressing beyond the historical one-size-fits-all approach. In this review, we evaluate current research efforts to personalize treatments for ASD and ADHD. Most pharmacogenetic testing has focused on the cytochrome P450 enzyme family with a particular focus on CYP2D6 and CYP2C19, which are genes that produce an enzyme that acts as a key metabolizer of many prescribed medications. This article provides an update on the state of the field of pharmacogenetics and "therapy-genetics" in the context of ASD and ADHD, and it also encourages clinicians to follow US Food and Drug Administration recommendations regarding pharmacogenetic testing.
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Affiliation(s)
- Dana M. Lapato
- Department of Human and Molecular Genetics, Virginia Commonwealth University
- Virginia Institute of Psychiatric and Behavioral Genetics, Virginia Commonwealth University
| | - Ashlee A. Moore
- Virginia Institute of Psychiatric and Behavioral Genetics, Virginia Commonwealth University
- Department of Psychiatry Virginia Commonwealth University
| | | | - Ruth C. Brown
- Virginia Institute of Psychiatric and Behavioral Genetics, Virginia Commonwealth University
- Department of Psychiatry Virginia Commonwealth University
| | - Roxann Roberson-Nay
- Virginia Institute of Psychiatric and Behavioral Genetics, Virginia Commonwealth University
- Department of Psychiatry Virginia Commonwealth University
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Schjøtt J, Heitmann K, Bakkebø T, Jahnsen JA. Review of Questions Concerning Clinical Drug Interactions in ADHD Treatment From Physicians in Norway. Front Pharmacol 2021; 11:607915. [PMID: 33408633 PMCID: PMC7780923 DOI: 10.3389/fphar.2020.607915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/26/2020] [Indexed: 11/13/2022] Open
Abstract
Pharmacological treatment of attention deficit hyperactivity disorder (ADHD) is challenging due to a wide age span among patients, risk of reduced adherence, and comorbidities like psychiatric disorders and drug addiction. Drugs used for ADHD are associated with risk of interactions and adverse drug reactions due to their potent pharmacological effect. In this brief report we aimed to describe real-world problem areas concerning interactions in pharmacotherapy of ADHD. We reviewed questions to a Norwegian drug information center from physicians concerning drug-drug interactions involving ADHD drugs in the last 10-year period. Questions were retrieved by a combination of indexed and Boolean database searches, in addition to manual inspection. ADHD drugs and interacting drugs were defined according to the Anatomical Therapeutic Chemical (ATC) classification system. Interactions were classified by use of Stockley’s Interactions Checker (SIC). Answers were examined with regard to whether the advice from the drug information center was more restrictive, similar or more liberal than SIC when assessing drug combinations. We retrieved 61 questions that included assessment of 96 drug combinations, and found 33 potential interactions according to SIC. Methylphenidate was involved in more than 50% of the interactions, and interacting drugs were in nearly 70% of the cases from ATC-group N (Nervous system) with antidepressants most frequently involved. Seventy percent of the interactions were pharmacodynamic, and interactions were frequently described as potentially severe although they were based on theoretical evidence. All the 33 interactions could be handled with monitoring or adjusting dose or with informative measures, and none was contraindicated according to SIC. More than 90% of the questions came from physicians in hospitals or outpatient specialist practice, and questions mainly concerned adults. In 75% of the drug combinations that involved ADHD drugs, we found similar advice from SIC and the drug information center. Our results suggest that future drug information efforts in ADHD treatment to clinicians, including specialists in the field, should focus on psychotropic interactions.
