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Abudahab S, Slattum PW, Price ET, McClay JL. Epigenetic regulation of drug metabolism in aging: utilizing epigenetics to optimize geriatric pharmacotherapy. Pharmacogenomics 2024; 25:41-54. [PMID: 38126340 PMCID: PMC10794944 DOI: 10.2217/pgs-2023-0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
We explore the relationship between epigenetic aging and drug metabolism. We review current evidence for changes in drug metabolism in normal aging, followed by a description of how epigenetic modifications associated with age can regulate the expression and functionality of genes. In particular, we focus on the role of epigenome-wide studies of human and mouse liver in understanding these age-related processes with respect to xenobiotic processing. We highlight genes encoding drug metabolizing enzymes and transporters revealed to be affected by epigenetic aging in these studies. We conclude that substantial evidence exists for epigenetic aging impacting drug metabolism and transport genes, but more work is needed. We further highlight the promise of pharmacoepigenetics applied to enhancing drug safety in older adults.
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Affiliation(s)
- Sara Abudahab
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Patricia W Slattum
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, USA
- Virginia Center on Aging, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Elvin T Price
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Joseph L McClay
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, USA
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Bousman CA, Maruf AA, Marques DF, Brown LC, Müller DJ. The emergence, implementation, and future growth of pharmacogenomics in psychiatry: a narrative review. Psychol Med 2023; 53:7983-7993. [PMID: 37772416 PMCID: PMC10755240 DOI: 10.1017/s0033291723002817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 08/24/2023] [Accepted: 08/30/2023] [Indexed: 09/30/2023]
Abstract
Psychotropic medication efficacy and tolerability are critical treatment issues faced by individuals with psychiatric disorders and their healthcare providers. For some people, it can take months to years of a trial-and-error process to identify a medication with the ideal efficacy and tolerability profile. Current strategies (e.g. clinical practice guidelines, treatment algorithms) for addressing this issue can be useful at the population level, but often fall short at the individual level. This is, in part, attributed to interindividual variation in genes that are involved in pharmacokinetic (i.e. absorption, distribution, metabolism, elimination) and pharmacodynamic (e.g. receptors, signaling pathways) processes that in large part, determine whether a medication will be efficacious or tolerable. A precision prescribing strategy know as pharmacogenomics (PGx) assesses these genomic variations, and uses it to inform selection and dosing of certain psychotropic medications. In this review, we describe the path that led to the emergence of PGx in psychiatry, the current evidence base and implementation status of PGx in the psychiatric clinic, and finally, the future growth potential of precision psychiatry via the convergence of the PGx-guided strategy with emerging technologies and approaches (i.e. pharmacoepigenomics, pharmacomicrobiomics, pharmacotranscriptomics, pharmacoproteomics, pharmacometabolomics) to personalize treatment of psychiatric disorders.
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Affiliation(s)
- Chad A. Bousman
- The Mathison Centre for Mental Health Research & Education, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, AB, Canada
- Department of Medical Genetics, University of Calgary, Calgary, AB, Canada
- Departments of Physiology and Pharmacology, and Community Health Sciences, University of Calgary, Calgary, AB, Canada
- AB Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
| | - Abdullah Al Maruf
- The Mathison Centre for Mental Health Research & Education, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, AB, Canada
- College of Pharmacy, Rady Faculty of Health Sciences, Winnipeg, MB, Canada
| | | | | | - Daniel J. Müller
- Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Wurzburg, Wurzburg, Germany
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Preskorn SH, Rode R. Personalized Medicine in the Treatment of a Patient With Obsessive-Compulsive Disorder With Clomipramine. J Psychiatr Pract 2023; 29:469-475. [PMID: 37948171 DOI: 10.1097/pra.0000000000000750] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Clomipramine (CIMI) is an effective treatment for obsessive-compulsive disorder in patients who have failed to respond to trials of selective serotonin transport inhibitors (eg, sertraline). The case presented here illustrates how knowledge of the pharmacodynamics and pharmacokinetics of CIMI in a specific patient can be used to personalize treatment to optimize the likelihood of efficacy (ie, maximum benefit to risk ratio). The approach described in this column considered: (1) the patient's diminished ability to clear CIMI and its major metabolite, desmethlyclomipramine due to a genetic deficiency in cytochrome P450 2D6 enzyme activity, and (2) the patient's ability to extensively convert CIMI to desmethlyclomipramine. That conversion impairs the ability to inhibit the serotonin transporter, the mechanism that is most likely responsible for the efficacy of CIMI in obsessive-compulsive disorder.
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Affiliation(s)
- Sheldon H Preskorn
- PRESKORN and RODE: Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine-Wichita, Wichita, KS
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Maciaszek J, Pawłowski T, Hadryś T, Machowska M, Wiela-Hojeńska A, Misiak B. The Impact of the CYP2D6 and CYP1A2 Gene Polymorphisms on Response to Duloxetine in Patients with Major Depression. Int J Mol Sci 2023; 24:13459. [PMID: 37686266 PMCID: PMC10487921 DOI: 10.3390/ijms241713459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/25/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
Depression is a global mental health concern, and personalized treatment approaches are needed to optimize its management. This study aimed to investigate the influence of the CYP2D6 and CYP1A2 gene polymorphisms on the efficacy of duloxetine in reducing depressive and anxiety symptoms. A sample of 100 outpatients with major depression, who initiated monotherapy with duloxetine, were followed up. Polymorphisms in the CYP2D6 and CYP1A2 genes were assessed. The severity of depressive and anxiety symptoms was recorded using standardized scales. Adverse drug reactions (ADRs) were analyzed. Statistical analyses, including linear regression, were conducted to examine the relationships between genetic polymorphisms, clinical variables, and treatment outcomes. Patients with higher values of the duloxetine metabolic index (DMI) for CYP2D6, indicating a faster metabolism, achieved a greater reduction in anxiety symptoms. The occurrence of ADRs was associated with a lower reduction in anxiety symptoms. However, no significant associations were found between studied gene polymorphisms and reduction in depressive symptoms. No significant effects of the DMI for CYP1A2 were found. Patients with a slower metabolism may experience less benefit from duloxetine therapy in terms of anxiety symptom reduction. Personalizing treatment based on the CYP2D6 and CYP1A2 gene polymorphisms can enhance the effectiveness of antidepressant therapy and improve patient outcomes.
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Affiliation(s)
- Julian Maciaszek
- Department of Psychiatry, Wroclaw Medical University, 50-367 Wroclaw, Poland; (T.P.); (T.H.); (B.M.)
| | - Tomasz Pawłowski
- Department of Psychiatry, Wroclaw Medical University, 50-367 Wroclaw, Poland; (T.P.); (T.H.); (B.M.)
| | - Tomasz Hadryś
- Department of Psychiatry, Wroclaw Medical University, 50-367 Wroclaw, Poland; (T.P.); (T.H.); (B.M.)
| | - Marta Machowska
- Department of Clinical Pharmacology, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.M.); (A.W.-H.)
| | - Anna Wiela-Hojeńska
- Department of Clinical Pharmacology, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.M.); (A.W.-H.)
| | - Błażej Misiak
- Department of Psychiatry, Wroclaw Medical University, 50-367 Wroclaw, Poland; (T.P.); (T.H.); (B.M.)
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den Uil MG, Hut HW, Wagelaar KR, Abdullah-Koolmees H, Cahn W, Wilting I, Deneer VHM. Pharmacogenetics and phenoconversion: the influence on side effects experienced by psychiatric patients. Front Genet 2023; 14:1249164. [PMID: 37693320 PMCID: PMC10486269 DOI: 10.3389/fgene.2023.1249164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/04/2023] [Indexed: 09/12/2023] Open
Abstract
Introduction: Preventing side effects is important to ensure optimal psychopharmacotherapy and therapeutic adherence among psychiatric patients. Obtaining the pharmacogenetic profile of CYP2C19 and CYP2D6 can play an important role in this. When the genotype-predicted phenotype shifts because of the use of co-medication, this is called phenoconversion. The aim was to study the influence of the pharmacogenetic (PGx) profile and phenoconversion on side effects experienced by psychiatric patients. Methods: A retrospective cohort study was performed using data from 117 patients from a psychiatric outpatient clinic. Patients were genotyped with a psychiatric PGx panel and side effects were evaluated using the Udvalg for Kliniske Undersølgelser side effects rating scale (UKU). Results: Of all patients, 10.3% and 9.4% underwent phenoconversion (any shift in predicted phenotype) for CYP2C19 and CYP2D6 respectively. No significant associations were found between the phenotype and UKU-score. 75% of the patients with an Intermediate metabolizer (IM) or Poor metabolizer (PM) phenoconverted phenotype of CYP2C19 experienced nausea and vomiting compared to 9.1% of the Normal metabolizer (NM) and Ultrarapid metabolizer (UM) patients (p = 0.033). 64% of the patients with an IM or PM phenoconverted phenotype of CYP2D6 experienced the side effect depression compared to 30.4% NMs and UMs (p = 0.020). CYP2D6 IM and PM patients had a higher concentration-dose ratio than NM patients (p < 0.05). Discussion: This study underlines the importance to consider phenoconversion when looking at a patient's genotype. This is important for a better prediction of the phenotype and preventing possible side effects under a specific psychopharmacotherapy.
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Affiliation(s)
- Manon G. den Uil
- Division Laboratories, Pharmacy and Biomedical Genetics, Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Hannelotte W. Hut
- Division Laboratories, Pharmacy and Biomedical Genetics, Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Kay R. Wagelaar
- Division Laboratories, Pharmacy and Biomedical Genetics, Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, Netherlands
- Department of Clinical Pharmacy, Medisch Spectrum Twente, Enschede, Netherlands
| | - Heshu Abdullah-Koolmees
- Pharmacy and Clinical Pharmacology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Wiepke Cahn
- Department of Psychiatry, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ingeborg Wilting
- Division Laboratories, Pharmacy and Biomedical Genetics, Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Vera H. M. Deneer
- Division Laboratories, Pharmacy and Biomedical Genetics, Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
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Moshetova LK, Soshina MM, Turkina KI, Grishina EA, Sozaeva ZA, Kachanova AA, Akmalova KA, Ivashchenko DV, Zastrozhin MS, Fisenko VP, Sychev DA. Effect of CYP2D6*4, CYP2D6*10 polymorphisms on the safety of treatment with timolol maleate in patients with glaucoma. Drug Metab Pers Ther 2023; 38:143-148. [PMID: 36001461 DOI: 10.1515/dmpt-2022-0117] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/30/2022] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Timolol maleate is used for the treatment of glaucoma and metabolized by cytochrome CYP2D6 in the liver. The aim of this study was the evaluation of the influence of CYP2D6*4 and CYP2D6*10 gene polymorphisms on the safety of medications containing 0.5% of timolol maleate as glaucoma treatment in patients with primary open-angle glaucoma (POAG). METHODS 105 patients with POAG were prescribed glaucoma medications, containing 0.5% timolol maleate. The safety of glaucoma treatment was determined by electrocardiography (ECG) (to assess heart rate (HR) and PQ interval) and blood pressure (BP) measurements. The real-time polymerase chain reaction method was used for the detection of single nucleotide polymorphisms (SNP). RESULTS The risk of adverse drug reactions was higher in patients with the CYP2D6*4 GA genotype compared with GG: mean HR change at 1 month (2.88 ± 4.68 and 6.44 ± 5.57, p<0.001) and 6 months (5.14 ± 8.93 and 7.88 ± 5.65, p<0.001), mean PQ interval change at 1 (0.01 ± 0.031 and 0.02 ± 0.022, p=0.003) and 6 months (0.01 ± 0.032 and 0.02 ± 0.024, p=0.003). The risk of adverse drug reactions was higher in patients with the CYP2D6*10 CT genotype compared with CC: mean HR change at 1 month (2.94 ± 4.65 and 6.34 ± 5.66, p<0.001) and 6 months (5.20 ± 8.90 and 7.78 ± 5.75, p<0.001), mean PQ interval change at 1 (0.01 ± 0.032 and 0.02 ± 0.021, p=0.014) and 6 months (0.01 ± 0.033 and 0.02 ± 0.022, p=0.014). CONCLUSIONS CYP2D6*4 and CYP2D6*10 gene polymorphisms may affect a higher risk of timolol-induced bradycardia and increased PQ interval of treatment medications containing 0.5% of timolol maleate in patients with POAG.
