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Frey M, Smigielski L, Tini E, Fekete S, Fleischhaker C, Wewetzer C, Karwautz A, Correll CU, Gerlach M, Taurines R, Plener PL, Malzahn U, Kornbichler S, Weninger L, Brockhaus M, Reuter-Dang SY, Reitzle K, Rock H, Imgart H, Heuschmann P, Unterecker S, Briegel W, Banaschewski T, Fegert JM, Hellenschmidt T, Kaess M, Kölch M, Renner T, Rexroth C, Walitza S, Schulte-Körne G, Romanos M, Egberts KM. Therapeutic Drug Monitoring in Children and Adolescents: Findings on Fluoxetine from the TDM-VIGIL Trial. Pharmaceutics 2023; 15:2202. [PMID: 37765171 PMCID: PMC10534581 DOI: 10.3390/pharmaceutics15092202] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 09/29/2023] Open
Abstract
Fluoxetine is the recommended first-line antidepressant in many therapeutic guidelines for children and adolescents. However, little is known about the relationships between drug dose and serum level as well as the therapeutic serum reference range in this age group. Within a large naturalistic observational prospective multicenter clinical trial ("TDM-VIGIL"), a transdiagnostic sample of children and adolescents (n = 138; mean age, 15; range, 7-18 years; 24.6% males) was treated with fluoxetine (10-40 mg/day). Analyses of both the last timepoint and all timepoints (n = 292 observations), utilizing (multiple) linear regressions, linear mixed-effect models, and cumulative link (mixed) models, were used to test the associations between dose, serum concentration, outcome, and potential predictors. The receiver operating curve and first to third interquartile methods, respectively, were used to examine concentration cutoff and reference values for responders. A strong positive relationship was found between dose and serum concentration of fluoxetine and its metabolite. Higher body weight was associated with lower serum concentrations, and female sex was associated with lower therapeutic response. The preliminary reference ranges for the active moiety (fluoxetine+norfluoxetine) were 208-328 ng/mL (transdiagnostically) and 201.5-306 ng/mL (depression). Most patients showed marked (45.6%) or minimal (43.5%) improvements and reported no adverse effects (64.9%). This study demonstrated a clear linear dose-serum level relationship for fluoxetine in youth, with the identified reference range being within that established for adults.
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Affiliation(s)
- Michael Frey
- Faculty of Applied Healthcare Science, Deggendorf Institute of Technology, 94469 Deggendorf, Germany
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, 80097 Munich, Germany
| | - Lukasz Smigielski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric University Hospital Zurich, University of Zurich, 8032 Zürich, Switzerland; (L.S.)
| | - Elvira Tini
- Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric University Hospital Zurich, University of Zurich, 8032 Zürich, Switzerland; (L.S.)
| | - Stefanie Fekete
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center for Mental Health, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Christian Fleischhaker
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Freiburg, 79104 Freiburg, Germany
| | | | - Andreas Karwautz
- Department of Child and Adolescent Psychiatry, Medical University Vienna, 1090 Vienna, Austria
| | - Christoph U. Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY 11004, USA
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Manfred Gerlach
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center for Mental Health, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Regina Taurines
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center for Mental Health, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Paul L. Plener
- Department of Child and Adolescent Psychiatry, Medical University Vienna, 1090 Vienna, Austria
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital Ulm, 89075 Ulm, Germany
| | - Uwe Malzahn
- Clinical Trial Center Wuerzburg, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Selina Kornbichler
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, 80097 Munich, Germany
| | - Laura Weninger
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, 80097 Munich, Germany
| | | | - Su-Yin Reuter-Dang
- Specialist Practice and Medical Care Centre for Child and Adolescent Psychiatry Munich, Dr. Epple & Dr. Reuter-Dang, 81241 Munich, Germany
| | - Karl Reitzle
- Specialist Practice and Medical Care Center for Child and Adolescent Psychiatry Munich, 81241 Munich, Germany
| | - Hans Rock
- Central Information Office, Department of Neurology, Philipps University of Marburg, 35112 Marburg, Germany
| | - Hartmut Imgart
- Parkland-Clinic, Clinic for Psychosomatics and Psychotherapy, Academic Teaching Hospital for the University Gießen, 34537 Bad Wildungen, Germany
| | - Peter Heuschmann
- Clinical Trial Center Wuerzburg, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
- Institute of Clinical Epidemiology and Biometry, University of Wuerzburg, 97080 Wuerzburg, Germany
| | - Stefan Unterecker
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Wolfgang Briegel
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center for Mental Health, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Leopoldina Hospital, 97422 Schweinfurt, Germany
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, 68159 Mannheim, Germany
| | - Jörg M. Fegert
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital Ulm, 89075 Ulm, Germany
| | - Tobias Hellenschmidt
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatic medicine, Vivantes Clinic Berlin Neukölln, 12351 Berlin, Germany
| | - Michael Kaess
- Clinic for Child and Adolescent Psychiatry, Center for Psychosocial Medicine, University Hospital Heidelberg, 69115 Heidelberg, Germany
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, 3000 Bern, Switzerland
| | - Michael Kölch
- Department of Child and Adolescent Psychiatry and Psychotherapy, Brandenburg Medical School Brandenburg, 16816 Neuruppin, Germany
- Department of Child and Adolescent Psychiatry, Neurology, Psychosomatics, and Psychotherapy, University Medical Center Rostock, 18147 Rostock, Germany
| | - Tobias Renner
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Psychiatry and Psychotherapy Tuebingen, Center of Mental Health Tuebingen, 72076 Tuebingen , Germany
| | - Christian Rexroth
- Clinic for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University of Regensburg at the Regensburg District Hospital, Medbo KU, 93053 Regensburg, Germany
| | - Susanne Walitza
- Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric University Hospital Zurich, University of Zurich, 8032 Zürich, Switzerland; (L.S.)