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Affiliation(s)
- Jan Schjøtt
- Regional Medicines Information and Pharmacovigilance Centres (RELIS Vest), Haukeland University Hospital, Bergen, Norway.,Department of Clinical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Kristine Heitmann
- Regional Medicines Information and Pharmacovigilance Centres (RELIS Vest), Haukeland University Hospital, Bergen, Norway.,Department of Clinical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Tina Bakkebø
- Regional Medicines Information and Pharmacovigilance Centres (RELIS Vest), Haukeland University Hospital, Bergen, Norway.,Department of Clinical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Jan Anker Jahnsen
- Regional Medicines Information and Pharmacovigilance Centres (RELIS Vest), Haukeland University Hospital, Bergen, Norway.,Department of Clinical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
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Management of anxiety disorders in children with attention-deficit hyperactivity disorder: a narrative review. Int Clin Psychopharmacol 2021; 36:1-11. [PMID: 33086253 DOI: 10.1097/yic.0000000000000338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anxiety disorders are common comorbidities of attention deficit/hyperactivity disorder (ADHD) and conversely, ADHD is prevalent among anxious youths. A variety of treatments, both psychopharmacological and nonpsychopharmacological, are used to manage combined ADHD/anxiety disorder. This article aims to review the literature on the treatment of ADHD with comorbid anxiety disorders, and make evidence-based recommendations for clinical practice. In most cases, when ADHD is the primary condition, stimulants are the first-line of treatment, frequently resulting not only in improvement in ADHD symptoms but also alleviating the symptoms of the comorbid anxiety disorder. Stimulant treatment is relatively safe and well-tolerated in ADHD with comorbid anxiety disorder. When the stimulant administration does not attenuate the severity of the comorbid anxiety disorder, a treatment that targets specifically the anxiety disorder should be added. This recommendation, however, might be challenged by the impressive efficacy of atomoxetine for both the ADHD and anxiety disorder symptoms. Adjunctive cognitive-behavior therapy for anxiety disorder symptoms is strongly recommended and is considered superior to medication alone. Other options include adding pharmacological treatment for the anxiety symptoms. In moderate and severe cases of comorbid Ads, selective serotonin reuptake inhibitors can be added to the stimulants, with the required caution.
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Kim E, Heo YA. Consider clinically relevant pharmacokinetic drug interactions when co-prescribing drugs in attention-deficit/hyperactivity disorder. DRUGS & THERAPY PERSPECTIVES 2020. [DOI: 10.1007/s40267-020-00749-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Schoretsanitis G, Haen E, Conca A, Piacentino D, Ridders F, Hiemke C, Gründer G, Paulzen M. Lack of Smoking Effects on Pharmacokinetics of Oral Paliperidone-analysis of a Naturalistic Therapeutic Drug Monitoring Sample. PHARMACOPSYCHIATRY 2020; 54:31-35. [PMID: 32767297 DOI: 10.1055/a-1221-5293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Major smoking effects have been reported for a series of psychotropic agents, mainly including substrates of CYP450 1A2, although smoking may also affect alternative metabolic pathways. To our knowledge, smoking effects on paliperidone pharmacokinetics have not been assessed yet. METHODS We compared plasma concentrations of paliperidone as well as dose-corrected-plasma concentrations (C/D) from a naturalistic database between smokers and nonsmokers using nonparametrical tests, such as the Mann-Whitney U-test (MWU). Additionally, we compared light and heavy smokers with nonsmokers separately. RESULTS Comparing 55 smokers with 37 nonsmokers treated with oral paliperidone, no differences in the percentage of females, age, body weight, body mass index, and daily paliperidone dose were reported (p=0.709 for χ2, p=0.26, p=0.38, p=0.67, and p=0.8 for MWU). No differences were detected in plasma concentrations or C/D values (p=0.50 and p=0.96 for MWU). Likewise, differences in daily dose, plasma concentrations, or C/D values were not significant between light smokers (n=17) and nonsmokers (p=0.61, p=0.81, and p=0.33 for MWU) or heavy smokers (n=22) and nonsmokers (p=0.874, p=0.38, and p=0.59; MWU in all cases). DISCUSSION Paliperidone is not affected by smoking, and paliperidone dose-adjustments in smokers may not be necessary. This may be seen as an essential difference to risperidone, whose cytochrome-mediated metabolism might be affected by smoking.