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Affiliation(s)
- Larisa K Moshetova
- Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Maria M Soshina
- Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Ksenia I Turkina
- Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Elena A Grishina
- Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Zhannet A Sozaeva
- Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Anastasia A Kachanova
- Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Kristina A Akmalova
- Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Dmitriy V Ivashchenko
- Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
- Penza Branch of Russian Medical Academy of Continuous Professional Education, Penza, Russian Federation
| | - Mikhail S Zastrozhin
- Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Vladimir P Fisenko
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Dmitry A Sychev
- Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
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Preskorn SH, Armstrong AG. Can the Publication of Case Series or Case Reports Lead to a Change in Clinical Practice? J Psychiatr Pract 2023; 29:137-141. [PMID: 36928200 DOI: 10.1097/pra.0000000000000701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
This column provides some criteria for evaluating whether a case series or case report may warrant publication. It will emphasize the value of having biomarker data in addition to clinical data to enhance the potential validation of the report and provide ways to test the findings in randomized, controlled clinical trials (RCTs). The potential validity of the case series or report is also high if the outcome is something that would not normally be expected such as, by way of example but not limited to, sudden death or malignant hypertension in someone who had always been normotensive. Examples illustrating how case series/case reports have changed the course of clinical practice or regulatory rules governing drug approval by the US Food and Drug Administration are presented, as well as examples of how those reports have been validated by more rigorous studies including RCTs. The column also includes a discussion of situations in which case series/case reports might have an endpoint (eg, sudden death) that would not be ethical to investigate in an RCT, as well as how biomarkers have been used in such instances to avoid serious untoward outcomes for a participant while still testing the hypothesis.
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Affiliation(s)
- Sheldon H Preskorn
- PRESKORN and ARMSTRONG: Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine-Wichita, Wichita, KS
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Case Report: Performing a Medication Safety Review Assisted by Pharmacogenomics to Explain a Prescribing Cascade Resulting in a Patient Fall. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010118. [PMID: 36676742 PMCID: PMC9863497 DOI: 10.3390/medicina59010118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/31/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
Pharmacotherapy for major depressive disorder (MDD) typically consists of trial-and-error and clinician preference approaches, where patients often fail one or more antidepressants before finding an optimal regimen. Pharmacogenomics (PGx) can assist in prescribing appropriate antidepressants, thereby reducing the time to MDD remission and occurrence of adverse drug events. Since many antidepressants are metabolized by and/or inhibit cytochrome P450 enzymes (e.g., CYP2C19 or CYP2D6), drug-induced phenoconversion is common in patients on antidepressant combinations. This condition influences the interpretation of a patient's PGx results, overall risk of ineffective/adverse medication response due to multi-drug interactions, and the recommendations. This complex case describes a patient with MDD, generalized anxiety disorder, and chronic pain who experienced a fall due to excessive sedation following a prescribing cascade of fluoxetine, bupropion, and doxepin. These antidepressants delivered a significant additive sedative effect and interacted with the patient's hydrocodone, potentially contributing to uncontrolled pain, upward dose titration of hydrocodone, and a higher overall sedative burden. The PGx results and drug-induced phenoconversion described in this case report explain the patient's excessive sedation and possibly ineffective/toxic antidepressant and opioid treatment. This case report also illustrates how a more timely multi-drug interaction assessment (preferably in conjunction with preemptive PGx testing) may have informed a different prescribing pattern, reduced/avoided a prescribing cascade, and potentially prevented a drug-related fall.
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Nahid NA, Johnson JA. CYP2D6 pharmacogenetics and phenoconversion in personalized medicine. Expert Opin Drug Metab Toxicol 2022; 18:769-785. [PMID: 36597259 PMCID: PMC9891304 DOI: 10.1080/17425255.2022.2160317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/15/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION CYP2D6 contributes to the metabolism of approximately 20-25% of drugs. However, CYP2D6 is highly polymorphic and different alleles can lead to impacts ranging from null to increase in activity. Moreover, there are commonly used drugs that potently inhibit the CYP2D6, thus causing 'phenoconversion' which can convert the genotypic normal metabolizer into phenotypic poor metabolizer. Despite growing literature on the clinical implications of non-normal CYP2D6 genotype and phenoconversion on patient-related outcomes, implementation of CYP2D6 pharmacogenetics and phenoconversion to guide prescribing is rare. This review focuses on providing the clinical importance of CYP2D6 pharmacogenetics and phenoconversion in precision medicine and summarizes the challenges and approaches to implement these into clinical practice. AREAS COVERED A literature search was performed using PubMed and clinical studies documenting the effects of CYP2D6 genotypes and/or CYP2D6 inhibitors on pharmacokinetics, pharmacodynamics or treatment outcomes of CYP2D6-metabolized drugs, and studies on implementation challenges and approaches. EXPERT OPINION Considering the extent and impact of genetic polymorphisms of CYP2D6, phenoconversion by the comedications, and contribution of CYP2D6 in drug metabolism, CYP2D6 pharmacogenetics is essential to ensure drug safety and efficacy. Utilization of proper guidelines incorporating both CYP2D6 pharmacogenetics and phenoconversion in clinical care assists in optimizing drug therapy.
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Affiliation(s)
- Noor A. Nahid
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL, USA
- Division of Cardiovascular Medicine, University of Florida College of Medicine, FL, USA
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Grzegorzewski J, Brandhorst J, König M. Physiologically based pharmacokinetic (PBPK) modeling of the role of CYP2D6 polymorphism for metabolic phenotyping with dextromethorphan. Front Pharmacol 2022; 13:1029073. [PMID: 36353484 PMCID: PMC9637881 DOI: 10.3389/fphar.2022.1029073] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/23/2022] [Indexed: 11/24/2022] Open
Abstract
The cytochrome P450 2D6 (CYP2D6) is a key xenobiotic-metabolizing enzyme involved in the clearance of many drugs. Genetic polymorphisms in CYP2D6 contribute to the large inter-individual variability in drug metabolism and could affect metabolic phenotyping of CYP2D6 probe substances such as dextromethorphan (DXM). To study this question, we (i) established an extensive pharmacokinetics dataset for DXM; and (ii) developed and validated a physiologically based pharmacokinetic (PBPK) model of DXM and its metabolites dextrorphan (DXO) and dextrorphan O-glucuronide (DXO-Glu) based on the data. Drug-gene interactions (DGI) were introduced by accounting for changes in CYP2D6 enzyme kinetics depending on activity score (AS), which in combination with AS for individual polymorphisms allowed us to model CYP2D6 gene variants. Variability in CYP3A4 and CYP2D6 activity was modeled based on in vitro data from human liver microsomes. Model predictions are in very good agreement with pharmacokinetics data for CYP2D6 polymorphisms, CYP2D6 activity as described by the AS system, and CYP2D6 metabolic phenotypes (UM, EM, IM, PM). The model was applied to investigate the genotype-phenotype association and the role of CYP2D6 polymorphisms for metabolic phenotyping using the urinary cumulative metabolic ratio (UCMR), DXM/(DXO + DXO-Glu). The effect of parameters on UCMR was studied via sensitivity analysis. Model predictions indicate very good robustness against the intervention protocol (i.e. application form, dosing amount, dissolution rate, and sampling time) and good robustness against physiological variation. The model is capable of estimating the UCMR dispersion within and across populations depending on activity scores. Moreover, the distribution of UCMR and the risk of genotype-phenotype mismatch could be estimated for populations with known CYP2D6 genotype frequencies. The model can be applied for individual prediction of UCMR and metabolic phenotype based on CYP2D6 genotype. Both, model and database are freely available for reuse.
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Gloor Y, Lloret-Linares C, Bosilkovska M, Perroud N, Richard-Lepouriel H, Aubry JM, Daali Y, Desmeules JA, Besson M. Drug metabolic enzyme genotype-phenotype discrepancy: High phenoconversion rate in patients treated with antidepressants. Biomed Pharmacother 2022; 152:113202. [PMID: 35653884 DOI: 10.1016/j.biopha.2022.113202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/23/2022] [Accepted: 05/23/2022] [Indexed: 11/02/2022] Open
Abstract
Cytochromes from the P450 family (CYP) play a central role in the primary metabolism of frequently prescribed antidepressants, potentially affecting their efficacy and tolerance. There are however important differences in the drug metabolic capacities of each individual resulting from a combination of intrinsic and environmental factors. This variability can present an important risk for patients and increases the difficulty of drug prescription in clinical practice. Pharmacogenetic studies have uncovered a number of alleles defining the intrinsic metabolizer status, however, additional factors affecting cytochrome activity can modify this activity and result in a phenoconversion. The present study investigates the discrepancy between the genetically predicted and actually measured activities for the six most important liver cytochromes (CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6 and CYP3A4) in a cohort of patients under antidepressant treatment, previously shown to have a high proportion of patients with low metabolizing activities. We now performed the genetic characterization of this cohort to determine the extent of the genetic versus environmental contribution in these decreased activities. For all enzyme tested, we observed an important rate of phenoconversion, affecting between 33 % and 65 % of the patients, as well as a significant (p < 1E-06) global reduction in the effective but not predicted activities of CYP2D6, CYP2C9 and CYP2C19 compared to the general population. Our results highlight the advantages of phenotyping versus genotyping as well as the increased risk of treatment failure or adverse effect occurrence in a polymedicated population.
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Affiliation(s)
- Y Gloor
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care and Emergency, Geneva University Hospitals (HUG), Geneva, Switzerland.
| | - C Lloret-Linares
- Department of Nutritional and Metabolic Diseases, Ramsay Générale de Santé, Pays de Savoie Private Hospital, Annemasse, France
| | - M Bosilkovska
- Clinical Pharmacology and Toxicology, Department of Anaesthetics Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland
| | - N Perroud
- Division of Psychiatric Specialties, Department of Mental Health and Psychiatry, University of Geneva, Geneva, Switzerland; Division of Psychiatric Specialties, Department of Psychiatry, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - H Richard-Lepouriel
- Division of Psychiatric Specialties, Department of Mental Health and Psychiatry, University of Geneva, Geneva, Switzerland; Division of Psychiatric Specialties, Department of Psychiatry, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - J-M Aubry
- Division of Psychiatric Specialties, Department of Mental Health and Psychiatry, University of Geneva, Geneva, Switzerland
| | - Y Daali
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care and Emergency, Geneva University Hospitals (HUG), Geneva, Switzerland; Clinical Pharmacology and Toxicology, Department of Anaesthetics Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland; Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), University of Geneva, Geneva, Switzerland
| | - J A Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care and Emergency, Geneva University Hospitals (HUG), Geneva, Switzerland; Clinical Pharmacology and Toxicology, Department of Anaesthetics Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland; Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), University of Geneva, Geneva, Switzerland
| | - M Besson
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care and Emergency, Geneva University Hospitals (HUG), Geneva, Switzerland; Clinical Pharmacology and Toxicology, Department of Anaesthetics Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland
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Amundson CJ, Knight R, Ybarra GM, Turgeon J, Bingham JM. Mitigating the Risk of Adverse Effects Related to Augmentation Therapy for Resistant Major Depressive Disorder: A Case Report. Medicina (B Aires) 2022; 58:medicina58030438. [PMID: 35334614 PMCID: PMC8953614 DOI: 10.3390/medicina58030438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 11/16/2022] Open
Abstract
Polypharmacy of psychotropic medications predisposes older adults to adverse drug events (ADEs). One contributing factor is inhibition of metabolic pathways between substrates (competitive inhibition) or between substrates and inhibitors of the same cytochrome P450 (CYP450) isoforms. The purpose of this case report is to demonstrate observed sedation and difficulty concentrating from augmentation therapy for resistant major depressive disorder (MDD) and to highlight the value of clinical tools to identify opportunities for treatment optimization to reduce ADEs. The pharmacist identified significant medication burden and competitive inhibition of drug metabolism in the CYP450 system during a telehealth medication therapy management consultation with a 69-year-old male. The pharmacist recommended clinical monitoring and communicated concerns about medication-induced sedation, difficulty concentrating, and other medication-related problems (MRP) to providers. Several recommendations were implemented which helped improved patient’s outcomes. Individualizing MDD pharmacotherapy based on pharmacokinetic and pharmacodynamic drug interactions and geriatric dosage considerations may lead to better outcomes and tolerability among older adults.
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Affiliation(s)
- Collin J. Amundson
- Ken R. Coit College of Pharmacy, University of Arizona, Tucson, AZ 85721, USA; (C.J.A.); (J.M.B.)
| | - Robert Knight
- Tabula Rasa HealthCare, MedWiseRx, 100 N Stone Ave Suite 109-222, Tucson, AZ 85701, USA; (R.K.); (G.M.Y.)
| | - Georgina M. Ybarra
- Tabula Rasa HealthCare, MedWiseRx, 100 N Stone Ave Suite 109-222, Tucson, AZ 85701, USA; (R.K.); (G.M.Y.)
| | - Jacques Turgeon
- Tabula Rasa HealthCare, Precision Pharmacotherapy Research & Development Institute, 13485 Veterans Way, Orlando, FL 32827, USA
- Correspondence: ; Tel.: +1-856-938-8793
| | - Jennifer M. Bingham
- Ken R. Coit College of Pharmacy, University of Arizona, Tucson, AZ 85721, USA; (C.J.A.); (J.M.B.)