- Zurich Center for Integrative Human Physiology, University of Zurich, 8057 Zürich, Switzerland
- Neuroscience Center Zurich, University of Zurich and ETH, 8057 Zürich, Switzerland
| | - Gerd Schulte-Körne
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, LMU Munich, 80097 Munich, Germany
| | - Marcel Romanos
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center for Mental Health, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Karin Maria Egberts
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center for Mental Health, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
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Kryst J, Majcher-Maślanka I, Chocyk A. Effects of chronic fluoxetine treatment on anxiety- and depressive-like behaviors in adolescent rodents - systematic review and meta-analysis. Pharmacol Rep 2022; 74:920-946. [PMID: 36151445 PMCID: PMC9584991 DOI: 10.1007/s43440-022-00420-w] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 12/09/2022]
Abstract
Background Drugs prescribed for psychiatric disorders in adolescence should be studied very extensively since they can affect developing and thus highly plastic brain differently than they affect the adult brain. Therefore, we aimed to summarize animal studies reporting the behavioral consequences of chronic exposure to the most widely prescribed antidepressant drug among adolescents i.e., fluoxetine. Methods Electronic databases (Medline via Pubmed, Web of Science Core Collection, ScienceDirect) were systematically searched until April 12, 2022, for published, peer-reviewed, controlled trials concerning the effects of chronic fluoxetine administration vs. vehicle on anxiety and depression measures in naïve and stress-exposed adolescent rodents. All of the relevant studies were selected and critically appraised, and a meta-analysis of eligible studies was performed. Results A total of 18 studies were included in the meta-analysis. In naïve animals, chronic adolescent fluoxetine administration showed dose-related anxiogenic-like effects, measured as a reduction in time spent in the open arms of the elevated plus maze. No significant effects of chronic adolescent fluoxetine on depression-like behavior were reported in naïve animals, while in stress-exposed rodents chronic adolescent fluoxetine significantly decreased immobility time in the forced swim test compared to vehicle. Conclusions These results suggest that although chronic fluoxetine treatment proves positive effects in animal models of depression, it may simultaneously increase anxiety in adolescent animals in a dose-related manner. Although the clinical implications of the data should be interpreted with extreme caution, adolescent patients under fluoxetine treatment should be closely monitored. Supplementary Information The online version contains supplementary material available at 10.1007/s43440-022-00420-w.
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Affiliation(s)
- Joanna Kryst
- Faculty of Physiotherapy, Institute for Basics Sciences, University of Physical Education, Jana Pawła II Av. 78, 31-571, Kraków, Poland
| | - Iwona Majcher-Maślanka
- Department of Pharmacology, Laboratory of Pharmacology and Brain Biostructure, Maj Institute of Pharmacology, Polish Academy of Sciences, Smętna Street 12, 31-343, Kraków, Poland
| | - Agnieszka Chocyk
- Department of Pharmacology, Laboratory of Pharmacology and Brain Biostructure, Maj Institute of Pharmacology, Polish Academy of Sciences, Smętna Street 12, 31-343, Kraków, Poland.
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Ruppert K, Geffert C, Clement HW, Bachmann C, Haberhausen M, Schulz E, Fleischhaker C, Biscaldi-Schäfer M. Therapeutic drug monitoring of atomoxetine in children and adolescents with attention-deficit/ hyperactivity disorder: a naturalistic study. J Neural Transm (Vienna) 2022; 129:945-959. [PMID: 35391568 PMCID: PMC9217867 DOI: 10.1007/s00702-022-02483-8] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/22/2022] [Indexed: 12/02/2022]
Abstract
The selective norepinephrine reuptake inhibitor atomoxetine is potentially among the first-line pharmacotherapy options for ADHD. Therapeutic drug monitoring (TDM) with the quantification and interpretation of atomoxetine serum concentrations is used to determine an individual dose followed by an optimal effectiveness and minimal side effects. The aim of this retrospective pharmacokinetic–pharmacodynamic analysis was to derive age-appropriate recommendations for the implementation of TDM to improve the efficacy and tolerability of atomoxetine in children and adolescents. Using the analytical method of high-performance liquid chromatography with UV detection, 94 serum concentrations of 74 patients between 6 and 21 years of age were determined. Therapeutic effectiveness and side effects were evaluated according to the categories “low”, “moderate”, and “significant”. As part of TDM, a time interval with maximum concentrations of 1–3 h after the administration of atomoxetine was determined for blood sampling. In this time interval, a significant correlation between the weight-normalized dose and the serum concentrations was found. The efficacy as well as the tolerability proved to be mainly moderate or significant. A preliminary therapeutic reference range was between 100 and 400 ng/ml. Naturalistic studies have limitations. Therefore, and due to a limited study population, the results have to be regarded as preliminary observations that must be confirmed in further studies. The preliminary therapeutic reference range for children and adolescents proved to be narrower than the reference range for adult patients. However, due to good efficacy and tolerability an exact reference range remained difficult to determine.
