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Avrahami M, Liwinski T, Eckstein Z, Peskin M, Perlman P, Sarlon J, Lang UE, Amital D, Weizman A. Predictors of valproic acid steady-state serum levels in adult and pediatric psychiatric inpatients: a comparative analysis. Psychopharmacology (Berl) 2024:10.1007/s00213-024-06603-y. [PMID: 38733528 DOI: 10.1007/s00213-024-06603-y] [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] [Received: 12/21/2023] [Accepted: 04/30/2024] [Indexed: 05/13/2024]
Abstract
RATIONALE Valproic acid (VPA) is commonly used as a second-line mood stabilizer or augmentative agent in severe mental illnesses. However, population pharmacokinetic studies specific to psychiatric populations are limited, and clinical predictors for the precision application of VPA remain undefined. OBJECTIVES To identify steady-state serum VPA level predictors in pediatric/adolescent and adult psychiatric inpatients. METHODS We analyzed data from 634 patients and 1,068 steady-state therapeutic drug monitoring (TDM) data points recorded from 2015 to 2021. Steady-state VPA levels were obtained after tapering during each hospitalization episode. Electronic patient records were screened for routine clinical parameters and co-medication. Generalized additive mixed models were employed to identify independent predictors. RESULTS Most TDM episodes involved patients with psychotic disorders, including schizophrenia (29.2%) and schizoaffective disorder (17.3%). Polypharmacy was common, with the most frequent combinations being VPA + quetiapine and VPA + promethazine. Age was significantly associated with VPA levels, with pediatric/adolescent patients (< 18 years) demonstrating higher dose-adjusted serum levels of VPA (β = 7.6±2.34, p < 0.001) after accounting for BMI. Women tended to have higher adjusted VPA serum levels than men (β = 5.08±1.62, p < 0.001). The formulation of VPA (Immediate-release vs. extended-release) showed no association with VPA levels. Co-administration of diazepam exhibited a dose-dependent decrease in VPA levels (F = 15.7, p < 0.001), suggesting a potential pharmacokinetic interaction. CONCLUSIONS This study highlights the utility of population-specific pharmacokinetic data for VPA in psychiatric populations. Age, gender, and co-administration of diazepam were identified as predictors of VPA levels. Further research is warranted to establish additional predictors and optimize the precision application of VPA in psychiatric patients.
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Affiliation(s)
- Matan Avrahami
- Young Children Department, Child & Adolescent Division, Petah Tikva and Faculty of Medicine, Geha Mental Health Center, Tel Aviv University, Tel Aviv, Israel
| | - Timur Liwinski
- University Psychiatric Clinics Basel, University of Basel, Clinic for Adults, Wilhelm Klein-Strasse 27, Basel, CH-4002, Switzerland.
| | - Zafrir Eckstein
- Faculty of Health Sciences, Geha Mental Health Center, Petah Tikva, and School of Pharmacy, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Miriam Peskin
- Young Children Department, Child & Adolescent Division, Petah Tikva and Faculty of Medicine, Geha Mental Health Center, Tel Aviv University, Tel Aviv, Israel
| | - Polina Perlman
- Young Children Department, Child & Adolescent Division, Petah Tikva and Faculty of Medicine, Geha Mental Health Center, Tel Aviv University, Tel Aviv, Israel
| | - Jan Sarlon
- University Psychiatric Clinics Basel, University of Basel, Clinic for Adults, Wilhelm Klein-Strasse 27, Basel, CH-4002, Switzerland
| | - Undine E Lang
- University Psychiatric Clinics Basel, University of Basel, Clinic for Adults, Wilhelm Klein-Strasse 27, Basel, CH-4002, Switzerland
| | - Daniela Amital
- Division of Psychiatry, Barzilai Medical Center, Ben-Gurion University of the Negev, Ashkelon, Israel
| | - Abraham Weizman
- Young Children Department, Child & Adolescent Division, Petah Tikva and Faculty of Medicine, Geha Mental Health Center, Tel Aviv University, Tel Aviv, Israel
- Laboratory of Biological and Molecular Psychiatry, Felsenstein Medical Research Center, Petah Tikva, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
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Nierenberg AA, Agustini B, Köhler-Forsberg O, Cusin C, Katz D, Sylvia LG, Peters A, Berk M. Diagnosis and Treatment of Bipolar Disorder: A Review. JAMA 2023; 330:1370-1380. [PMID: 37815563 DOI: 10.1001/jama.2023.18588] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Importance Bipolar disorder affects approximately 8 million adults in the US and approximately 40 million individuals worldwide. Observations Bipolar disorder is characterized by recurrent episodes of depression and mania or hypomania. Bipolar depressive episodes are similar to major depressive episodes. Manic and hypomanic episodes are characterized by a distinct change in mood and behavior during discrete time periods. The age of onset is usually between 15 and 25 years, and depression is the most frequent initial presentation. Approximately 75% of symptomatic time consists of depressive episodes or symptoms. Early diagnosis and treatment are associated with a more favorable prognosis. Diagnosis and