- Tabula Rasa HealthCare, Office of Translational Research & Residency Programs, 228 Strawbridge Dr, Moorestown, NJ 08057, USA
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13
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Mifsud Buhagiar L, Casha M, Grech A, Serracino Inglott A, LaFerla G. The interplay between pharmacogenetics, concomitant drugs and blood levels of amitriptyline and its main metabolites. Per Med 2022; 19:113-123. [PMID: 35118877 DOI: 10.2217/pme-2021-0022] [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: 11/21/2022]
Abstract
Background: The research considers the impact of genotype-inferred variability on blood levels of amitriptyline and its main metabolites, as may be moderated by phenocopying. Patients & methods: CYP2D6 and CYP2C19 genotypes, and serum concentrations of amitriptyline, nortriptyline and hydroxymetabolites, were determined in 33 outpatients. Co-medications were reviewed to identify CYP inhibition risk. Results: CYP2C19 metabolizer status explained interpatient variation in nortriptyline to amitriptyline concentration ratios. The hydroxymetabolite to parent ratios increased with higher CYP2D6 activity scores and lower CYP2D6 inhibition risk. In patients at high CYP2D6 inhibition risk, the amitriptyline + nortriptyline concentration was, on average, 52% above the higher end of expected ranges. Conclusion: Practical construal of pharmacogenetics and drug interactions tantamount to aberrant metabolism can facilitate patient-tailored use of the established drug.
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Affiliation(s)
- Luana Mifsud Buhagiar
- Department of Pharmacy, Faculty of Medicine & Surgery, University of Malta, Msida, MSD 2080, Malta.,Medicines Authority, Malta Life Sciences Park, San Ġwann, SĠN 3000, Malta
| | - Marilyn Casha
- Department of Surgery, Faculty of Medicine & Surgery, University of Malta, Msida, MSD 2080, Malta
| | - Anton Grech
- Department of Psychiatry, Faculty of Medicine & Surgery, University of Malta, Msida, MSD 2080, Malta
| | - Anthony Serracino Inglott
- Department of Pharmacy, Faculty of Medicine & Surgery, University of Malta, Msida, MSD 2080, Malta.,Medicines Authority, Malta Life Sciences Park, San Ġwann, SĠN 3000, Malta
| | - Godfrey LaFerla
- Department of Surgery, Faculty of Medicine & Surgery, University of Malta, Msida, MSD 2080, Malta
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14
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Zastrozhin MS, Skryabin VY, Petukhov AE, Pankratenko EP, Grishina EA, Ryzhikova KA, Torrado MV, Shipitsyn VV, Bryun EA, Sychev DA. Impact of CYP2D6 Polymorphism on Equilibrium Concentration of Fluoxetine in Patients Diagnosed With Major Depressive Disorder and Comorbid Alcohol Use Disorders. J Psychiatr Pract 2021; 27:372-379. [PMID: 34529603 DOI: 10.1097/pra.0000000000000568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Fluoxetine is used in the treatment of patients with recurrent depressive disorder. Some of these patients do not achieve an adequate response to a treatment regimen containing fluoxetine, and many of these patients experience dose-dependent adverse drug reactions. The cytochrome P450 enzyme CYP2D6 is involved in the biotransformation of fluoxetine, the activity of which is quite dependent on the polymorphism of the gene encoding this enzyme. OBJECTIVE The objective of the study was to investigate the influence of the 1846G>A polymorphism of the CYP2D6 gene on the concentration/dose indicator of fluoxetine in patients diagnosed with major depressive disorder and comorbid alcohol use disorder. METHODS Our study included 101 patients with major depressive disorder and alcohol use disorder (average age: 41.3±14.5 y) who were treated with fluoxetine at an average dose of 26.1±8.7 mg/d. Treatment efficacy was assessed using validated psychometric scales, and the safety/tolerability of the therapy was assessed using the Udvalg for Kliniske Undersogelser Side-Effect Rating Scale. Genotyping was done using a real-time polymerase chain reaction. Therapeutic drug monitoring was performed using high-performance liquid chromatography-mass spectrometry. RESULTS CYP2D6 genotyping by polymorphic marker 1846G>A (rs3892097) in the 101 patients found that there were 81 patients (80.2%) with the GG genotype ("wild-type," normal metabolism), 20 (19.8%) with the GA genotype (intermediate metabolism), and no subjects with the AA genotype (poor metabolism). Statistically significant results in treatment efficacy as evaluated by Hamilton Rating Scale for Depression scores at the end of the treatment course were found: GG 9.0 [confidence interval (CI): 6.0; 12.0] and GA 12.0 (CI: 9.5; 14.0), P=0.005. Statistically significant results were also obtained for the safety profile as measured by scores on the Udvalg for Kliniske Undersogelser Side-Effect Rating Scale: GG 3.0 (CI 2.0; 4.0) and GA 5.0 (CI: 4.0; 5.0), P<0.001. Finally, a statistically significant difference was found in concentration/dose indicators of fluoxetine in patients with the different genotypes: GG 4.831 (CI: 3.654; 6.204) and GA 7.011 (CI: 5.431; 8.252), P<0.001. CONCLUSION The effect of the genetic polymorphism of the CYP2D6 gene on the efficacy and safety profiles of fluoxetine was demonstrated in a group of 101 patients with major depressive disorder and alcohol use disorder.
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15
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Cicali EJ, Elchynski AL, Cook KJ, Houder JT, Thomas CD, Smith DM, Elsey A, Johnson JA, Cavallari LH, Wiisanen K. How to Integrate CYP2D6 Phenoconversion Into Clinical Pharmacogenetics: A Tutorial. Clin Pharmacol Ther 2021; 110:677-687. [PMID: 34231197 PMCID: PMC8404400 DOI: 10.1002/cpt.2354] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/15/2021] [Indexed: 01/26/2023]
Abstract
CYP2D6 genotype is increasingly being integrated into practice to guide prescribing of certain medications. The CYP2D6 drug metabolizing enzyme is susceptible to inhibition by concomitant drugs, which can lead to a clinical phenotype that is different from the genotype-based phenotype, a process referred to as phenoconversion. Phenoconversion is highly prevalent but not widely integrated into practice because of either limited experience on how to integrate or lack of knowledge that it has occurred. We built a calculator tool to help clinicians integrate a standardized method of assessing CYP2D6 phenoconversion into practice. During tool-building, we identified several clinical factors that need to be considered when implementing CYP2D6 phenoconversion into clinical practice. This tutorial shares the steps that the University of Florida Health Precision Medicine Program took to build the calculator tool and identified clinical factors to consider when implementing CYP2D6 phenoconversion in clinical practice.
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Affiliation(s)
- Emily J. Cicali
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, USA
| | - Amanda L. Elchynski
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, USA
| | - Kelsey J. Cook
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Jacksonville, Florida, USA
- Nemours Children’s Specialty Care, Jacksonville, FL, USA
| | - John T. Houder
- Dean’s Office, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Cameron D. Thomas
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, USA
| | - D. Max Smith
- MedStar Health, Columbia, Maryland
- Georgetown University Medical Center, Washington, DC
| | - Amanda Elsey
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, USA
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, USA
| | - Kristin Wiisanen
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, USA
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16
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Just KS, Dormann H, Freitag M, Schurig M, Böhme M, Steffens M, Scholl C, Seufferlein T, Graeff I, Schwab M, Stingl JC. CYP2D6 in the Brain: Potential Impact on Adverse Drug Reactions in the Central Nervous System-Results From the ADRED Study. Front Pharmacol 2021; 12:624104. [PMID: 34025403 PMCID: PMC8138470 DOI: 10.3389/fphar.2021.624104] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 04/19/2021] [Indexed: 12/15/2022] Open
Abstract
Cytochrome P450 (CYP) 2D6 is a polymorphic enzyme expressed in the central nervous system (CNS), important in drug metabolism and with a potentially constitutive role in CNS function such as vigilance. This study aimed to analyze variability in CYP2D6 activity linked to vigilance-related adverse drug reactions (ADRs) in the CNS. A dataset of N = 2939 ADR cases of the prospective multicenter observational trial in emergency departments (EDs) (ADRED; trial registration: DRKS-ID: DRKS00008979) was analyzed. Dizziness as the most frequent reported CNS ADR symptom (12.7% of patients, n = 372) related to vigilance was chosen as the outcome. The association of dizziness with CYP2D6 activity markers was analyzed. The number of CYP2D6 substrates taken, a CYP2D6 saturation score (no, moderate, and strong saturation), a CYP2D6 saturation/inhibition score (no, weak, moderate, and strong), and composed CYP2D6 activity using a genotyped subsample (n = 740) calculating additive effects of genotype and CYP2D6 saturation by drug exposure were used as CYP2D6 activity markers. Effects were compared to other frequent nonvigilance-related CNS ADR symptoms (syncope and headache). Secondary analyses were conducted to control for other ADR symptoms frequently associated with dizziness (syncope, nausea, and falls). The majority of all patients (64.5%, n = 1895) took at least one drug metabolized by CYP2D6. Around a third took a CNS drug (32.5%, n = 955). The chance to present with drug-related dizziness to the ED increased with each CYP2D6 substrate taken by OR 1.11 [1.01–1.23]. Presenting with drug-related dizziness was more likely with CYP2D6 saturation and saturation/inhibition (both OR 1.27 [1.00–1.60]). The composed CYP2D6 activity was positively associated with dizziness (p = 0.028), while poorer activity affected patients more often with dizziness as an ADR. In contrast, nonvigilance-related ADR symptoms such as syncope and nausea were not consistently significantly associated with CYP2D6 activity markers. This study shows an association between the number of CYP2D6 substrates, the predicted CYP2D6 activity, and the occurrence of dizziness as a CNS ADR symptom. As dizziness is a vigilance-related CNS symptom, patients with low CYP2D6 activity might be more vulnerable to drug-related dizziness. This study underlines the need for understanding individual drug metabolism activity and individual risks for ADRs.
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Affiliation(s)
- Katja S Just
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, Aachen, Germany
| | - Harald Dormann
- Central Emergency Department, Hospital Fürth, Fürth, Germany
| | - Mathias Freitag
- Department of Geriatric Medicine, University Hospital of RWTH Aachen, Aachen, Germany
| | - Marlen Schurig
- Research Department, Federal Institute of Drugs and Medical Devices, Bonn, Germany
| | - Miriam Böhme
- Research Department, Federal Institute of Drugs and Medical Devices, Bonn, Germany
| | - Michael Steffens
- Research Department, Federal Institute of Drugs and Medical Devices, Bonn, Germany
| | - Catharina Scholl
- Research Department, Federal Institute of Drugs and Medical Devices, Bonn, Germany
| | - Thomas Seufferlein
- Internal Medicine Emergency Department, Ulm University Medical Centre, Ulm, Germany
| | - Ingo Graeff
- Interdisciplinary Emergency Department (INZ), University Hospital of Bonn, Bonn, Germany
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany.,Department of Clinical Pharmacology, University of Tuebingen, Tuebingen, Germany.,Department of Pharmacy and Biochemistry, University of Tuebingen, Tuebingen, Germany
| | - Julia C Stingl
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, Aachen, Germany
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17
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Abstract
Genetic tests, unlike most other laboratory tests, are trait rather than state tests. That means the results almost always stay the same. Exceptions to this rule are discussed in this column. Trait tests require documentation in such a way that they are not buried in the chart and forgotten, as usually happens with state (or point-in-time tests) such as serum potassium levels. Genetic test results and their implications should be explained to the patient in as much detail as possible and also shared and discussed with all health care providers treating the patient. This column explains the rationale for and the means to accomplish the goals of optimally charting and disseminating the results of such tests.
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18
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Bousman CA, Wu P, Aitchison KJ, Cheng T. Sequence2Script: A Web-Based Tool for Translation of Pharmacogenetic Data Into Evidence-Based Prescribing Recommendations. Front Pharmacol 2021; 12:636650. [PMID: 33815120 PMCID: PMC8015939 DOI: 10.3389/fphar.2021.636650] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/27/2021] [Indexed: 12/14/2022] Open
Abstract
Pharmacogenomic (PGx) testing has emerged as an effective strategy for informing drug selection and dosing. This has led to an increase in the use of PGx testing in the clinic and has catalyzed the emergence of a burgeoning commercial PGx testing industry. However, not all PGx tests are equivalent in their approach to translating testing results into prescribing recommendations, due to an absence of regulatory standards. As such, those generating and using PGx data require tools for ensuring the prescribing recommendations they are provided align with current peer-reviewed PGx-based prescribing guidelines developed by expert groups or approved product labels. Herein, we present Sequence2Script (sequence2script.com), a simple, free, and transparent web-based tool to assist in the efficient translation of PGx testing results into evidence-based prescribing recommendations. The tool was designed with a wide-range of user groups (e.g., healthcare providers, laboratory staff, researchers) in mind. The tool supports 97 gene-drug pairs with evidence-based prescribing guidelines, allows users to adjust recommendations for concomitant inhibitors and inducers, and generates a clinical report summarizing the patient's genotype, inferred phenotype, phenoconverted phenotype (if applicable), and corresponding prescribing recommendations. In this paper, we describe each of the tool's features, provide use case examples, and discuss limitations of and future development plans for the tool. Although we recognize that Sequecnce2Script may not meet the needs of every user, the hope is that this novel tool will facilitate more standardized use of PGx testing results and reduce barriers to implementing these results into practice.