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Affiliation(s)
- Katrin Ruppert
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Hans-Willi Clement
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Bachmann
- Department of Child and Adolescent Psychiatry, University Hospital Marburg, Philipps-University Marburg, Marburg, Germany
- Department of Child and Adolescent Psychiatry and Psychotherapy, University of Ulm, Ulm, Germany
| | - Michael Haberhausen
- Department of Child and Adolescent Psychiatry, University Hospital Marburg, Philipps-University Marburg, Marburg, Germany
| | - Eberhard Schulz
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Fleischhaker
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.
| | - Monica Biscaldi-Schäfer
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
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Egberts K, Fekete S, Häge A, Hiemke C, Scherf-Clavel M, Taurines R, Unterecker S, Gerlach M, Romanos M. [Therapeutic drug monitoring to optimize psychopharmacotherapy in children and adolescents - Update and guidelines for practice]. Z Kinder Jugendpsychiatr Psychother 2022; 50:133-152. [PMID: 35274573 DOI: 10.1024/1422-4917/a000845] [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] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Therapeutic drug monitoring to optimize psychopharmacotherapy in children and adolescents - Update and guidelines for practice Abstract. Despite the improved evidence base, many uncertainties remain in child and adolescent psychiatric pharmacotherapy about the efficacy and tolerability of drugs, which are often prescribed off-label or in combination therapy in this age group. Because medium- to long-term use is unavoidable in many cases, clinicians should minimize adverse drug reactions as far as possible and tailor an effective dosage to the individual characteristics of the patient. Not only are children and adolescents particularly vulnerable to certain adverse drug effects, they are also exposed to iatrogenic risks from dosing or application errors, which can lead to under- or overdosing with correspondingly negative effects on the success of the therapy. In addition to determining a strict indication, it is therefore essential to establish precise dosage and systematic monitoring of the safety of the psychopharmacotherapy. This article introduces therapeutic drug monitoring as a useful clinical tool and describes how its correct application in practice can improve the efficacy as well as the safety and tolerability of psychotropic therapy in children and adolescents for the immediate benefit of patients. Keywords: Psychopharmacotherapy, adverse drug reactions, pharmacovigilance, therapeutic drug monitoring, quality assurance.
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Affiliation(s)
- Karin Egberts
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Stefanie Fekete
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V
| | - Alexander Häge
- Klinik für Psychiatrie und Psychotherapie des Kindes- und Jugendalters, Zentralinstitut für Seelische Gesundheit, Medizinische Fakultät Mannheim, Universität Heidelberg.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Christoph Hiemke
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Mainz.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V
| | - Maike Scherf-Clavel
- Speziallabor für Therapeutisches Drug Monitoring, Klinik und Poliklinik für Psychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V
| | - Regina Taurines
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Stefan Unterecker
- Speziallabor für Therapeutisches Drug Monitoring, Klinik und Poliklinik für Psychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V
| | - Manfred Gerlach
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Marcel Romanos
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
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Kloosterboer SM, Vierhout D, Stojanova J, Egberts KM, Gerlach M, Dieleman GC, Hillegers MHJ, Passe KM, Gelder TV, Dierckx B, Koch BCP. Psychotropic drug concentrations and clinical outcomes in children and adolescents: a systematic review. Expert Opin Drug Saf 2020; 19:873-890. [PMID: 32421365 DOI: 10.1080/14740338.2020.1770224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The use of psychotropic drugs in children and adolescents is widespread but associated with suboptimal treatment effects. Therapeutic drug monitoring (TDM) can improve safety of psychotropic drugs in children and adolescents but is not routinely performed. A major reason is that the relationship between drug concentrations and effects is not well known. AREAS COVERED This systematic review evaluated studies assessing the relationship between psychotropic drug concentrations and clinical outcomes in children and adolescents, including antipsychotics, psychostimulants, alpha-agonists, antidepressants, and mood-stabilizers. PRISMA guidelines were used and a quality assessment of the retrieved studies was performed. Sixty-seven eligible studies involving 24 psychotropic drugs were identified from 9,298 records. The findings were generally heterogeneous and the majority of all retrieved studies were not of sufficient quality. For 11 psychotropic drugs, a relationship between drug concentrations and side-effects and/or effectiveness was evidenced in reasonably reported and executed studies, but these findings were barely replicated. EXPERT OPINION In order to better support routine TDM in child- and adolescent psychiatry, future work must improve in aspects of study design, execution and reporting to demonstrate drug concentration-effect relationships. The quality criteria proposed in this work can guide future TDM research. Systematic review protocol and registration PROSPERO CRD42018084159.