optimal treatment are often delayed by a mean of approximately 9 years following an initial depressive episode. Long-term treatment consists of mood stabilizers, such as lithium, valproate, and lamotrigine. Antipsychotic agents, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine, are recommended, but some are associated with weight gain. Antidepressants are not recommended as monotherapy. More than 50% of patients with bipolar disorder are not adherent to treatment. Life expectancy is reduced by approximately 12 to 14 years in people with bipolar disorder, with a 1.6-fold to 2-fold increase in cardiovascular mortality occurring a mean of 17 years earlier compared with the general population. Prevalence rates of metabolic syndrome (37%), obesity (21%), cigarette smoking (45%), and type 2 diabetes (14%) are higher among people with bipolar disorder, contributing to the risk of early mortality. The annual suicide rate is approximately 0.9% among individuals with bipolar disorder, compared with 0.014% in the general population. Approximately 15% to 20% of people with bipolar disorder die by suicide. Conclusions and Relevance Bipolar disorder affects approximately 8 million adults in the US. First-line therapy includes mood stabilizers, such as lithium, anticonvulsants, such as valproate and lamotrigine, and atypical antipsychotic drugs, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine.
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Affiliation(s)
- Andrew A Nierenberg
- Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Bruno Agustini
- Deakin University, IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
| | - Ole Köhler-Forsberg
- Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Boston
- Department for Affective Disorder, Aarhus University Hospital, Aarhus, Denmark
- Psychosis Research Unit, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Cristina Cusin
- Harvard Medical School, Boston, Massachusetts
- Depression Clinical and Research Program, Massachusetts General Hospital, Boston
| | - Douglas Katz
- Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Louisa G Sylvia
- Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Amy Peters
- Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Michael Berk
- Deakin University, IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
- Orygen, The National Centre of Excellence in Youth Mental Health, Centre for Youth Mental Health, Florey Institute for Neuroscience and Mental Health and the Department of Psychiatry, The University of Melbourne, Melbourne, Australia
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Paton C, Citrome L, Fernandez-Egea E, Rendora O, Barnes TRE. Who is prescribed valproate and how carefully is this treatment reviewed in UK mental health services? Data from a clinical audit. Ther Adv Psychopharmacol 2022; 12:20451253221110016. [PMID: 36051503 PMCID: PMC9425878 DOI: 10.1177/20451253221110016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 06/08/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The licensed indications for valproate are narrow, yet this medication is commonly prescribed in mental health services. OBJECTIVES To explore the target symptoms/behaviours for which valproate is prescribed and how well the efficacy and tolerability of this treatment are monitored in routine clinical practice. DESIGN An audit-based quality improvement (QI) programme in UK mental health services. METHODS Information on valproate prescribing was collected from clinical records using a bespoke data collection tool. RESULTS Sixty-four NHS mental health Trusts/healthcare organisations submitted data on valproate treatment for 5320 patients. Valproate was clearly prescribed for a licensed indication in 1995 (38%) patients, off-label in 1987 (37%) while the indication was uncertain/not available in 1338 (25%). Of the 919 patients started on valproate treatment within the past year, between a half and two-thirds had each of the relevant baseline physical health checks documented. In 539 (59%) of these patients, valproate was prescribed for an unlicensed indication; the prescription was recognised as off-label in 363 (67%), 20 (6%) of whom were documented as having had this explained to them. Of 631 patients prescribed valproate for between 3 months and a year, early on-treatment assessments of response and side effects were documented in 441 (70%) and 332 (53%), respectively. Of 4401 patients treated for more than a year, annual on-treatment reviews of clinical response and side effects were documented in 2771 (63%) and 2140 (49%), respectively. CONCLUSION Our data suggest the majority of prescriptions for valproate in mental health services are not for a licensed indication. Furthermore, patients rarely receive an explanation that their valproate prescription is off-label, perhaps partly because the licensed indications are not widely understood by prescribers. Given the very limited evidence for efficacy for the off-label uses of valproate, failure to routinely conduct early on-treatment and annual reviews of the benefits and side effects of this medication may result in patients remaining on ineffective and poorly tolerated treatment by default.