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Affiliation(s)
- Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA
| | - Ekkehard Haen
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Andreas Conca
- Servizio Psichiatrico del Comprensorio Sanitario di Bolzano, Bolzano, Italy
| | - Daria Piacentino
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, 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, USA
| | - Florian Ridders
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy and Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of 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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Kuzin M, Schoretsanitis G, Haen E, Ridders F, Hiemke C, Gründer G, Paulzen M. Pharmacokinetic interactions between clozapine and sertraline in smokers and non-smokers. Basic Clin Pharmacol Toxicol 2020; 127:303-308. [PMID: 32307853 DOI: 10.1111/bcpt.13421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 11/30/2022]
Abstract
Clozapine is an effective antipsychotic drug for treatment-resistant schizophrenia. Sertraline is a widely prescribed antidepressant and often concomitantly applied to address negative symptoms or depression. However, data on interactions between clozapine and sertraline are inconsistent. The aim of our study was to evaluate pharmacokinetic interactions between clozapine and sertraline analysing a therapeutic drug monitoring database of 1644 clozapine-medicated patients. We compared four groups: non-smokers (n = 250) and smokers (n = 326) with co-medication without known effects on cytochrome P450 and without sertraline, and non-smokers (n = 18) and smokers (n = 17) with sertraline co-medication. Measured and dose-corrected concentrations (C/D) of clozapine were compared between the groups using non-parametrical tests with a significance level of 0.05. Post hoc analyses included pairwise comparisons to account for smoking status. Although we detected significant differences for clozapine levels and C/D values between study groups (P < .001 for Kruskal-Wallis test in both cases), post hoc analyses revealed no differences for concentrations and C/D values of clozapine (P > .05 for Mann-Whitney U test in both cases). A negative correlation between the sertraline dose and the clozapine concentration was found in non-smokers (Spearman's rank correlation, rs = -0.535, P = .048). A potential pharmacokinetic interaction between clozapine and a standard therapeutic sertraline dose seems to be of minor clinical importance.
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Affiliation(s)
- Maxim Kuzin
- Psychiatric and Psychotherapeutic Private Clinic Clienia Schlössli, Academic Teaching Hospital of the University of Zurich, Oetwil am See, Switzerland
| | | | - Ekkehard Haen
- Department of Psychiatry and Psychotherapy, Clinical Pharmacology, University of Regensburg, Regensburg, Germany.,Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Florian Ridders
- Department of Psychiatry and Psychotherapy, Clinical Pharmacology, University of Regensburg, Regensburg, Germany.,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
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany.,JARA - Translational Brain Medicine, Jülich, Germany.,Alexianer Hospital Aachen, Aachen, Germany
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15
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Schoretsanitis G, Spigset O, Stingl JC, Deligiannidis KM, Paulzen M, Westin AA. The impact of pregnancy on the pharmacokinetics of antidepressants: a systematic critical review and meta-analysis. Expert Opin Drug Metab Toxicol 2020; 16:431-440. [PMID: 32238008 DOI: 10.1080/17425255.2020.1750598] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Pregnancy-related physiological changes exert a crucial impact on the pharmacokinetics of antidepressants; however, the current evidence presents inconsistencies. A clearer understanding of pregnancy-related effects on antidepressant disposition may facilitate the development of guidelines for appropriate dose adjustments during the course of pregnancy based on therapeutic drug monitoring.Areas covered: We systematically reviewed studies comparing antidepressant levels in the same individuals during pregnant and non-pregnant states. Using dose-adjusted plasma concentration measurements, we estimated alteration ratios between the 3rd trimester and baseline (before or after pregnancy). Additionally, we performed a meta-analysis for changes in dose-adjusted concentrations to estimate mean differences.Expert opinion: Data for several antidepressants display clear alteration patterns during pregnancy. On the basis of the alteration ratios trimipramine, fluvoxamine, and nortriptyline show a prominent decrease in dose-adjusted levels, especially in the 3rd trimester. Clomipramine, imipramine, citalopram, and paroxetine show smaller decreases in dose-adjusted concentrations in the third trimester. For escitalopram, venlafaxine and fluoxetine, changes are considered negligible. For sertraline, there was a tendency toward increased dose-adjusted concentrations in pregnancy. Available evidence suffers from major limitations and factors affecting pharmacokinetics have been insufficiently addressed. Further research is required to promote knowledge on pregnancy effects on antidepressant pharmacokinetics.
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Affiliation(s)
- Georgios Schoretsanitis
- The Zucker Hillside Hospital, Department of Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
| | - Olav Spigset
- Department of Clinical Pharmacology, St Olav University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Julia C Stingl
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, Aachen, Germany
| | - Kristina M Deligiannidis
- The Zucker Hillside Hospital, Department of Psychiatry Research, Northwell Health, Glen Oaks, NY, USA.,Zucker School of Medicine, Hempstead, New York, Manhasset, New York, USA.,The Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Michael Paulzen
- Alexianer Hospital Aachen, Aachen, Germany and Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, and JARA - Translational Brain Medicine, Aachen, Germany
| | - Andreas A Westin
- Department of Clinical Pharmacology, St Olav University Hospital, Trondheim, Norway
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