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Affiliation(s)
- Chad A Bousman
- Departments of Medical Genetics, Psychiatry, and Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Mathison Centre for Mental Health Research & Education, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Patrick Wu
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Katherine J Aitchison
- Departments of Psychiatry, Medical Genetics and the Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Tony Cheng
- Ushiosoft Corporation, Calgary, AB, Canada
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Meta-analysis of probability estimates of worldwide variation of CYP2D6 and CYP2C19. Transl Psychiatry 2021; 11:141. [PMID: 33627619 PMCID: PMC7904867 DOI: 10.1038/s41398-020-01129-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 11/17/2020] [Accepted: 12/01/2020] [Indexed: 01/31/2023] Open
Abstract
Extensive migration has led to the necessity of knowledge regarding the treatment of migrants with different ethnical backgrounds. This is especially relevant for pharmacological treatment, because of the significant variation between migrant groups in their capacity to metabolize drugs. For psychiatric medications, CYP2D6 and CYP2C19 enzymes are clinically relevant. The aim of this meta-analysis was to analyze studies reporting clinically useful information regarding CYP2D6 and CYP2C19 genotype frequencies, across populations and ethnic groups worldwide. To that end, we conducted a comprehensive meta-analysis using Embase, PubMed, Web of Science, and PsycINFO (>336,000 subjects, 318 reports). A non-normal metabolizer (non-NM) probability estimate was introduced as the equivalent of the sum-prevalence of predicted poor, intermediate, and ultrarapid metabolizer CYP2D6 and CYP2C19 phenotypes. The probability of having a CYP2D6 non-NM predicted phenotype was highest in Algeria (61%) and lowest in Gambia (2.7%) while the probability for CYP2C19 was highest in India (80%) and lowest in countries in the Americas, particularly Mexico (32%). The mean total probability estimates of having a non-NM predicted phenotype worldwide were 36.4% and 61.9% for CYP2D6 and CYP2C19, respectively. We provide detailed tables and world maps summarizing clinically relevant data regarding the prevalence of CYP2D6 and CYP2C19 predicted phenotypes and demonstrating large inter-ethnic differences. Based on the documented probability estimates, pre-emptive pharmacogenetic testing is encouraged for every patient who will undergo therapy with a drug(s) that is metabolized by CYP2D6 and/or CYP2C19 pathways and should be considered in case of treatment resistance or serious side effects.
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20
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Jallaq SA, Verba M, Strawn JR, Martin LJ, DelBello MP, Ramsey LB. CYP2D6 Phenotype Influences Aripiprazole Tolerability in Pediatric Patients with Mood Disorders. J Child Adolesc Psychopharmacol 2021; 31:56-62. [PMID: 32845723 PMCID: PMC8255312 DOI: 10.1089/cap.2020.0058] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Objective: To determine the effect of CYP2D6 metabolizer status on aripiprazole tolerability in pediatric patients with mood disorders. Methods: We retrospectively reviewed electronic medical record data for 277 patients ≤18 years of age (at the time of CYP2D6 testing) with a mood disorder, receiving oral aripiprazole, and CYP2D6 genotyped as part of routine care. The maximum aripiprazole dose and concomitant medications were extracted from the medical record. The reason for aripiprazole discontinuation was determined to be from side effects (e.g., weight gain, akathisia, GI upset), nonresponse, or other reasons (e.g., financial). Associations with CYP2D6 were analyzed using multivariate linear regression models and chi-square tests. Results: Of the 277 patients (mean age: 14.3 ± 2.4), 57% were normal metabolizers (NMs), 37% were intermediate metabolizers (IMs), 5% were poor metabolizers (PMs), and 1.4% were ultrarapid metabolizers (UMs). A total of 72.2% of the cohort were concomitantly taking a CYP2D6 inhibitor, resulting in phenoconversion. Accounting for phenoconversion resulted in 27% phenoconverted NMs (pNMs), 24% phenoconverted IMs (pIMs), 48% phenoconverted PMs (pPMs), and <1% phenoconverted ultrarapid metabolizers. CYP2D6 pPMs discontinued treatment due to side effects more often than any other CYP2D6 group (67% for pPM, 51% pIM, 57% pNM, chi-square p = 0.024). Body mass index percentile change was associated with the CYP2D6 phenotype (p = 0.038), the time on aripiprazole (p = 0.001), and the number of concomitant CYP2D6 substrates (p = 0.044) in multivariable models. Conclusions: Phenoconverted CYP2D6 metabolizer status is associated with aripiprazole discontinuation. In addition, dose adjustments based on CYP2D6 metabolizer status and concomitant medications could improve aripiprazole treatment outcomes.
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Affiliation(s)
- Sahar A. Jallaq
- Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pharmaceutical Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio, USA
| | - Mark Verba
- Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Molecular, Cellular, and Biochemical Pharmacology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, and University of Cincinnati, Cincinnati, Ohio, USA.,Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lisa J. Martin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Melissa P. DelBello
- Department of Psychiatry and Behavioral Neuroscience, and University of Cincinnati, Cincinnati, Ohio, USA.,Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Laura B. Ramsey
- Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA.,Address correspondence to: Laura B. Ramsey, PhD, Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229, USA
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21
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Mostafa S, Polasek TM, Sheffield LJ, Huppert D, Kirkpatrick CMJ. Quantifying the Impact of Phenoconversion on Medications With Actionable Pharmacogenomic Guideline Recommendations in an Acute Aged Persons Mental Health Setting. Front Psychiatry 2021; 12:724170. [PMID: 34489765 PMCID: PMC8416898 DOI: 10.3389/fpsyt.2021.724170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 07/27/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Polypharmacy and genetic variants that strongly influence medication response (pharmacogenomics, PGx) are two well-described risk factors for adverse drug reactions. Complexities arise in interpreting PGx results in the presence of co-administered medications that can cause cytochrome P450 enzyme phenoconversion. Aim: To quantify phenoconversion in a cohort of acute aged persons mental health patients and evaluate its impact on the reporting of medications with actionable PGx guideline recommendations (APRs). Methods: Acute aged persons mental health patients (N = 137) with PGx and medication data at admission and discharge were selected to describe phenoconversion frequencies for CYP2D6, CYP2C19 and CYP2C9 enzymes. The expected impact of phenoconversion was then assessed on the reporting of medications with APRs. Results: Post-phenoconversion, the predicted frequency at admission and discharge increased for CYP2D6 intermediate metabolisers (IMs) by 11.7 and 16.1%, respectively. Similarly, for CYP2C19 IMs, the predicted frequency at admission and discharge increased by 13.1 and 11.7%, respectively. Nineteen medications with APRs were prescribed 120 times at admission, of which 50 (42%) had APRs pre-phenoconversion, increasing to 60 prescriptions (50%) post-phenoconversion. At discharge, 18 medications with APRs were prescribed 122 times, of which 48 (39%) had APRs pre-phenoconversion, increasing to 57 prescriptions (47%) post-phenoconversion. Discussion: Aged persons mental health patients are commonly prescribed medications with APRs, but interpretation of these recommendations must consider the effects of phenoconversion. Adopting a collaborative care model between prescribers and clinical pharmacists should be considered to address phenoconversion and ensure the potential benefits of PGx are maximised.
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Affiliation(s)
- Sam Mostafa
- Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia.,MyDNA Life, Australia Limited, South Yarra, VIC, Australia
| | - Thomas M Polasek
- Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia.,Certara, Princeton, NJ, United States.,Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Leslie J Sheffield
- MyDNA Life, Australia Limited, South Yarra, VIC, Australia.,Department of Genetic Medicine, Melbourne Health, Parkville, VIC, Australia
| | - David Huppert
- Department of Aged & Liaison Psychiatry, Alfred Health, Melbourne, VIC, Australia.,Northwestern Mental Health, Melbourne Health, Melbourne, VIC, Australia
| | - Carl M J Kirkpatrick
- Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
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22
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Ortega-Vázquez A, Mayen-Lobo YG, Dávila-Ortiz de Montellano DJ, Tristán-López L, Aviña-Cervantes CL, Ríos C, López-López M, Monroy-Jaramillo N. Alcohol intake potentiates clozapine adverse effects associated to CYP1A2*1C in patients with refractory psychosis. Drug Dev Res 2020; 82:685-694. [PMID: 33336447 DOI: 10.1002/ddr.21774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/24/2020] [Accepted: 12/03/2020] [Indexed: 12/24/2022]
Abstract
Clozapine (CLZ) is an atypical antipsychotic and the gold standard for refractory psychosis treatment. However, there is little information regarding pharmacogenetics of CLZ in patients with refractory psychosis and its clinical correlation with alcohol intake. Although neurological effects of CLZ in patients with concomitant alcohol intake are documented, its use is very common in patients with psychosis. We explored the impact of CYP1A2, CYP2D6, CYP2C19, and CYP3A4 genetic variants on CLZ pharmacokinetics and side effects, along with coffee/alcohol/tobacco consumption habits and clinical data of 48 adult patients with refractory psychosis on CLZ antipsychotic monotherapy. Relevant CYP variants in CLZ metabolism were evaluated by targeted genotyping and multiplex ligation-dependent probe amplification. CLZ and its main metabolite plasma concentrations were determined by high performance liquid chromatography. Biochemical and molecular data, along with other potential confounders, were included in the analysis by linear regression. Overall, CYP variants showed no effect on CLZ pharmacokinetics. The rs2069514 variant in homozygous genotype (also known as CYP1A2*1C/*1C) was associated with CLZ adverse reactions in Mexican patients with refractory psychosis (OR = 3.55 CI95 = 1.041-12.269, p = .043) and demonstrated that this effect is doubled by concomitant alcohol consumption (OR = 7.9 CI95 = 1.473-42.369, p = .016). Clinicians should be aware of this information before starting CLZ use, when treating patients with refractory psychosis, who are alcohol drinkers and carriers of this genetic variant in order to prevent CLZ-related adverse reactions. Nevertheless, our findings should be replicated in larger samples.
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Affiliation(s)
- Alberto Ortega-Vázquez
- Department of Biological Systems, Metropolitan Autonomous University-Xochimilco, Mexico City, Mexico
| | - Yerye G Mayen-Lobo
- Department of Biological Systems, Metropolitan Autonomous University-Xochimilco, Mexico City, Mexico.,Master's Program in Pharmaceutical Sciences, Metropolitan Autonomous University-Xochimilco, Mexico City, Mexico
| | | | - Luis Tristán-López
- Department of Neurochemistry, National Institute of Neurology and Neurosurgery, "Manuel Velasco Suárez", Mexico City, Mexico
| | - Carlos L Aviña-Cervantes
- Department of Psychiatry, National Institute of Neurology and Neurosurgery, "Manuel Velasco Suárez", Mexico City, Mexico
| | - Camilo Ríos
- Department of Biological Systems, Metropolitan Autonomous University-Xochimilco, Mexico City, Mexico.,Master's Program in Pharmaceutical Sciences, Metropolitan Autonomous University-Xochimilco, Mexico City, Mexico.,Department of Neurochemistry, National Institute of Neurology and Neurosurgery, "Manuel Velasco Suárez", Mexico City, Mexico
| | - Marisol López-López
- Department of Biological Systems, Metropolitan Autonomous University-Xochimilco, Mexico City, Mexico
| | - Nancy Monroy-Jaramillo
- Department of Genetics, National Institute of Neurology and Neurosurgery, "Manuel Velasco Suárez", Mexico City, Mexico
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Bain KT, Knowlton CH. Role of Opioid-Involved Drug Interactions in Chronic Pain Management. J Osteopath Med 2020; 119:839-847. [PMID: 31790129 DOI: 10.7556/jaoa.2019.136] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The use of opioids for chronic pain management is extraordinarily common despite substantial evidence of only modest benefits, when compared with nonopioid analgesics. Opioid use is also associated with serious risks, including overdose and death. A growing body of evidence suggests that opioids are involved in significant drug interactions that often go unrecognized in clinical practice. Understanding opioid-involved drug interactions is of great practical importance for all health care professionals caring for patients with chronic pain. In this article, we describe the mechanisms of opioid-involved drug interactions and their potential consequences, which have major public health implications. Additionally, this article provides practical strategies to aid health care professionals in avoiding and mitigating opioid-involved drug interactions in order to obtain a favorable balance in the risk-benefit ratio associated with opioid use. These strategies include using osteopathic principles for chronic pain management, separating the times of administration of the opioid(s) from the nonopioid(s) involved in the interaction, changing the opioid(s) adversely affected by the interaction, changing the nonopioid(s) causing the interaction, and partnering with pharmacists in clinical practice.