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Affiliation(s)
- Sanne M Kloosterboer
- Department of Hospital Pharmacy, Erasmus Medical Center , Rotterdam, The Netherlands.,Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Denise Vierhout
- Department of Hospital Pharmacy, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Jana Stojanova
- Interdisciplinary Center for Health Studies (CIESAL), Universidad de Valparaíso , Valparaíso, Chile
| | - Karin M Egberts
- Department for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Würzburg , Würzburg, Germany
| | - Manfred Gerlach
- Department for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Würzburg , Würzburg, Germany
| | - Gwen C Dieleman
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Manon H J Hillegers
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Kimberly M Passe
- Department of Psychiatry, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Bram Dierckx
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus Medical Center , Rotterdam, The Netherlands
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Schmid Y, Navarini A, Thomas ZRM, Pfleiderer B, Krähenbühl S, Mueller SM. Sex differences in the pharmacology of itch therapies-a narrative review. Curr Opin Pharmacol 2019; 46:122-142. [PMID: 31299512 DOI: 10.1016/j.coph.2019.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Chronic itch is the most common skin-related condition, associated with a high psychosocial and economic burden. In recent years, increasing evidence of sex differences in the perception, clinical presentation and treatment requirements of itch points towards potential benefits when using sex-adapted therapies. It is well-known that body composition, absorption, metabolism, elimination and adverse drug reactions (ADRs) differ between sexes, but only little is known about the impact of sex in the pharmacology of itch treatments, which could help to rationalise sex-adapted treatment strategies. AIM To evaluate and review sex effects in the pharmacokinetics and /-dynamics of drugs used to treat itch. METHODS In this narrative review we performed a PubMed and MEDLINE (Ovid) search using the terms (itch OR pruritus) AND (gender OR sex) AND (drug OR medication OR pharmacokinetics OR pharmacodynamics). Additional searches were performed for the topical and systemic drugs recommended by the European Guideline on Chronic Pruritus. RESULTS We found numerous reports with variable levels of evidence of sex effects with respect to the pharmacokinetics and/or pharmacodynamics of 14 drug classes used for the treatment of itch, including a total of 19 systemic and 3 topical drugs. Women seem to present higher plasma levels of several drugs used in itch treatment, including tri- and tetracyclic antidepressants (e.g. doxepin, amitriptyline, mirtazapine), serotonin reuptake inhibitors (e.g. paroxetine, sertraline, fluoxetine), immunosuppressive drugs (e.g. cyclosporine, mycophenolate mofetil), serotonin receptor antagonists (e.g. ondansetron) and betablockers (e.g. propranolol). Adverse drug reactions (ADRs) were generally more common in women. Being female was reported to be an independent risk factor for QTc-prolongation associated with antihistamines and tetracyclic antidepressants. Additionally, women seem to be more prone to sedative effects of antihistamines, and to suffer from a higher frequency as well as severity of side effects with systemic calcineurin inhibitors, opioid agonists, and opioid antagonists. Women were also sensitised more often to topically applied drugs. Of note, apart from only one experimental study with capsaicin, none of these reports were designed specifically to assess the effect of sex (and gender) in the treatment of itch. DISCUSSION/CONCLUSION Our review supports previous reports that sex is of importance in the pharmacokinetics and /-dynamics of several drugs used to treat itch although those drugs were mostly evaluated for non-itch indications. However, the results are limited by methodological limitations evident in most studies such as underrepresentation of women in clinical trials. This emphasises the need to study the impact of sex (and gender) in future itch trials to yield better outcomes and prevent ADRs in both sexes.
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Affiliation(s)
- Yasmin Schmid
- Clinical Pharmacology & Toxicology, University Hospital Basel, Switzerland
| | | | | | - Bettina Pfleiderer
- Department of Clinical Radiology, University Hospital Münster and Medical Faculty, University of Münster, Germany; Competence Center Chronic Pruritus (KCP), University of Muenster, Germany
| | - Stephan Krähenbühl
- Clinical Pharmacology & Toxicology, University Hospital Basel, Switzerland
| | - Simon M Mueller
- Department of Dermatology, University Hospital Basel, Switzerland.
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Chow TW, Nguyen TA, Riggs KW, Rurak DW. An in vivo evaluation of the ontogeny of stereoselective fluoxetine metabolism and disposition in lambs from birth to one year of age. Xenobiotica 2019; 49:1360-1372. [PMID: 30587071 DOI: 10.1080/00498254.2018.1563922] [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] [Indexed: 10/27/2022]
Abstract
1. The objective was to determine the ontogeny of stereoselective fluoxetine (FX) disposition in postnatal sheep from newborn to adulthood. 2. Catheters were implanted in a carotid artery and jugular vein. FX was administered intravenously, followed by serial arterial blood and cumulative urine collection. The concentrations of R,S-FX and R,S-norfluoxetine (R,S-NFX) in samples were measured using a validated enantioselective LC/MS/MS analytical method. 3. The metabolism of FX at 4.2 ± 0.4 days was limited compared to adults, but had developed compared to the fetus. Total body clearance (ClTB) did not significantly increase up to 33.6 ± 0.9 days, but significantly increased at 98.5 ± 2.0 days, with no further changes up to 397.3 ± 8.5 days. Up to 13.4 ± 0.8 days, the disposition of FX included Phase I metabolism to NFX and trifluoromethylphenol (TFMP), and renal elimination. At 32.9 ± 0.9 days, metabolism included Phase II conjugates of FX and NFX. Renal elimination of these compounds was low. 4. The elimination of FX increased in a non-linear manner during the first year in sheep. The metabolism and disposition of FX and NFX in plasma and urine were stereoselective and this appeared due to both stereoselective protein binding and metabolism.