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Affiliation(s)
- Carol Paton
- Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, 21 Prescot Street, Whitechapel, London E1 8BB, UK.,Division of Psychiatry, Imperial College London, London, UK
| | - Leslie Citrome
- Department of Psychiatry and Behavioural Sciences, New York Medical College, New York, USA
| | - Emilio Fernandez-Egea
- Department of Psychiatry and Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK.,Cambridge Psychosis Centre, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Olivia Rendora
- Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Thomas R E Barnes
- Division of Psychiatry, Imperial College London, London, UK.,Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
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Samalin L, Godin O, Olié E, Etain B, Henry C, Pelletier A, Poinso F, Encely L, Mazer N, Roux P, Loftus J, Gard S, Bennabi D, Polosan M, Schwitzer T, Aubin V, Schwan R, Passerieux C, Bougerol T, Dubertret C, Aouizerate B, Haffen E, Courtet P, Bellivier F, Leboyer M, Llorca PM, Belzeaux R. Evolution and characteristics of the use of valproate in women of childbearing age with bipolar disorder: Results from the FACE-BD cohort. J Affect Disord 2020; 276:963-969. [PMID: 32745833 DOI: 10.1016/j.jad.2020.07.078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/19/2020] [Accepted: 07/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Valproate is associated with teratogenic and neurodevelopmental effects. Several agencies have restricted the conditions of its prescription in bipolar disorders (BD). We aimed to assess the evolution of valproate prescription and the clinical profile of BD women of childbearing age receiving valproate. METHODS Based on a large national cohort, we included all BD women 16-50 years old. Sociodemographic, clinical and pharmacological data were recorded. Logistic regression analyses were used to describe variables associated with valproate prescription. RESULTS Of the 1018 included women 16-50 years old, 26.9% were treated with valproate with a mean daily dosage of 968 mg. The prevalence of BD women using valproate was 32.6% before May 2015 and 17.3% after May 2015 (p<0.001), the date of French regulatory publication of restriction of valproate prescription. The multivariate analysis revealed that the inclusion period after May 2015 (OR=0.54, CI 95% 0.37-0.78, p=0.001), the age lower than 40 years (OR=0.65, CI 95% 0.43-0.98, p=0.040) and the number of lifetime mood episodes (OR=0.98, CI 95% 0.95-0.99, p=0.040) were the variables negatively associated with the use of valproate. LIMITATIONS Study could be underpowered to determine a clinical profile associated with valproate prescription. CONCLUSIONS The regulatory change in BD women of childbearing age had a significant impact on valproate prescription, even if the prescription rate remains high. Important efforts are needed to help clinicians and patients to improve quality of care in BD women of childbearing age.
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Affiliation(s)
- L Samalin
- Fondation Fondamental, Créteil, France; Department of Psychiatry, CHU Clermont-Ferrand, University of Clermont Auvergne, EA 7280, Clermont-Ferrand, France.
| | - O Godin
- Fondation Fondamental, Créteil, France; INSERM U955, Équipe de Psychiatrie Translationnelle, Université Paris-Est Créteil, DHU Pe-PSY, Pôle de Psychiatrie des Hôpitaux Universitaires H Mondor, Créteil, France
| | - E Olié
- Fondation Fondamental, Créteil, France; Department of Emergency Psychiatry and Acute Care, CHU de Montpellier, PSNREC, University Montpellier, INSERM, Montpellier, France
| | - B Etain
- Fondation Fondamental, Créteil, France; AP-HP, GH Saint-Louis - Lariboisière - Fernand Widal, Pôle Neurosciences Tête et Cou, Département de Psychiatrie et de Médecine Addictologique, INSERM UMRS 1144, Université de Paris, Paris, France
| | - C Henry
- Department of Psychiatry, Service Hospitalo-Universitaire, GHU Paris Psychiatrie and Neurosciences, Université Descartes, Paris, France
| | - A Pelletier
- Fondation Fondamental, Créteil, France; AP-HP, DMU IMPACT, Psychiatry and Addictology of Mondor University Hospital, University Paris-Est-Créteil, Créteil, France