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24
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Two Clinically Important but Underutilized and Misunderstood Tools: Formulas to Estimate Creatinine Clearance and Therapeutic Drug Monitoring. J Psychiatr Pract 2020; 26:305-308. [PMID: 32692127 DOI: 10.1097/pra.0000000000000471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This column first reviews 2 key equations that are central to clinical pharmacology. Clinicians can use the first equation to predict the effect of a specific dose of a specific drug in specific circumstances on the basis of 3 variables: (1) the drug's pharmacodynamics, (2) the drug's pharmacokinetics, and (3) biological variance in the individual patient. Clinicians can use the second equation to determine the concentration of a drug that a patient will achieve on a given dose depending on the patient's ability to clear the drug from the body. These 2 equations allow prescribers to predict whether the dose of a drug a patient is receiving is likely to achieve the desired clinical response (not so low that it is clinically ineffective or so high that it causes adverse effects that interfere with the patient's ability to tolerate or benefit from the treatment). The author then describes 2 tools clinicians can use to determine a patient's ability to clear a drug from the body, and thus calculate the concentration of the drug using Equation 2. These tools are: (1) estimation of creatinine clearance and (2) therapeutic drug monitoring.
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25
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Marshe VS, Islam F, Maciukiewicz M, Bousman C, Eyre HA, Lavretsky H, Mulsant BH, Reynolds CF, Lenze EJ, Müller DJ. Pharmacogenetic Implications for Antidepressant Pharmacotherapy in Late-Life Depression: A Systematic Review of the Literature for Response, Pharmacokinetics and Adverse Drug Reactions. Am J Geriatr Psychiatry 2020; 28:609-629. [PMID: 32122803 DOI: 10.1016/j.jagp.2020.01.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 01/14/2020] [Accepted: 01/15/2020] [Indexed: 02/06/2023]
Abstract
Affecting up to 15% of older adults, late-life depression (LLD) is characterized by the occurrence of depressive symptoms after the age of 50-65 years and maybe pathophysiologically distinct from depression in younger adults. Therefore, LLD is challenging to treat, and predictive genetic testing might be essential to improve treatment in this vulnerable population. The current review aims to provide a summary of the literature exploring genetic associations with antidepressant treatment outcomes in late-life. We conducted a systematic search of three integrated electronic databases. We identified 29 articles investigating genetic associations with antidepressant treatment outcomes, pharmacokinetic parameters, and adverse drug reactions in older adults. Given the small number of investigations conducted in older adults, it is difficult to conclude the presence or absence of genetic associations with the outcomes of interest. In sum, the most substantial amount of evidence exists for the CYP2D6 metabolizer status, SLC6A4 5-HTTLPR, and BDNF rs6265. These findings are consistent in the literature when not restricting to older adults, suggesting that similar treatment recommendations may be provided for older adults regarding genetic variation, such as those outlined for CYP2D6 by the Clinical Pharmacogenetics Implementation Consortium. Nonetheless, further studies are required in well-characterized samples, including genome-wide data, to validate if similar treatment adjustments are appropriate in older adults, given that there appear to be significant effects of genetic variation on antidepressant treatment factors.
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Affiliation(s)
- Victoria S Marshe
- Institute of Medical Science, University of Toronto (VSM, BHM, DJM), Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (VSM, FI, MM, BHM, DJM), Toronto, ON, Canada
| | - Farhana Islam
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (VSM, FI, MM, BHM, DJM), Toronto, ON, Canada; Department of Pharmacology (FI, DJM), University of Toronto, Toronto, ON, Canada
| | - Malgorzata Maciukiewicz
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (VSM, FI, MM, BHM, DJM), Toronto, ON, Canada
| | - Chad Bousman
- Departments of Medical Genetics, Psychiatry, and Physiology & Pharmacology (CB), University of Calgary, Calgary, AB, Canada; Department of Psychiatry (CB), University of Melbourne, Melbourne, Victoria, Australia
| | - Harris A Eyre
- Innovation Institute, Texas Medical Center (HAE), Houston, TX; School of Medicine, IMPACT SRC, Deakin University (HAE), Geelong, Victoria, Australia; Brainstorm Lab, Department of Psychiatry and Behavioral Sciences (HAE), Stanford University, Palo Alto, CA; Discipline of Psychiatry (HAE), The University of Adelaide, Adelaide, South Australia, Australia
| | - Helen Lavretsky
- Department of Psychiatry (HL), University of California, Los Angeles, CA
| | - Benoit H Mulsant
- Institute of Medical Science, University of Toronto (VSM, BHM, DJM), Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (VSM, FI, MM, BHM, DJM), Toronto, ON, Canada; Department of Psychiatry (BHM, DJM), University of Toronto, Toronto, ON, Canada
| | - Charles F Reynolds
- Department of Psychiatry (CFR), University of Pittsburgh, Pittsburgh, PA
| | - Eric J Lenze
- Healthy Mind Lab, Department of Psychiatry (EJL), Washington University, St. Louis, MO
| | - Daniel J Müller
- Institute of Medical Science, University of Toronto (VSM, BHM, DJM), Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (VSM, FI, MM, BHM, DJM), Toronto, ON, Canada; Department of Pharmacology (FI, DJM), University of Toronto, Toronto, ON, Canada; Department of Psychiatry (BHM, DJM), University of Toronto, Toronto, ON, Canada.
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Cytochrome P450 (CYP450) Interactions Involving Atypical Antipsychotics are Common in Community-Dwelling Older Adults Treated for Behavioral and Psychological Symptoms of Dementia. PHARMACY 2020; 8:pharmacy8020063. [PMID: 32276526 PMCID: PMC7355621 DOI: 10.3390/pharmacy8020063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 12/11/2022] Open
Abstract
Treatment of behavioral and psychological symptoms of dementia (BPSD) and comorbidities often necessitates the concomitant use of antipsychotics and non-antipsychotic drugs, thereby potentiating the risk for drug–drug interactions (DDIs). The primary objective of our study was to identify potentially clinically relevant cytochrome P450 (CYP)-mediated DDIs involving antipsychotics among participants enrolled in the Program of All-Inclusive Care for the Elderly (PACE) with BPSD. Additionally, we wanted to determine the prevalence of antipsychotic use in this population. The study included 10,001 PACE participants. The practice setting used a proprietary clinical decision support system (CDSS) to analyze simultaneous multidrug interactions. A retrospective analysis of pharmacy claims data was conducted to identify DDIs involving antipsychotics prescribed for BPSD, using snapshots of medication profiles paired with the CDSS. Of the participants who met inclusion criteria, 1190 (11.9%) were prescribed an antipsychotic; of those, 1071 (90.0%) were prescribed an atypical antipsychotic. Aripiprazole commonly caused (being a perpetrator drug 94.6% of the time) potential DDIs with antidepressants (e.g., duloxetine, venlafaxine, mirtazapine), opioids (e.g., hydrocodone, oxycodone, tramadol) and metoprolol via the CYP2D6 isoform. Risperidone commonly caused (85.7%) potential DDIs with donepezil, lamotrigine and trazodone via the CYP3A4 isoform. Quetiapine exclusively suffered (100%) from potential DDIs with amlodipine, buspirone, omeprazole or topiramate via the CYP3A4 isoform. Antipsychotics are commonly prescribed to PACE participants for BPSD treatment and they may interact with other drugs used to treat comorbidities. A thorough review of concomitant medications will help mitigate the likelihood of potentially dangerous CYP-mediated DDIs involving antipsychotics.
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Bain KT, McGain D, Cicali EJ, Knowlton CH, Michaud V, Turgeon J. Precision medication: An illustrative case series guiding the clinical application of multi-drug interactions and pharmacogenomics. Clin Case Rep 2020; 8:305-312. [PMID: 32128178 PMCID: PMC7044418 DOI: 10.1002/ccr3.2604] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 11/06/2019] [Accepted: 11/21/2019] [Indexed: 12/22/2022] Open
Abstract
Precision medication entails selecting the precise medication, dose, and timing of administration. Multi-drug interactions and genetics significantly affect precision medication. In this article, we present two simulated cases for real-world applications of precision medication. Clinicians may need to acquire additional skills to apply the principles illustrated by these cases.
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Affiliation(s)
- Kevin T. Bain
- Tabula Rasa HealthCareMoorestownNJUSA
- Department of PharmacyUniversity of the SciencesPhiladelphiaPAUSA
| | | | - Emily J. Cicali
- Department of Pharmacotherapy and Translational ResearchUniversity of FloridaGainesvilleFLUSA
| | | | - Veronique Michaud
- Tabula Rasa HealthCareMoorestownNJUSA
- Faculty of PharmacyUniversité de MontréalMontrealQCCanada
| | - Jacques Turgeon
- Tabula Rasa HealthCareMoorestownNJUSA
- Faculty of PharmacyUniversité de MontréalMontrealQCCanada
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28
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Lesche D, Mostafa S, Everall I, Pantelis C, Bousman CA. Impact of CYP1A2, CYP2C19, and CYP2D6 genotype- and phenoconversion-predicted enzyme activity on clozapine exposure and symptom severity. THE PHARMACOGENOMICS JOURNAL 2019; 20:192-201. [PMID: 31616047 DOI: 10.1038/s41397-019-0108-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 09/09/2019] [Accepted: 10/02/2019] [Indexed: 12/14/2022]
Abstract
Clozapine is an atypical antipsychotic metabolized by CYP1A2, CYP2D6, and CYP2C19 enzymes. Among 66 adult schizophrenia patients treated with clozapine-based combination therapies, we explored the impact of genotype-predicted CYP1A2, CYP2D6, and CYP2C19 activity on dose-adjusted clozapine concentrations and symptom severity, with and without correction for inhibitors and inducers of these enzymes. Uncorrected activity scores were not associated with dose-adjusted clozapine concentrations or symptom severity. CYP1A2 and CYP2D6 activity scores corrected for known inducers (i.e., smoking) and inhibitors (e.g., concomitant medications) were associated with dose-adjusted clozapine levels and in the case of CYP1A2, symptom severity. However, smoking status and certain inhibitors of clozapine metabolism (i.e., esomeprazole) explained significantly more variance in dose-adjusted clozapine levels relative to corrected activity scores. These findings highlight the clinical importance of nongenetic factors (smoking, concomitant medications) and suggest that the added utility of CYP1A2, CYP2D6, and CYP2C19 activity scores to guide clozapine dosing is currently limited.
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Affiliation(s)
- Dorothea Lesche
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, University of Melbourne & Melbourne Health, Melbourne, VIC, Australia
| | - Sam Mostafa
- myDNA Life Australia Limited, South Yarra, VIC, Australia.,Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
| | - Ian Everall
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, University of Melbourne & Melbourne Health, Melbourne, VIC, Australia.,Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia.,The Cooperative Research Centre (CRC) for Mental Health, VIC, Australia
| | - Christos Pantelis
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, University of Melbourne & Melbourne Health, Melbourne, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia.,The Cooperative Research Centre (CRC) for Mental Health, VIC, Australia
| | - Chad A Bousman
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, University of Melbourne & Melbourne Health, Melbourne, VIC, Australia. .,The Cooperative Research Centre (CRC) for Mental Health, VIC, Australia. .,Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. .,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. .,Departments of Medical Genetics, Psychiatry, and Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada.
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29
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Schoretsanitis G, Haen E, Hiemke C, Endres K, Ridders F, Veselinovic T, Gründer G, Paulzen M. Pharmacokinetic correlates of venlafaxine: associated adverse reactions. Eur Arch Psychiatry Clin Neurosci 2019; 269:851-857. [PMID: 30923938 DOI: 10.1007/s00406-019-01005-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 03/21/2019] [Indexed: 01/03/2023]
Abstract
To address the potential correlation between plasma concentrations of venlafaxine (VEN), its active metabolite O-desmethylvenlafaxine (ODVEN) and the active moiety, AM, (ODVEN + VEN) and adverse drug reactions (ADR) in a large naturalistic sample of in- and outpatients. We compared plasma concentrations of VEN, ODVEN and AM and dose-adjusted (C/D) levels as well the ODVEN/VEN ratios between patients complaining ADRs, following the Udvalg for Kliniske Undersogelser side effect rating scales (UKU) (n = 114) and patients without ADRs (control group, n = 688) out of a naturalistic database. We also investigated potential pharmacokinetic correlates of the four UKU categories by comparing patients complaining ADRs with those who did not. Based on previous literature we applied different ODVEN/VEN ratio values as cut-offs to split our sample into two groups at a time and compare frequencies of ADRs between the groups. No differences for demographic and pharmacokinetic variables including plasma and C/D concentrations as well as ODVEN/VEN ratios were observed between study groups. Neither the comparisons between females and males nor between elderly and non-elderly patients revealed significant differences (p > 0.05 in all cases). No differences were also reported exploring the patients complaining ADRs from the 4 UKU categories separately. After applying various ODVEN/VEN cut-offs, groups did not display differences in frequencies of ADRs (p > 0.05 in all cases). Our findings do not demonstrate a direct link between venlafaxine metabolism measures and ADRs. Therefore, additional dimensions are needed to be considered in future trials aiming to disentangle the involved aspects of ADRs in patients receiving venlafaxine.