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Affiliation(s)
- Timothy W Chow
- a Faculty of Pharmaceutical Sciences, The University of British Columbia , Vancouver , British Columbia , Canada
| | - Tuan-Anh Nguyen
- b BC Children's Hospital Research Institute, The University of British Columbia , Vancouver , British Columbia , Canada
| | - K Wayne Riggs
- a Faculty of Pharmaceutical Sciences, The University of British Columbia , Vancouver , British Columbia , Canada
| | - Dan W Rurak
- b BC Children's Hospital Research Institute, The University of British Columbia , Vancouver , British Columbia , Canada
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8
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Abstract
BACKGROUND Despite the obvious potential of Therapeutic Drug Monitoring (TDM) as a tool to optimize psychopharmacotherapy, especially treatment with mood-stabilizing, antidepressant and antipsychotic drugs, acceptance of TDM as a routine tool is still limited. A serious scientific argument against the regular use of TDM is the lack of evidence for a concentration-dependent clinical effect. The aim of this review was to highlight methodological problems leading to poor or even negative concentration-effect relationships and to show how therapeutically effective concentrations of psychoactive drugs can be determined using routine TDM databases. METHODS Reports on concentration-effect relationships of psychoactive drugs were analyzed with regard to applied methods. From routine TDM databases of patients who had been treated with antidepressant or antipsychotic drugs and whose improvement was measured by the clinical global impressions scale, mean and median drug concentrations were calculated and compared with reference ranges recommended by TDM guidelines. RESULTS Few fixed-dose studies with adequate design and data analysis demonstrated a correlation between drug concentration and clinical effect for psychoactive drugs. Most studies, however, mostly retrospective analyses of TDM databases, failed to find significant concentration-effect relationships because of flexible dosing. They were not suitable for the determination of therapeutically effective drug concentrations. Using TDM databases of antidepressant and antipsychotic drug concentrations in blood of patients who were categorized as responders by the clinical global impressions score, the interquartile ranges of drug concentrations (25th-75th percent range) can be shown to be very close to the therapeutic reference ranges recommended in guidelines for TDM in psychiatry. CONCLUSIONS This review provides a discussion on why simple correlation analyses of psychoactive drug concentrations in blood and clinical effects are obsolete for flexible-dose studies or TDM databases. TDM databases, however, can and should be used to calculate drug concentrations in blood of patients who had responded to the drugs. Interquartile ranges can be regarded and used as preliminary therapeutic reference ranges.
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9
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Vloet TD, Egberts K, Taurines R, Wewetzer C, Mehler-Wex C, Plener PL, Romanos M, Gerlach M. [Polypharmacy of psychotropic drugs in child and adolescent psychiatry in Germany - rather the rule than the exception]. Z Kinder Jugendpsychiatr Psychother 2018; 47:193-202. [PMID: 30422047 DOI: 10.1024/1422-4917/a000632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Polypharmacy of psychotropic drugs in child and adolescent psychiatry in Germany - rather the rule than the exception Abstract. Background: Polypharmacy increases the risk of interactions and enhances the chance of adverse drug reactions (ADRs). Hence, child and adolescent psychiatrists generally try to avoid polypharmacy with psychotropic drugs. However, only little data regarding the frequency of polypharmacy in child and adolescent psychiatry are available. This study analyzes clinical data on polypharmacy and the possible association with a higher risk of ADRs in Germany, with a focus on antidepressants and antipsychotics. Methods: We investigated a total of 940 datasets from descriptive studies on therapeutic drug monitoring (TDM) of pediatric patients treated with different psychotropic drugs. Results: The frequency of polypharmacy ranged up to 45.6 % (escitalopram) and 72.1 % (olanzapine). In 17.4 % of the cases, polypharmacy consisted of four or more psycho-/neuropharmacological substances. No increased incidence of ADRs was reported with polypharmacy of antipsychotics compared to monotherapy. Polypharmacy with sertraline was associated with a higher number of ADRs. Discussion and Conclusion: There is a high prevalence of polypharmacy with psychotropic drugs in child and adolescent psychiatry in Germany. Conclusions concerning individual drugs should be drawn with care since the subsample sizes were relatively small. However, our results do provide an indication of the prevalence of polypharmacy, although the validity of the data is limited. There is an urgent need to analyze data from larger and more homogeneous groups under more controlled conditions.
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Affiliation(s)
- Timo D Vloet
- a geteilte Erstautorenschaft.,1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
| | - Karin Egberts
- a geteilte Erstautorenschaft.,1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
| | - Regina Taurines
- 1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
| | - Christoph Wewetzer
- 2 Abteilung für Kinder- und Jugendpsychiatrie und Psychotherapie, Kliniken der Stadt Köln gGmbH, Köln
| | - Claudia Mehler-Wex
- 3 Privatklinik für Seelische Gesundheit, Jugendliche und junge Erwachsene, HEMERA Klinik, Bad Kissingen
| | - Paul L Plener
- 4 Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universitätsklinik Ulm, Ulm
| | - Marcel Romanos
- 1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
| | - Manfred Gerlach
- 1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
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10
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Li W, Zhu Y, Liu X, Hou J, Fang J, Shen J, Ma X. Phencynonate mediates antidepressant response by activating sirtuin 6-SOD2/Prdx6 pathway. Biochem Biophys Res Commun 2018; 505:898-904. [PMID: 30309657 DOI: 10.1016/j.bbrc.2018.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 10/04/2018] [Indexed: 01/03/2023]
Abstract
Major depression is a highly prevalent disorder with no effective medical treatments available. Recent evidence has shown that sirtuins (SIRTs) signaling has been implicated to play an essential in the pathogenesis of depression. Here in this study, we aimed to investigate the potential role of the phencynonate hydrochloride (PHH) in rat models of chronic unpredictable mild stress (CUMS)-induced depression. SIRT6 expression was up-regulated by PHH via increasing NAD+/NADH ratio in the prefrontal cortex. PHH was able to suppress CUMS-induced oxidative stress and enhance the antioxidant capacity and antioxidant proteins activity, such as superoxide dismutase 2 (SOD2) and peroxiredoxin 6 (Prdx6). In vitro study, we found that SIRT6 directly bound to SOD2 and Prdx6 and deacetylated them at Lys68/122 and Lys63/209, which were acetylated by p300/CBP-associated factor (PCAF). Finally, we showed that PHH ameliorated CUMS-induced depressive phenotypes by up-regulating SIRT6 deacetylation activity. In summary, PHH-mediating SIRT6 pathway is required for antidepressant response and PHH can be used as a novel therapeutic to effectively treat depression.