| | - F Poinso
- Pôle de Psychiatrie, APHM, Marseille, France; INT-UMR7289, CNRS Aix-Marseille Université, Marseille, France
| | - L Encely
- Pôle de Psychiatrie, APHM, Marseille, France; INT-UMR7289, CNRS Aix-Marseille Université, Marseille, France
| | - N Mazer
- Fondation Fondamental, Créteil, France; AP-HP, Groupe Hospitalo-universitaire AP-HP Nord, DMU ESPRIT, Service de Psychiatrie et Addictologie, Hôpital Louis Mourier, Colombes, Inserm U1266, Faculté de Médecine, Université de Paris, France
| | - P Roux
- Fondation Fondamental, Créteil, France; Centre Hospitalier de Versailles, Service Universitaire de psychiatrie d'adulte et d'addictologie, Le Chesnay, EA 4047 HANDIReSP, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin-en-Yvelines, Equipe « PsyDev », CESP, Université Paris-Saclay, Inserm, 94807 Villejuif, France
| | - J Loftus
- Fondation Fondamental, Créteil, France; Department of Psychiatry, Princess-Grace Hospital, Monaco, Monaco
| | - S Gard
- Fondation Fondamental, Créteil, France; Department of Psychiatry, Princess-Grace Hospital, Monaco, Monaco
| | - D Bennabi
- Fondation Fondamental, Créteil, France; Department of Clinical Psychiatry, CIC-1431 INSERM, CHU de Besançon, EA481 Neurosciences, University Bourgogne Franche-Comté, France
| | - M Polosan
- Fondation Fondamental, Créteil, France; CHU Grenoble Alpes, Grenoble Institut Neurosciences, Inserm, U1216, University of Grenoble Alpes, Grenoble, France
| | - T Schwitzer
- Fondation Fondamental, Créteil, France; Centre Psychothérapique de Nancy, Pôle Hospitalo-universitaire de Psychiatrie d'Adultes du Grand Nancy, Laxou F-54520, France
| | - V Aubin
- Fondation Fondamental, Créteil, France; Department of Psychiatry, Princess-Grace Hospital, Monaco, Monaco
| | - R Schwan
- Fondation Fondamental, Créteil, France; Centre Psychothérapique de Nancy, Pôle Hospitalo-universitaire de Psychiatrie d'Adultes du Grand Nancy, Laxou F-54520, France
| | - C Passerieux
- Fondation Fondamental, Créteil, France; Centre Hospitalier de Versailles, Service Universitaire de psychiatrie d'adulte et d'addictologie, Le Chesnay, EA 4047 HANDIReSP, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin-en-Yvelines, Equipe « PsyDev », CESP, Université Paris-Saclay, Inserm, 94807 Villejuif, France
| | - T Bougerol
- Fondation Fondamental, Créteil, France; CHU Grenoble Alpes, Grenoble Institut Neurosciences, Inserm, U1216, University of Grenoble Alpes, Grenoble, France
| | - C Dubertret
- Fondation Fondamental, Créteil, France; AP-HP, Groupe Hospitalo-universitaire AP-HP Nord, DMU ESPRIT, Service de Psychiatrie et Addictologie, Hôpital Louis Mourier, Colombes, Inserm U1266, Faculté de Médecine, Université de Paris, France
| | - B Aouizerate
- Fondation Fondamental, Créteil, France; Department of Clinical and Academic Psychiatry, Charles-Perrens Hospital, Bordeaux, France; NutriNeuro, UMR INRA 1286, University of Bordeaux, Bordeaux, France
| | - E Haffen
- Fondation Fondamental, Créteil, France; Department of Clinical Psychiatry, CIC-1431 INSERM, CHU de Besançon, EA481 Neurosciences, University Bourgogne Franche-Comté, France
| | - P Courtet
- Fondation Fondamental, Créteil, France; Department of Emergency Psychiatry and Acute Care, CHU de Montpellier, PSNREC, University Montpellier, INSERM, Montpellier, France
| | - F Bellivier
- Fondation Fondamental, Créteil, France; AP-HP, GH Saint-Louis - Lariboisière - Fernand Widal, Pôle Neurosciences Tête et Cou, Département de Psychiatrie et de Médecine Addictologique, INSERM UMRS 1144, Université de Paris, Paris, France
| | - M Leboyer
- Fondation Fondamental, Créteil, France; AP-HP, DMU IMPACT, Psychiatry and Addictology of Mondor University Hospital, University Paris-Est-Créteil, Créteil, France
| | | | - P M Llorca
- Fondation Fondamental, Créteil, France; Department of Psychiatry, CHU Clermont-Ferrand, University of Clermont Auvergne, EA 7280, Clermont-Ferrand, France
| | - R Belzeaux
- Fondation Fondamental, Créteil, France; Pôle de Psychiatrie, APHM, Marseille, France; INT-UMR7289, CNRS Aix-Marseille Université, Marseille, France
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