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Affiliation(s)
- Georgios Schoretsanitis
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA.
| | - Ekkehard Haen
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany.,Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Mainz, Germany
| | - Katharina Endres
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany.,Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Florian Ridders
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany.,Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Tanja Veselinovic
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany.,JARA: Translational Brain Medicine, Aachen, Germany
| | - Gerhard Gründer
- Department of Molecular Neuroimaging, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Paulzen
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany.,JARA: Translational Brain Medicine, Aachen, Germany.,Alexianer Hospital Aachen, Aachen, Germany
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Zebala JA, Searle SL, Webster LR, Johnson MS, Schuler AD, Maeda DY, Kahn SJ. Desmetramadol Has the Safety and Analgesic Profile of Tramadol Without Its Metabolic Liabilities: Consecutive Randomized, Double-Blind, Placebo- and Active Comparator-Controlled Trials. THE JOURNAL OF PAIN 2019; 20:1218-1235. [PMID: 31005596 PMCID: PMC6790288 DOI: 10.1016/j.jpain.2019.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/25/2019] [Accepted: 04/15/2019] [Indexed: 01/16/2023]
Abstract
Desmetramadol is an investigational analgesic consisting of (+) and (-) enantiomers of the tramadol metabolite O-desmethyltramadol (M1). Tramadol is racemic and exerts analgesia by monoaminergic effects of (-)-tramadol and (-)-M1, and by the opioid (+)-M1. Tramadol labeling indicates cytochrome P450 (CYP) isozyme 2D6 ultrarapid metabolizer can produce dangerous (+)-M1 levels, and CYP2D6 poor metabolizers insufficient (+)-M1 for analgesia. We hypothesized that desmetramadol could provide the safety and analgesia of tramadol without its metabolic liabilities. We conducted consecutive double-blind, randomized, placebo-controlled, 3 segment cross-over trials A and B to investigate the steady-state pharmacokinetics and analgesia of 20 mg desmetramadol and 50 mg tramadol in 103 healthy participants without (n = 43) and with (n = 60) cotreatment with the CYP inhibitor paroxetine. In the absence of CYP inhibition (trial A), 20 mg desmetramadol and 50 mg tramadol dosed every 6 hours gave equivalent steady-state (+)-M1, similar adverse events, and analgesia significantly greater than placebo, but equal to each other. In trial B, CYP inhibition significantly depressed tramadol steady-state (+)-M1, reduced its adverse events, and led to insignificant analgesia comparable with placebo. In contrast, CYP inhibition in trial B had no deleterious effect on desmetramadol (+)-M1 or (-)-M1, which gave significant analgesia as in trial A and superior to tramadol (P = .003). Desmetramadol has the safety and efficacy of tramadol without its metabolic liabilities. CLINICALTRIALS.GOV REGISTRATIONS: NCT02205554, NCT03312777 PERSPECTIVE: To our knowledge, this is the first study of desmetramadol in humans and the first to show it provides the same safety and analgesia as tramadol, but without tramadol's metabolic liabilities and related drug-drug interactions. Desmetramadol could potentially offer expanded safety and usefulness to clinicians seeking an alternative to schedule II opioids.
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Abstract
The events leading up to the discovery of genetically controlled polymorphic metabolism of xenobiotics and pharmaceutical chemicals are briefly summarised with the salient historical features being emphasised. Especial attention has been given to seminal works in the then emerging field.The evolving knowledge of such polymorphic metabolism and its role in the quest for personalised medicine and the individualisation of patient drug therapy are appraised. Opinion is offered as to whether or not the full potential has been exploited and if the practical application of this information may be regarded as a success or failure within the present clinical arena.
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Affiliation(s)
- Robert L Smith
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Stephen C Mitchell
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
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32
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Wyska E. Pharmacokinetic considerations for current state-of-the-art antidepressants. Expert Opin Drug Metab Toxicol 2019; 15:831-847. [DOI: 10.1080/17425255.2019.1669560] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Elżbieta Wyska
- Department of Pharmacokinetics and Physical Pharmacy, Jagiellonian University Medical College, Kraków, Poland
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Abstract
In recent years, β-adrenergic blockers have become the first choice drugs for glaucoma treatment. Timolol holds the main position among them, being a part of most combined antiglaucoma preparations. The use of timolol maleate in clinical practice may be accompanied by severe side effects affecting different organs and systems. The fact that cells with β-adrenergic receptors are widely common within the human body explains pharmacodynamic effects of timolol maleate. Because of these undesirable side effects, timolol maleate often evokes negative reaction from doctors and patients, which to certain extent limits its usage in ophthalmological practice. Obviously, efficacy and safety of timolol administration depends on individual characteristics making personalized approach necessary for every patient. Such particular approach, being the foundation of personalized medicine, increases efficacy and safety of timolol while reducing costs by using targeted doses.
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Affiliation(s)
- L K Moshetova
- Russian Medical Academy of Continuous Professional Education, Department of Ophthalmology, 2/1 Barricadnaya St., Moscow, Russian Federation, 125993
| | - M M Soshina
- Russian Medical Academy of Continuous Professional Education, Department of Ophthalmology, 2/1 Barricadnaya St., Moscow, Russian Federation, 125993
| | - D A Sychev
- Russian Medical Academy of Continuous Professional Education, Department of Clinical Pharmacology and Therapy, 2/1 Barricadnaya St., Moscow, Russian Federation, 125993
| | - K I Turkina
- Russian Medical Academy of Continuous Professional Education, Department of Ophthalmology, 2/1 Barricadnaya St., Moscow, Russian Federation, 125993
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Bain KT, Matos A, Knowlton CH, McGain D. Genetic variants and interactions from a pharmacist-led pharmacogenomics service for PACE. Pharmacogenomics 2019; 20:709-718. [DOI: 10.2217/pgs-2019-0047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Aim: Evaluate results of pharmacogenomics testing for participants enrolled in the Program of All-inclusive Care for the Elderly (PACE). Materials & methods: A convenience sample of 100 participants from the PHARM-GENOME-PACE study. Genetic variants were determined by pharmacogenomics testing. Drug–gene interactions (DGIs), drug–drug–gene interactions (DDGIs) and phenoconversions were interrogated from a clinical decision support system. Results: In total, 146 genetic variants, 169 DGIs and 125 DDGIs were detected. DGIs and DDGIs occurred most commonly with the CYP2D6 gene (36.1 and 39.2%, respectively). There were 280 instances of phenoconversions; majority (62.9%) affecting the CYP3A4 isoenzyme. Conclusion: Prevalence of exposures to DGIs and DDGIs among PACE participants is high. Pharmacists using a clinical decision support system can support PACE practitioners with assessing multidrug simultaneous interactions. Clinical trial registration: NCT03257605
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Affiliation(s)
- Kevin T Bain
- Tabula Rasa HealthCare, Department of Research & Development, 228 Strawbridge Drive, Moorestown, NJ 08057, USA
- University of the Sciences, Philadelphia College of Pharmacy, Department of Pharmacy Practice and Administration, 600 South 43rd Street, Philadelphia, PA 19104, USA
| | - Adriana Matos
- Tabula Rasa HealthCare, Department of Research & Development, 228 Strawbridge Drive, Moorestown, NJ 08057, USA
| | - Calvin H Knowlton
- Tabula Rasa HealthCare, Executive Department, 228 Strawbridge Drive, Moorestown, NJ 08057, USA
| | - David McGain
- Tabula Rasa HealthCare, Department of Research & Development, 228 Strawbridge Drive, Moorestown, NJ 08057, USA
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35
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An economic model of the cost-utility of pre-emptive genetic testing to support pharmacotherapy in patients with major depression in primary care. THE PHARMACOGENOMICS JOURNAL 2019; 19:480-489. [PMID: 30647446 DOI: 10.1038/s41397-019-0070-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 10/26/2018] [Accepted: 12/21/2018] [Indexed: 12/28/2022]
Abstract
The pharmacokinetics of many antidepressants (tricyclic antidepressants (TCA) or selective serotonin re-uptake inhibitors (SSRI)) are influenced by the highly polymorphic CYP2D6 enzyme. Therefore, pharmacogenetics could play an important role in the treatment of depressive patients. The potential cost-utility of screening patients is however still unknown. Therefore, a Markov model was developed to compare the strategy of screening for CYP2D6 and subsequently adjust antidepressant treatment according to a patient's metabolizer profile of poor, extensive, or ultra metabolizer, with the strategy of no screening ('one size fits all' principle). Each week a patient had a probability of side effects, which was followed by dosage titration or treatment switching. After 6 weeks treatment effect was evaluated followed by treatment adjustments if necessary, with a total time horizon of the model of 12 weeks. The analysis was performed from a societal perspective. The strategy of screening compared with no screening resulted in incremental costs of €91 (95 percentiles: €39; €152) more expensive but also more effect with 0.001 quality adjusted life years (QALYs) (95 percentiles: 0.001; 0.002) gain. The incremental cost-effectiveness ratio (ICER) was therefore €77,406 per QALY gained, but varied between €22,500 and €377,500 depending on the price of screening and productivity losses. According to our model, we cannot unequivocally conclude that screening for CYP2D6 in primary care patients using antidepressants is be cost-effective, as the results are surrounded by large uncertainty. Therefore, information from ongoing studies should be used to reduce these uncertainties.
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Abstract
This column is the third in a series exploring drug-drug interactions (DDIs) with a special emphasis on psychiatric medications. The first column in this series discussed why patients being treated with psychiatric medications are at increased risk for taking multiple medications and thus experiencing DDIs and how to recognize such DDIs, and strategies for avoiding them. The second column in the series further discussed strategies for avoiding and/or minimizing adverse outcomes from DDIs. This third column deals with pharmacokinetic considerations concerning DDIs in psychiatric practice. Specifically, this column discusses the 2 major types of pharmacokinetically mediated DDIs: those mediated by cytochrome P450 (CYP) enzymes and those mediated by transport proteins. The role of each of these regulatory proteins in the pharmacokinetics of drugs is reviewed as well as how genetically determined variation in the functional activity of these regulatory proteins can alter the accumulation of a drug in the body (ie, via CYP enzymes) and in specific compartments of the body (ie, via transport proteins), either increasing or decreasing their accumulation leading to either reduced efficacy or increased toxicity. This column further explains how coprescribed drugs can also affect the functional integrity of these regulatory proteins and lead to differences from usual in the accumulation of drugs dependent on the activity of these CYP enzymes and drug transporters. This phenomenon is known as phenoconversion in which a patient can functionally change from his or her genetic status, for example, having extensive or normal metabolism, to having poor or slow metabolism and hence greater accumulation than would be expected based on the patient's genotype.
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Suzuki Y, Muraya N, Fujioka T, Sato F, Tanaka R, Matsumoto K, Sato Y, Ohno K, Mimata H, Kishino S, Itoh H. Factors involved in phenoconversion of CYP3A using 4β-hydroxycholesterol in stable kidney transplant recipients. Pharmacol Rep 2018; 71:276-281. [PMID: 30826567 DOI: 10.1016/j.pharep.2018.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/19/2018] [Accepted: 12/14/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Phenoconversion is a phenomenon whereby some genotypic extensive metabolizers transiently exhibit drug metabolizing enzyme activity at similar level as that of poor metabolizers. Renal failure is known to decrease CYP3A activity in humans. Indoxyl sulfate, parathyroid hormone (PTH), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) have been reported to cause CYP3A downregulation in renal failure. We measured plasma concentrations of the above compounds in stable kidney transplant recipients, and evaluated their relations with phenoconversion of CYP3A evaluated by plasma concentration of 4β-hydroxycholesterol, a biomarker of CYP3A activity. Phenoconversion was defined as a genotypic extensive/intermediate metabolizer exhibiting CYP3A activity below the cutoff value that discriminates extensive/intermediate from poor metabolizers. METHODS Sixty-three Japanese kidney transplant recipients who underwent transplantation more than 180 days prior to the study were included. Morning blood samples were collected, and CYP3A5 polymorphism as well as plasma concentrations of 4β-hydroxycholesterol, indoxyl sulfate, intact-PTH, IL-6 and TNF-α were determined. RESULTS Significantly higher plasma 4β-hydroxycholesterol concentration was observed in recipients with CYP3A5*1 allele (n = 23) compared to those without the allele (n = 40), and the cut-off value was 40.0 ng/mL. Ten recipients with CYP3A5*1 allele exhibited CYP3A activity below 40.0 ng/mL (phenoconversion). Only plasma indoxyl sulfate concentration was significantly higher in recipients with CYP3A phenoconversion compared to those without phenoconversion. CONCLUSIONS These findings suggest that higher plasma indoxyl sulfate concentration may be involved in CYP3A phenoconversion. Dose adjustment of drugs metabolized by CYP3A may be needed in patients with CYP3A5*1 allele and high blood indoxyl sulfate.