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Affiliation(s)
- Wang Li
- Department of Molecular Neurobiology, Shaanxi Normal University, Xi'an, PR China
| | - Yingqi Zhu
- Department of Molecular Neurobiology, Shaanxi Normal University, Xi'an, PR China
| | - Xin Liu
- Department of Molecular Neurobiology, Shaanxi Normal University, Xi'an, PR China
| | - Jun Hou
- Department of Molecular Neurobiology, Shaanxi Normal University, Xi'an, PR China
| | - Jie Fang
- Department of Molecular Neurobiology, Shaanxi Normal University, Xi'an, PR China
| | - Jingxuan Shen
- Department of Molecular Neurobiology, Shaanxi Normal University, Xi'an, PR China
| | - Xinming Ma
- Department of Molecular Neurobiology, Shaanxi Normal University, Xi'an, PR China.
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11
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Golub MS, Hogrefe CE, Sherwood RJ, Turck CW. Fluoxetine Administration in Juvenile Monkeys: Implications for Pharmacotherapy in Children. Front Pediatr 2018; 6:21. [PMID: 29473029 PMCID: PMC5809484 DOI: 10.3389/fped.2018.00021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 01/22/2018] [Indexed: 02/03/2023] Open
Abstract
Fluoxetine therapy has been approved for children with major depressive disorder and obsessive compulsive disorder for over 14 years and has expanded to other childhood behavior disorders. As use increases, more detail on fluoxetine effects during juvenile brain development can help maintain safe and effective use of this therapy. Here, a narrative review is provided of previously published findings from a large nonhuman primate project. Fluoxetine was administered to juvenile male rhesus monkeys for an extended period (2 years) prior to puberty. Compared to controls, treated monkeys showed sleep disruption, facilitated social interaction, greater impulsivity, and impaired sustained attention during treatment. No effects on growth were seen. Metabolomics assays characterized a distinctive response to fluoxetine and demonstrated individual differences that were related to the impulsivity measure. Fluoxetine interactions with monoamine oxidase A polymorphisms that influenced behavior and metabolomics markers were an important, previously unrecognized finding of our studies. After treatment was discontinued, some behavioral effects persisted, but short-term memory and cognitive flexibility testing did not show drug effects. This detailed experimental work can contribute to clinical research and continued safe and effective fluoxetine pharmacotherapy in children.
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Affiliation(s)
- Mari S Golub
- California National Primate Research Center, University of California, Davis, Davis, CA, United States
| | - Casey E Hogrefe
- California National Primate Research Center, University of California, Davis, Davis, CA, United States
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12
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Abstract
BACKGROUND Despite an increasingly recognized relationship between depression and smoking, little is known about how smoking influences antidepressant response and treatment outcomes. The aim of this study was to systematically review the evidence of the impact of smoking on new-generation antidepressants with an emphasis on the pharmacokinetic perspective. METHODS We present a systematic review of clinical trials comparing the serum levels of new-generation antidepressants in smokers and nonsmokers. Data were obtained from MEDLINE/PubMed, Embase, and other sources. Risk of bias was assessed for selection, performance, detection, attrition, and reporting of individual studies. RESULTS Twenty-one studies met inclusion criteria; seven involved fluvoxamine, two evaluated fluoxetine, sertraline, venlafaxine, duloxetine or mirtazapine, and escitalopram, citalopram, trazodone and bupropion were the subject of a single study. No trials were found involving other common antidepressants such as paroxetine or agomelatine. Serum levels of fluvoxamine, duloxetine, mirtazapine and trazodone were significantly higher in nonsmokers compared with smokers. CONCLUSIONS There is evidence showing a reduction in the concentration of serum levels of fluvoxamine, duloxetine, mirtazapine and trazodone in smoking patients as compared to nonsmokers. The evidence regarding other commonly used antidepressants is scarce. Nonetheless, smoking status should be considered when choosing an antidepressant treatment, given the risk of pharmacokinetic interactions.
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Affiliation(s)
- Pedro Oliveira
- Psychiatry Department, Coimbra Hospital University Centre, Praceta Mota Pinto, 3000-075 Coimbra, Portugal
| | - Joana Ribeiro
- Psychiatry Department, Coimbra Hospital University Centre, Praceta Mota Pinto, 3000-075 Coimbra, Portugal
| | - Helena Donato
- Documentation Department, Coimbra Hospital University Centre, Coimbra, Portugal
| | - Nuno Madeira
- Psychiatry Department, Coimbra Hospital University Centre, Praceta Mota Pinto, 3000-075 Coimbra, Portugal
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13
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Gerlach M, Egberts K, Dang SY, Plener P, Taurines R, Mehler-Wex C, Romanos M. Therapeutic drug monitoring as a measure of proactive pharmacovigilance in child and adolescent psychiatry. Expert Opin Drug Saf 2016; 15:1477-1482. [PMID: 27551945 DOI: 10.1080/14740338.2016.1225721] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Off-label or unlicensed use of psychotropic drugs is common rather than the exception in child and adolescent psychiatry. This use exposes patients to an unknown additional risk of ineffective or even harmful treatment. In addition, treatment with psychotropic drugs during a period of life when the patient undergoes marked developmental hormonal and neurobiological changes often requires different dosing regimes in later life and may result in adverse drug reactions, which are either not seen in adults at all or not in the same frequency. Areas covered: Given these critical safety issues, efficient pharmacovigilance methods as part of routine practice are essential for the improvement of patient care. The purpose of this article is to introduce methods to increase the safety of psychotropic drug use in youngsters. In particular, therapeutic drug monitoring (TDM) as a routine measure of proactive pharmacovigilance is discussed. Expert opinion: Given the special features of psychopharmacological therapy in children and adolescents in day-to-day clinical practise, proactive surveillance by using a close standardized 'patient monitoring' and long-term follow-up with TDM is very important. This approach could minimize the risk of exposing paediatric patients to ineffective treatments of uncertain or unknown risks.
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Affiliation(s)
- Manfred Gerlach
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
| | - Karin Egberts
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
| | - Su-Yin Dang
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
| | - Paul Plener
- b Department of Child and Adolescent Psychiatry and Psychotherapy , Central Institute of Mental Health , Mannheim , Germany
| | - Regina Taurines
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
| | - Claudia Mehler-Wex
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany.,c HEMERA Private Hospital for Mental Health, Adolescents and Young Adults , Bad Kissingen , Germany
| | - Marcel Romanos
- a Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health , University Hospital of Würzburg , Würzburg , Germany
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14
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Golub MS, Hogrefe CE, Bulleri AM. Peer social interaction is facilitated in juvenile rhesus monkeys treated with fluoxetine. Neuropharmacology 2016; 105:553-560. [PMID: 26905291 DOI: 10.1016/j.neuropharm.2016.02.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 09/15/2015] [Revised: 02/16/2016] [Accepted: 02/19/2016] [Indexed: 10/22/2022]
Abstract
Fluoxetine improves social interactions in children with autism, social anxiety and social phobia. It is not known whether this effect is mediated directly or indirectly by correcting the underlying pathology. Genetics may also influence the drug effect. Polymorphisms of the MAOA (monoamine oxidase A) gene interact with fluoxetine to influence metabolic profiles in juvenile monkeys. Juvenile nonhuman primates provide an appropriate model for studying fluoxetine effects and drug*gene interactions in children. Male rhesus monkeys 1-3 years of age living in permanent social pairs were treated daily with a therapeutic dose of fluoxetine or vehicle (n = 16/group). Both members of each social pair were assigned to the same treatment group. They were observed for social interactions with their familiar cagemate over a 2-year dosing period. Subjects were genotyped for MAOA variable number of tandem repeats (VNTR) polymorphisms categorized for high or low transcription rates (hi-MAOA, low-MAOA). Fluoxetine-treated animals spent 30% more time in social interaction than vehicle controls. Fluoxetine significantly increased the duration of quiet interactions, the most common type of interaction, and also of immature sexual behavior typical of rhesus in this age group. Specific behaviors affected depended on MAOA genotype of the animal and its social partner. When given fluoxetine, hi-MOAO monkeys had more social invitation and initiation behaviors and low-MAOA subjects with low-MAOA partners had more grooming and an increased frequency of some facial and vocal expressive behaviors. Fluoxetine may facilitate social interaction in children independent of remediation of psychopathology. Common genetic variants may modify this effect.
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Affiliation(s)
- Mari S Golub
- Department of Environmental Toxicology, University of California Davis, Davis, CA 95616, USA.
| | - Casey E Hogrefe
- California National Primate Research Center, University of California Davis, Davis, CA 95616, USA
| | - Alicia M Bulleri
- California National Primate Research Center, University of California Davis, Davis, CA 95616, USA
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15
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Egberts K, Karwautz A, Plener PL, Mehler-Wex C, Kölch M, Dang SY, Taurines R, Romanos M, Gerlach M. [Pharmacovigilance in child and adolescent psychiatry]. Z Kinder Jugendpsychiatr Psychother 2015; 43:21-8. [PMID: 25536893 DOI: 10.1024/1422-4917/a000329] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Rational pharmacotherapy is a challenging task in child and adolescent psychiatry. Increasing prescription numbers contrast with the uncertainties of safety and efficacy issues. The lack of clinical (authorization) trials often implies a non- age-specific use of drugs. However, young patients show particular metabolic conditions and a higher vulnerability for adverse drug reactions. Thus it seems mandatory to create age-specific pharmacological data about efficacy and safety of psychotropic drug use in minors. Legislation authorities became aware of this situation and introduced European and national scientific pharmacovigilance regulations and programmes accordingly in order to continuously evaluate the benefit-risk-ratio, detect, collect, minimize, and prevent adverse effects of drugs by appropriate measures, e.g., therapeutic drug monitoring. In this paper the principles and needs of pharmacovigilance in child and adolescent psychiatry are discussed. Furthermore a large multicenter clinical trial («TDM-VIGIL»), funded by the German Federal Institute for Drugs and Medical Devices, is presented, which appeals to collect epidemiological prescription and safety data of psychotropic drugs in children and adolescents using an internet-based data infrastructure (patient registry).