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Affiliation(s)
- Yosuke Suzuki
- Department of Clinical Pharmacy, Oita University Hospital, 1-1 Hasama-machi, Oita, 879-5593, Japan; Department of Medication Use Analysis and Clinical Research, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo, 204-8588, Japan.
| | - Nanako Muraya
- Department of Clinical Pharmacy, Oita University Hospital, 1-1 Hasama-machi, Oita, 879-5593, Japan
| | - Takashi Fujioka
- Department of Clinical Pharmacy, Oita University Hospital, 1-1 Hasama-machi, Oita, 879-5593, Japan
| | - Fuminori Sato
- Department of Urology, Oita University Faculty of Medicine, 1-1 Hasama-machi, Oita, 879-5593, Japan
| | - Ryota Tanaka
- Department of Clinical Pharmacy, Oita University Hospital, 1-1 Hasama-machi, Oita, 879-5593, Japan
| | - Kunihiro Matsumoto
- Department of Medication Use Analysis and Clinical Research, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo, 204-8588, Japan
| | - Yuhki Sato
- Department of Clinical Pharmacy, Oita University Hospital, 1-1 Hasama-machi, Oita, 879-5593, Japan
| | - Keiko Ohno
- Department of Medication Use Analysis and Clinical Research, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo, 204-8588, Japan
| | - Hiromitsu Mimata
- Department of Urology, Oita University Faculty of Medicine, 1-1 Hasama-machi, Oita, 879-5593, Japan
| | - Satoshi Kishino
- Department of Medication Use Analysis and Clinical Research, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo, 204-8588, Japan
| | - Hiroki Itoh
- Department of Clinical Pharmacy, Oita University Hospital, 1-1 Hasama-machi, Oita, 879-5593, Japan
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Chang DD, Eyre HA, Abbott R, Coudreaut M, Baune BT, Shaman JA, Lavretsky H, Lenze EJ, Merrill DA, Singh AB, Mulsant BH, Reynolds CF, Müller DJ, Bousman C. Pharmacogenetic guidelines and decision support tools for depression treatment: application to late-life. Pharmacogenomics 2018; 19:1269-1284. [DOI: 10.2217/pgs-2018-0099] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Late-life depression (LLD) is a major depressive disorder that affects someone after the age of 60 years. LLD is frequently associated with inadequate response and remission from antidepressants, in addition to polypharmacy. Pharmacogenetics offers a promising approach to improve clinical outcomes in LLD via new discoveries determining the genetic basis of response rates and side effects, as well as the development of tailored pharmacogenetic-based decision support tools. This invited review evaluates the LLD pharmacogenetic evidence base and the extent to which this was incorporated into existing commercial decision support tools and clinical pharmacogenetic guidelines.
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Affiliation(s)
- Donald D Chang
- School of Medicine, University of Queensland-Ochsner Clinical School, Brisbane, Queensland, 4072, Australia
| | - Harris A Eyre
- Innovation Institute, Texas Medical Center, Houston, TX 77006, USA
- IMPACT SRC, School of Medicine, Deakin University, Geelong, Victoria, 3220, Australia
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, 3003, Australia
- Discipline of Psychiatry, University of Adelaide, Adelaide, South Australia, 5055, Australia
| | - Ryan Abbott
- University of Surrey, Surrey, GU2 7XH, UK
- David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA 90095, USA
| | - Michael Coudreaut
- Department of Psychiatry, Intermountain Healthcare, Salt Lake City, UT 84102, USA
| | - Bernhard T Baune
- Discipline of Psychiatry, University of Adelaide, Adelaide, South Australia, 5055, Australia
| | | | - Helen Lavretsky
- David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA 90095, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University, St Louis, MO 63130, USA
| | - David A Merrill
- David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA 90095, USA
| | - Ajeet B Singh
- IMPACT SRC, School of Medicine, Deakin University, Geelong, Victoria, 3220, Australia
| | - Benoit H Mulsant
- Department of Psychiatry, University of Toronto, Toronto, ON, M5S 3H7, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5S 3H7, Canada
| | - Charles F Reynolds
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Daniel J Müller
- Department of Psychiatry, University of Toronto, Toronto, ON, M5S 3H7, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5S 3H7, Canada
| | - Chad Bousman
- Departments of Medical Genetics, Psychiatry, & Physiology & Pharmacology, University of Calgary, Calgary, AB, AN T2N 1N4, Canada
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Storelli F, Samer C, Reny JL, Desmeules J, Daali Y. Complex Drug-Drug-Gene-Disease Interactions Involving Cytochromes P450: Systematic Review of Published Case Reports and Clinical Perspectives. Clin Pharmacokinet 2018; 57:1267-1293. [PMID: 29667038 DOI: 10.1007/s40262-018-0650-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Drug pharmacokinetics (PK) is influenced by multiple intrinsic and extrinsic factors, among which concomitant medications are responsible for drug-drug interactions (DDIs) that may have a clinical relevance, resulting in adverse drug reactions or reduced efficacy. The addition of intrinsic factors affecting cytochromes P450 (CYPs) activity and/or expression, such as genetic polymorphisms and diseases, may potentiate the impact and clinical relevance of DDIs. In addition, greater variability in drug levels and exposures has been observed when such intrinsic factors are present in addition to concomitant medications perpetrating DDIs. This variability results in poor predictability of DDIs and potentially dramatic clinical consequences. The present review illustrates the issue of complex DDIs using systematically searched published case reports of DDIs involving genetic polymorphisms, renal impairment, cirrhosis, and/or inflammation. Current knowledge on the impact of each of these factors on drug exposure and DDIs is summarized and future perspectives for the management of such complex DDIs in clinical practice are discussed, including the use of advanced Computerized Physician Order Entry (CPOE) systems, the development of model-based dose optimization strategies, and the education of healthcare professionals with respect to personalized medicine.
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Affiliation(s)
- Flavia Storelli
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland
| | - Caroline Samer
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Center for Applied Human Toxicology, Geneva, Switzerland
| | - Jean-Luc Reny
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Center for Applied Human Toxicology, Geneva, Switzerland
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland.
- Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland.
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.
- Swiss Center for Applied Human Toxicology, Geneva, Switzerland.
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Affiliation(s)
- Samet Kose
- Psychiatry and Clinical Psychopharmacology, Psychiatry and Behavioral Sciences, Franklin, TN, USA
| | - Mesut Cetin
- Psychiatry &Clinical Psychopharmacology and Psychiatry and Behavioral Sciences, Istanbul, Turkey
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An analysis of allele, genotype and phenotype frequencies, actionable pharmacogenomic (PGx) variants and phenoconversion in 5408 Australian patients genotyped for CYP2D6, CYP2C19, CYP2C9 and VKORC1 genes. J Neural Transm (Vienna) 2018; 126:5-18. [DOI: 10.1007/s00702-018-1922-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 08/27/2018] [Indexed: 12/22/2022]
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Bain KT, Schwartz EJ, Knowlton OV, Knowlton CH, Turgeon J. Implementation of a pharmacist-led pharmacogenomics service for the Program of All-Inclusive Care for the Elderly (PHARM-GENOME-PACE). J Am Pharm Assoc (2003) 2018; 58:281-289.e1. [PMID: 29602745 DOI: 10.1016/j.japh.2018.02.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/19/2018] [Accepted: 02/25/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the feasibility of implementing a pharmacist-led pharmacogenomics (PGx) service for the Program of All-Inclusive Care for the Elderly (PACE). SETTING A national centralized pharmacy providing PGx services to community-based PACE centers. PRACTICE DESCRIPTION Individuals 55 years of age and older enrolled in PACE who underwent PGx testing as part of their medical care (n = 296). PRACTICE INNOVATION Pharmacist-led PGx testing, interpreting, and consulting. EVALUATION Implementation processes and roles were ascertained by reviewing policies and procedures for the PGx service and documented observations made by pharmacists providing the service. Genetic variants and drug-gene interactions (DGIs) were determined by interpretations of PGx test results. Types of recommendations provided by pharmacists were ascertained from PGx consultations. Prescribers' acceptance of recommendations were ascertained by documented responses or drug changes made after PGx consultations. RESULTS Challenges to implementation included lack of systems interoperability, limited access to medical electronic health records, determining prescribers' responses, and knowledge and competency gaps in PGx. Pharmacist roles most essential to overcoming challenges were interpreting and applying PGx data, determining how to disseminate those data to prescribers, advocating for appropriate PGx testing, and educating about the application of test results to clinical practice. Participants frequently used drugs posing DGI risks, with the majority (73.6%) reporting more than 1 interaction. The overwhelming majority (89.0%) of pharmacists' recommendations to mitigate risks were accepted by referring prescribers. CONCLUSION Implementing a pharmacist-led PGx service for PACE is feasible. Implementation of this service highlights the leadership role of pharmacists in moving PGx from research to practice.
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Abstract
Psychiatric and physical conditions often coexist, and there is robust evidence that associates the frequency of depression with single and multiple physical conditions. More than half of patients with depression may have at least one chronic physical condition. Therefore, antidepressants are often used in cotherapy with other medications for the management of both psychiatric and chronic physical illnesses. The risk of drug-drug interactions (DDIs) is augmented by complex polypharmacy regimens and extended periods of treatment required, of which possible outcomes range from tolerability issues to lack of efficacy and serious adverse events. Optimal patient outcomes may be achieved through drug selection with minimal potential for DDIs. Desvenlafaxine is a serotonin-norepinephrine reuptake inhibitor approved for the treatment of adults with major depressive disorder. Pharmacokinetic studies of desvenlafaxine have shown a simple metabolic profile unique among antidepressants. This review examines the DDI profiles of antidepressants, particularly desvenlafaxine, in relation to drugs of different therapeutic areas. The summary and comparison of information available is meant to help clinicians in making informed decisions when using desvenlafaxine in patients with depression and comorbid chronic conditions.
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Affiliation(s)
- Yvette Low
- Department of Pharmacy, National University of Singapore, Singapore
| | | | - Graca Lima
- Global Medical Affairs, Asia-Pacific Region, Pfizer, Hong Kong
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Paulzen M, Haen E, Hiemke C, Fay B, Unholzer S, Gründer G, Schoretsanitis G. Antidepressant polypharmacy and the potential of pharmacokinetic interactions: Doxepin but not mirtazapine causes clinically relevant changes in venlafaxine metabolism. J Affect Disord 2018; 227:506-511. [PMID: 29156365 DOI: 10.1016/j.jad.2017.11.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/07/2017] [Accepted: 11/11/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND To uncover pharmacokinetic interactions between venlafaxine and doxepin or mirtazapine in a naturalistic sample. METHODS A therapeutic drug monitoring database containing plasma concentrations of venlafaxine (VEN) and its active metabolite O-desmethylvenlafaxine (ODVEN) was analyzed. We included 1067 of 1594 patients in the analysis. Three study groups were considered; a group of patients under venlafaxine without confounding medications, V0 (n = 905), a group of patients co-medicated with doxepin, VDOX (n = 25) and a second group, co-medicated with mirtazapine, VMIR, n = 137. Plasma concentrations of VEN, ODVEN and the clinically relevant active moiety, sum of venlafaxine and O-desmethylvenlafaxine (ODVEN) (AM), as well as dose-adjusted plasma concentrations (C/D) were compared. RESULTS Median concentrations in the doxepin group showed 57.7% and 194.4% higher values for AM and VEN respectively; these differences were statistically significant (p < 0.001 for AM and p = 0.002 for VEN). Similar differences were detected for C/D concentrations of active moiety and VEN (p < 0.001 and p = 0.001) with higher values also in the doxepin group. The ratios ODVEN/VEN were lower in the doxepin group (p < 0.001). A co-medication with mirtazapine did not cause any changes in venlafaxine metabolism. CONCLUSIONS Higher concentrations for VEN and AM imply an inhibiting effect of doxepin on the metabolism of venlafaxine, although the huge variability of concentrations has to be taken into account. It is recommended to monitor plasma concentrations in combination treatment to avoid problems in safety and efficacy. LIMITATIONS Despite the large size of our study sample, the naturalistic nature of this data may arise some concerns of information bias potentially resulting from non-standardized data recording.
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Affiliation(s)
- Michael Paulzen
- Alexianer Hospital Aachen, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany; JARA - Translational Brain Medicine, Aachen, Germany
| | - Ekkehard Haen
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy and Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Germany
| | - Bianca Fay
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Sandra Unholzer
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Gerhard Gründer
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany; JARA - Translational Brain Medicine, Aachen, Germany
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany; JARA - Translational Brain Medicine, Aachen, Germany; University Hospital of Psychiatry, Bern, Switzerland.
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Montané Jaime LK, Paul J, Lalla A, Legall G, Gaedigk A. Impact of CYP2D6 on venlafaxine metabolism in Trinidadian patients with major depressive disorder. Pharmacogenomics 2018; 19:197-212. [PMID: 29327975 DOI: 10.2217/pgs-2017-0142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM This study aimed to assess the impact of CYP2D6 and CYP2C19 variation on venlafaxine (VEN) at steady state in patients from Trinidad and Tobago of Indian and African descent with major depressive disorder. PATIENTS & METHODS Patients were phenotyped with dextromethorphan, genotyped for CYP2D6 and CYP2C19, and metabolic ratios for VEN obtained at 2-week intervals. RESULTS Of 61 patients, 55 were genotyped and phenotyped and 47 completed 8 weeks of VEN treatment. The majority of patients had metabolic ratios for VEN that were consistent with those for dextromethorphan and genotype-predicted phenotype using activity scores. One subject presented with a novel no-function allele, CYP2D6*99. No correlations were observed with CYP2C19 genotype. CONCLUSION CYP2D6 genotype analysis provides valuable information to individualize drug therapy with VEN.