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Affiliation(s)
- Karin Egberts
- Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie der Universität Würzburg Arbeitsgruppe «Therapeutisches Drug Monitoring» der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP), Nürnberg Arbeitsgemeinschaft «Kinder- und jugendpsychiatrische Pharmakologie» der AGNP, Nürnberg
| | | | - Paul L Plener
- Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Ulm
| | - Claudia Mehler-Wex
- Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Ulm HEMERA Klinik, Privatklinik für Seelische Gesundheit, Jugendliche und junge Erwachsene, Bad Kissingen
| | - Michael Kölch
- Arbeitsgemeinschaft «Kinder- und jugendpsychiatrische Pharmakologie» der AGNP, Nürnberg Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Ulm Vivantes Klinikum, Kinder- und Jugendpsychiatrie, Psychotherapie und Psychosomatik, Berlin
| | - Su-Yin Dang
- Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie der Universität Würzburg
| | - Regina Taurines
- Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie der Universität Würzburg
| | - Marcel Romanos
- Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie der Universität Würzburg
| | - Manfred Gerlach
- Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie der Universität Würzburg Arbeitsgruppe «Therapeutisches Drug Monitoring» der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP), Nürnberg Arbeitsgemeinschaft «Kinder- und jugendpsychiatrische Pharmakologie» der AGNP, Nürnberg
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16
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Abstract
RATIONALE The selective serotonin reuptake inhibitor (SSRI) fluoxetine is the only psychopharmacological agent approved for use in children. While short-term studies of side effects have been performed, long-term consequences for brain development are not known. Such studies can be performed in appropriate animal models if doses modeling therapeutic use in children are known. OBJECTIVES The goal of this study was to identify a daily dose of fluoxetine in juvenile monkeys which would result in serum fluoxetine and norfluoxetine concentrations in the therapeutic range for children. METHODS Juvenile (2.5-year-old rhesus monkeys, n = 6) received single administration of doses of 1, 2, and 4 mg/kg day fluoxetine on a background of chronic dosing at an intermediate level to provide steady-state conditions to model therapeutic administration. Using nonlinear modeling, standard pharmacokinetic parameters were derived. Cerebrospinal fluid monoamine neurotransmitters were assayed to confirm the pharmacological effects. RESULTS Dose-dependent area under the curve (AUC) and C max values were seen, while T max and absorption/elimination half-lives were minimally influenced by dose. A dosage of 2 mg/kg day given over a 14-week period led to steady-state serum concentrations of active agent (fluoxetine + norfluoxetine) similar to those recorded from drug monitoring studies in children. Cisternal cerebrospinal fluid concentrations of serotonin increased significantly over the 14-week period, while concentrations of the serotonin metabolite (5-HIAA) were lower but not significantly different. CONCLUSIONS A dose of 2 mg/kg day fluoxetine in juvenile rhesus monkeys provides an internal dose similar to therapeutic use in children and will help establish a valuable animal model for understanding fluoxetine's therapeutic and potential adverse effects in children.
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Blázquez A, Mas S, Plana MT, Gassó P, Méndez I, Torra M, Arnaiz JA, Lafuente A, Lázaro L. Plasma fluoxetine concentrations and clinical improvement in an adolescent sample diagnosed with major depressive disorder, obsessive-compulsive disorder, or generalized anxiety disorder. J Clin Psychopharmacol 2014; 34:318-26. [PMID: 24743718 DOI: 10.1097/JCP.0000000000000121] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
UNLABELLED Fluoxetine (FLX) has been one of the most widely studied selective serotonin reuptake inhibitors in adolescents. Despite its efficacy, however, 30% to 40% of patients do not respond to treatment. AIMS The aim of this study was to evaluate whether clinical improvement or adverse events are related to the corrected dose of FLX at 8 and 12 weeks after starting treatment in a sample of adolescents diagnosed with major depressive disorder, obsessive-compulsive disorder, or generalized anxiety disorder. METHODS Seventy-four subjects aged between 10 and 17 years participated in the study. Clinical improvement was measured with the Clinical Global Impression-Improvement Scale, whereas the UKU (Udvalg for Klinske Undersogelser) scale was administered to assess adverse effects of treatment. RESULTS Fluoxetine per kilograms of body weight was related to serum concentration of FLX, NORFLX (norfluoxetine), FLX + NORFLX, and FLX/NORFLX. No relationship was found between dose-corrected FLX levels and therapeutic or adverse effects. No differences in serum concentrations were found between responders and nonresponders to treatment. Sex differences were observed in relation to dose and FLX serum concentration. The analysis by diagnosis revealed differences in FLX dose between obsessive-compulsive disorder patients and both generalized anxiety disorder and major depressive disorder patients. CONCLUSIONS Fluoxetine response seems to be influenced by factors such as sex, diagnosis, or certain genes that might be involved in the drug's pharmacokinetics and pharmacodynamics. Clinical and pharmacogenetic studies are needed to elucidate further the differences between treatment responders and nonresponders.
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Plener PL, Fegert JM, Kölch MG. Psychopharmakologische Behandlung von Depressionen im Kindes- und Jugendalter. Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie 2012; 40:365-71. [DOI: 10.1024/1422-4917/a000196] [Citation(s) in RCA: 8] [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: 11/19/2022]
Abstract
Die psychopharmakologische Behandlung kann – je nach Schweregrad- eine wichtige Option in der Therapie depressiver Erkrankungen bei Kindern und Jugendlichen darstellen. Diese Überblicksarbeit gibt klinische Behandlungsempfehlungen mit einem Fokus auf den Umgang mit Suizidalität und therapieresistenten Patienten. Die Studienlage zur medikamentösen Therapie der depressiven Erkrankung im Kindes- und Jugendalter hat sich seit den Warnungen der amerikanischen Zulassungsbehörde zum Auftreten von Suizidalität unter Therapie mit Selektiven Serotonin Wiederaufnahmehemmern (SSRIs) deutlich verbessert. In der Versorgung von depressiven Kindern und Jugendlichen ist in den letzten Jahren in Deutschland ein Trend hin zu einer evidenzbasierten psychopharmakologischen Therapie zu erkennen.
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Affiliation(s)
- Paul L. Plener
- Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Ulm
| | - Jörg M. Fegert
- Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Ulm
| | - Michael G. Kölch
- Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Ulm
- Kliniken für Kinder- und Jugendpsychiatrie, Psychotherapie und Psychosomatik, Vivantes Netzwerk für Gesundheit GmbH, Berlin
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