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Affiliation(s)
- Lazara Karelia Montané Jaime
- Pharmacology Unit, Department of Paraclinical Sciences, Faculty of Medical Sciences, The University of The West Indies, St Augustine, Trinidad & Tobago
| | | | - Anthony Lalla
- Health Science Technologies Department, College of Science, Technology & Applied Arts of Trinidad & Tobago, El Dorado Campus, Corner College & St. Cecelia Roads, El Dorado, Trinidad & Tobago
| | - George Legall
- Pharmacology Unit, Department of Paraclinical Sciences, Faculty of Medical Sciences, The University of The West Indies, St Augustine, Trinidad & Tobago
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Kansas City & Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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Koopmans AB, Vinkers DJ, Poulina IT, Gelan PJA, van Schaik RHN, Hoek HW, van Harten PN. No Effect of Dose Adjustment to the CYP2D6 Genotype in Patients With Severe Mental Illness. Front Psychiatry 2018; 9:349. [PMID: 30131727 PMCID: PMC6090167 DOI: 10.3389/fpsyt.2018.00349] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 07/10/2018] [Indexed: 12/12/2022] Open
Abstract
Background: The CYP2D6 enzyme is involved in the metabolism of numerous psychopharmacological drugs. Guidelines recommend how to adjust the dose of medication based on the CYP2D6 genotype. Aims: To evaluate the effect of dose adjustment to the CYP2D6 genotype and phenotype, in patients with severe mental illness (SMI) already receiving psychopharmacological treatment. Methods: A total of 269 psychiatric patients (on the island Curaçao) receiving antipsychotic treatment were genotyped for CYP2D6. Of these, 45 patients were included for dose adjustment according to the clinical guideline of the Royal Dutch Association for the Advancement of Pharmacy, i.e., 17 CYP2D6 poor metabolizers, 26 intermediate metabolizers, and 2 ultrarapid metabolizers. These 45 patients were matched for age, gender, and type of medication with a control group of 41 patients who were CYP2D6 extensive metabolizers (i.e., with a normal CYP2D6 function). At baseline and at 4 months after dose adjustment, subjective experience, psychopathology, extrapyramidal side-effects, quality of life, and global functioning were assessed in these two groups. Results: At baseline, there were no differences between the groups regarding the prescribed dosage of antipsychotics, the number of side-effects, psychiatric symptoms, global functioning, or quality of life. After dose adjustment, no significant improvement in these parameters was reported. Conclusion: In psychiatric patients with SMI already receiving antipsychotic treatment, dose adjustment to the CYP2D6 genotype or phenotype according to the guidelines showed no beneficial effect. This suggests that dose adjustment guidelines are currently not applicable for patients already using antipsychotics. ClinicalTrials.gov: Cost-effectiveness of CYP2D6 and CYP2C19 Genotyping in Psychiatric Patients in Curacao; Identifier: NCT02713672; https://clinicaltrials.gov/ct2/show/NCT02713672?term=CYP2D6&rank=5.
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Affiliation(s)
- Anne B Koopmans
- Parnassia Academy, Parnassia Psychiatric Institute, The Hague, Netherlands.,School of Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - David J Vinkers
- School of Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Igmar T Poulina
- Parnassia Academy, Parnassia Psychiatric Institute, The Hague, Netherlands
| | | | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hans W Hoek
- Parnassia Academy, Parnassia Psychiatric Institute, The Hague, Netherlands.,Department of Psychiatry, University Medical Center Groningen, Groningen, Netherlands.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Peter N van Harten
- School of Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands.,Innova, Psychiatric Centre GGz Centraal, Amersfoort, Netherlands
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Modak AS. Point-of-care companion diagnostic tests for personalizing psychiatric medications: fulfilling an unmet clinical need. J Breath Res 2017; 12:017101. [PMID: 28920579 DOI: 10.1088/1752-7163/aa8d2e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Over the last decade stable isotope-labeled substrates have been used as probes for rapid, point-of-care, non-invasive and user-friendly phenotype breath tests to evaluate activity of drug metabolizing enzymes. These diagnostic breath tests can potentially be used as companion diagnostics by physicians to personalize medications, especially psychiatric drugs with narrow therapeutic windows, to monitor the progress of disease severity, medication efficacy and to study in vivo the pharmacokinetics of xenobiotics. Several genotype tests have been approved by the FDA over the last 15 years for both cytochrome P450 2D6 and 2C19 enzymes, however they have not been cleared for use in personalizing medications since they fall woefully short in identifying all non-responders to drugs, especially for the CYP450 enzymes. CYP2D6 and CYP2C19 are among the most extensively studied drug metabolizing enzymes, involved in the metabolism of approximately 30% of FDA-approved drugs in clinical use, associated with large individual differences in medication efficacy or tolerability essentially due to phenoconversion. The development and commercialization via FDA approval of the non-invasive, rapid (<60 min), in vivo, phenotype diagnostic breath tests to evaluate polymorphic CYP2D6 and CYP2C19 enzyme activity by measuring exhaled 13CO2 as a biomarker in breath will effectively resolve the currently unmet clinical need for individualized psychiatric drug therapy. Clinicians could personalize treatment options for patients based on the CYP2D6 and CYP2C19 phenotype by selecting the optimal medication at the right initial and subsequent maintenance dose for the desired clinical outcome (i.e. greatest efficacy and minimal side effects).
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Affiliation(s)
- Anil S Modak
- Cambridge Isotope Laboratories, Inc., 3 Highwood Drive, Tewksbury, MA 01876, United States of America
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Mangal N, James MO, Stacpoole PW, Schmidt S. Model Informed Dose Optimization of Dichloroacetate for the Treatment of Congenital Lactic Acidosis in Children. J Clin Pharmacol 2017; 58:212-220. [PMID: 28914978 DOI: 10.1002/jcph.1009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/01/2017] [Indexed: 01/13/2023]
Abstract
Dichloroacetate (DCA) is an investigational drug used to treat congenital lactic acidosis and other mitochondrial disorders. Response to DCA therapy in young children may be suboptimal following body weight-based dosing. This is because of autoinhibition of its metabolism, age-dependent changes in pharmacokinetics, and polymorphisms in glutathione transferase zeta 1 (GSTZ1), its primary metabolizing enzyme. Our objective was to predict optimal DCA doses for the treatment of congenital lactic acidosis in children. Accordingly, a semimechanistic pharmacokinetic-enzyme turnover model was developed in a step-wise approach: (1) a population pharmacokinetic model for adults was developed; (2) the adult model was scaled to children using allometry and physiology-based scaling; and (3) the scaled model was externally qualified, updated with clinical data, and optimal doses were projected. A 2-compartment model accounting for saturable clearance and GSTZ1 enzyme turnover successfully characterized the DCA PK in adults and children. DCA-induced inactivation of GSTZ1 resulted in phenoconversion of all subjects into slow metabolizers after repeated dosing. However, rate and extent of inactivation was 2-fold higher in subjects without the wild-type EGT allelic variant of GSTZ1, resulting in further phenoconversion into ultraslow metabolizers after repeated DCA administration. Furthermore, DCA-induced GSTZ1 inactivation rate and extent was found to be 25- to 30-fold lower in children than in adults, potentially accounting for the observed age-dependent changes in PK. Finally, a 12.5 and 10.6 mg/kg twice-daily DCA dose was optimal in achieving the target steady-state trough concentrations (5-25 mg/L) for EGT carrier and EGT noncarrier children, respectively.
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Affiliation(s)
- Naveen Mangal
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Margaret O James
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Peter W Stacpoole
- Department of Medicine and Department of Biochemistry and Molecular Biology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Stephan Schmidt
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL, USA
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49
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Just KS, Schneider KL, Schurig M, Stingl JC, Brockmöller J. Falls: the adverse drug reaction of the elderly and the impact of pharmacogenetics. Pharmacogenomics 2017; 18:1281-1297. [PMID: 28776468 DOI: 10.2217/pgs-2017-0018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Falls is a frequent type of adverse drug reactions causing significant morbidity and mortality in the elderly. We reviewed, with which drugs the risk of falls is relevant and might depend on genomic variation. Pharmacogenetic variability may contribute to drug-induced falls for instance mediated by impaired drug elimination due to inherited deficiency in enzymes like CYP2C9, CYP2C19 and CYP2D6. The relative role of specific genes and polymorphisms in old age may differ from younger people. Biomarkers for frailty, but also genomic biomarkers might help identifying patients at high risk for drug-induced falls. Many other factors including disease and drug-drug interactions also contribute to risk of falls. Further studies analyzing the impact of genomic variation on the medication-related fall risk in the older adult are urgently needed.
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Affiliation(s)
- Katja Susanne Just
- Research Division, Federal Institute for Drugs & Medical Devices, Bonn, Germany
| | | | - Marlen Schurig
- Research Division, Federal Institute for Drugs & Medical Devices, Bonn, Germany
| | - Julia Carolin Stingl
- Research Division, Federal Institute for Drugs & Medical Devices, Bonn, Germany.,Centre for Translational Medicine, MedicalFaculty, University of Bonn, Bonn, Germany
| | - Jürgen Brockmöller
- Institute of Clinical Pharmacology, University of Göttingen, Göttingen, Germany
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50
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Taranu A, Colle R, Gressier F, El Asmar K, Becquemont L, Corruble E, Verstuyft C. Should a routine genotyping of CYP2D6 and CYP2C19 genetic polymorphisms be recommended to predict venlafaxine efficacy in depressed patients treated in psychiatric settings? Pharmacogenomics 2017; 18:639-650. [PMID: 28480819 DOI: 10.2217/pgs-2017-0003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIM The antidepressant venlafaxine (VEN) is metabolized by CYP2D6 and CYP2C19. The aim of this study was to assess the relevance of generalizing to daily practice the genotyping of CYP2D6 and CYP2C19 to predict VEN efficacy in depressed patients treated in psychiatric settings. PATIENTS & METHODS This study was nested in a naturalistic cohort, with 206 patients requiring a new antidepressant treatment and genotyped for CYP2D6 *3, *4, *5 del, *6, *2xN, *10, *41 and CYP2C19 *2, *3, *4, *5, *17 alleles. RESULTS CYP2D6 and CYP2C19 phenotypes were associated neither with the Hamilton depression rating scale score improvement, nor with response and remission. CONCLUSION Routine CYP2D6 and CYP2C19 genotyping cannot be recommended to predict VEN efficacy in depressed patients treated in psychiatry settings.
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Affiliation(s)
- Adela Taranu
- INSERM UMR1178, Team (Depression & Antidepressants), Faculté de Médecine Paris-Sud, Univ. Paris-Sud, Le Kremlin Bicêtre, France
| | - Romain Colle
- INSERM UMR1178, Team (Depression & Antidepressants), Faculté de Médecine Paris-Sud, Univ. Paris-Sud, Le Kremlin Bicêtre, France.,Service de Psychiatrie, Hôpital Bicêtre, Groupe Hospitalier Paris Sud, AP-HP, Le Kremlin Bicêtre, France
| | - Florence Gressier
- INSERM UMR1178, Team (Depression & Antidepressants), Faculté de Médecine Paris-Sud, Univ. Paris-Sud, Le Kremlin Bicêtre, France.,Service de Psychiatrie, Hôpital Bicêtre, Groupe Hospitalier Paris Sud, AP-HP, Le Kremlin Bicêtre, France
| | - Khalil El Asmar
- INSERM UMR1178, Team (Depression & Antidepressants), Faculté de Médecine Paris-Sud, Univ. Paris-Sud, Le Kremlin Bicêtre, France
| | - Laurent Becquemont
- INSERM UMR1178, Team (Depression & Antidepressants), Faculté de Médecine Paris-Sud, Univ. Paris-Sud, Le Kremlin Bicêtre, France.,Centre de Recherche Clinique (CRC), Hôpital Bicêtre, Groupe Hospitalier Paris Sud, AP-HP, Le Kremlin Bicêtre, France
| | - Emmanuelle Corruble
- INSERM UMR1178, Team (Depression & Antidepressants), Faculté de Médecine Paris-Sud, Univ. Paris-Sud, Le Kremlin Bicêtre, France.,Service de Psychiatrie, Hôpital Bicêtre, Groupe Hospitalier Paris Sud, AP-HP, Le Kremlin Bicêtre, France
| | - Céline Verstuyft
- INSERM UMR1178, Team (Depression & Antidepressants), Faculté de Médecine Paris-Sud, Univ. Paris-Sud, Le Kremlin Bicêtre, France.,Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpital Bicêtre, Groupe Hospitalier Paris Sud, AP-HP, Le Kremlin Bicêtre, France.,Centre de Ressources Biologiques, CRB Paris-Sud, Hôpital Bicêtre, Groupe Hospitalier Paris Sud, AP-HP, Le Kremlin Bicêtre, France
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