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Preskorn SH. How the Food and Drug Administration Drug Approval Process Relates to the Potential Approval of Intravenous Racemic Ketamine for Treatment-resistant Major Depression. J Psychiatr Pract 2024; 30:134-138. [PMID: 38526401 DOI: 10.1097/pra.0000000000000768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
This column focuses on the status of intravenous racemic ketamine for the treatment of patients suffering from a form of major depressive disorder that does not respond to trials of currently available biogenic amine antidepressants. To provide context, the column reviews the 3 pivotal elements of the usual Food and Drug Administration (FDA) drug approval process: (1) the unmet medical need (ie, the indication) for which the drug is being developed, (2) the efficacy of the drug for that condition, and (3) the safety/tolerability of the drug. This column is based on the author's 45-year history of drug development work and is not a statement of the FDA. There are typically 3 phases in the drug development process: (1) studies done in normal volunteers, (2) typically small-scale proof of concept studies, and (3) large-scale registration trials. This third phase is critical in determining the efficacy, safety, and tolerability of the drug in a manner that most closely follows the clinical use of the drug. This column focuses specifically on whether generally small-scale studies done in academic centers are sufficient for drug approval, and it briefly reviews lithium and clozapine as examples of psychiatric medications that had such academic research in the literature, as well as clinical use in other countries. Those data supported the unique value of these medications in patients with bipolar disorder and treatment-resistant schizophrenia (ie, the unmet medical need), respectively, and the findings led American psychiatrists to advocate for FDA approval of these medications. Their efforts led to the needed registration trials for FDA approval of these medications. This column reviews the key features of registration trials and the reason that they are critical for FDA approval, and it discusses 2 special considerations related to the intravenous administration of racemic ketamine. First, racemic ketamine is not esketamine but, instead, it contains R-ketamine in addition to S-ketamine (ie, esketamine). The second consideration is that differences between intravenous and intranasal administration may affect the safety of the drug. While safety concerns were specifically addressed in the registration trials for esketamine, comparable research remains to be done for intravenous racemic ketamine. Understanding how the FDA's drug approval process works is important for prescribers, their patients, and the public.
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Affiliation(s)
- Sheldon H Preskorn
- PRESKORN: Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Kansas, Wichita, KS
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Preskorn SH. The Essential Parallels Between Clinical Practice and the Scientific Method. J Psychiatr Pract 2024; 30:43-45. [PMID: 38227726 DOI: 10.1097/pra.0000000000000759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
This column presents a way of conceptualizing the clinical practice of medicine including psychiatry within the framework of the scientific method. The goal is to aid practicing clinicians as well as trainees. This conceptual framework will improve the care of patients as it applies a discipline relative to giving time-limited trials of the various treatments available and then an assessment of whether the treatment worked adequately or not and what to do in the latter case. In this way, this approach should decrease the risk of excessive multiple medication use to treat a specific patient. Incorporating this conceptual framework early in the training of mental health care prescribers would be desirable.
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Affiliation(s)
- Sheldon H Preskorn
- PRESKORN: Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine-Wichita, Wichita, KS
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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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Abstract
Eight different cases are presented in this column, along with the lessons and principles that can be learned from each. The lessons and principles are general in nature and hence they are applicable to patients that readers will likely encounter.
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Affiliation(s)
- Sheldon H Preskorn
- PRESKORN: Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine-Wichita, Wichita, KS
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Preskorn SH. Seven Mechanistically Different Classes of Medications Can Be Used to Treat Insomnia and Related Sleep Disorders. J Psychiatr Pract 2023; 29:227-234. [PMID: 37200141 DOI: 10.1097/pra.0000000000000709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
This column reviews the neurobiology of the sleep-wake cycle as it is currently known, the 7 classes of currently available sleep-enhancing medications, and how their mechanisms of action relate to the neurobiology of sleep. Clinicians can use this information to select medications for their patients, which is particularly important because some patients respond to some of these medications but not others, or tolerate some but not others. This knowledge can also help the clinician switch among classes when a medication that was initially efficacious begins to fail a patient. It can also prevent the clinician from cycling through all of the members of a single medication class. Such a strategy is unlikely to be helpful for a patient except in the situation in which pharmacokinetic differences among members of the medication class result in some agents in that class being helpful for a patient who has either a delayed onset of action or undesirable carry-over effects with other agents in that class. An understanding of the classes of sleep-enhancing medications highlights the importance of knowing the neurobiology that underlies a psychiatric illness. The activity of a number of neurobiological circuits, such as the one reviewed in this column, has now been well established, while work to understand others is still at a much earlier stage. Psychiatrists who gain an understanding of such circuits will be better able to provide effective care for their patients.
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Affiliation(s)
- Sheldon H Preskorn
- PRESKORN: Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine-Wichita, Wichita, KS
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Schwasinger-Schmidt T, Preskorn SH. Reverse Engineering Drugs: Lorcaserin as an Example. Adv Neurobiol 2023; 30:195-206. [PMID: 36928851 DOI: 10.1007/978-3-031-21054-9_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Novel central nervous system (CNS)-based therapies have been difficult to produce due to the complexity of the brain, limited knowledge of CNS-based disease development and associated pathways, difficulty in penetrating the blood brain barrier, and a lack of reliable biomarkers of disease. Reverse engineering in drug development allows the utilization of new knowledge of disease pathways and the use of innovative technology to develop medications with enhanced efficacy and reduced toxicities. Lorcaserin was developed as a specific 5HT2C serotonin receptor agonist for the treatment of obesity with limited off-target effects at the 5HT2A and 5HT2B receptors. This receptor specificity limited the hallucinogenic and cardiovascular side effects noted with other serotonin receptor agonists. Reverse engineering approaches to drug development reduce the cost of producing new medications, identify specific populations of patients that will derive the most benefit from therapy, and produce novel therapies with greater efficacy and limited toxicity.
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Affiliation(s)
| | - Sheldon H Preskorn
- Department of Psychiatry and Behavioral Science, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
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Preskorn SH. Comparative Pharmacology of the 3 Marketed Dual Orexin Antagonists-Daridorexant, Lemborexant, and Suvorexant-Part 2. Principal Drug Metabolizing Enzyme, Drug-Drug Interactions, and Effects of Liver and Renal Impairment on Metabolism. J Psychiatr Pract 2023; 29:38-41. [PMID: 36649550 DOI: 10.1097/pra.0000000000000690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This column is the second in a 2-part series presenting the comparative pharmacology of the 3 Food and Drug Administration-approved dual orexin receptor antagonists, daridorexant, lemborexant, and suvorexant. Both of the columns in this series emphasize the pharmacokinetics of these drugs as they are relevant to their use as sleep medications. Although other classes of sleep medications are not discussed, the same pharmacokinetic principles also apply to them in terms of endeavoring to match the pharmacokinetics of an agent to the individual's usual sleep cycle. This second column in the series focuses on the metabolism of each of the 3 drugs by the cytochrome P450 enzyme CYP3A, guidance for using these agents in combination with drugs that are CYP3A inhibitors or inducers, and how to adjust dosing in patients with comorbid conditions such as hepatic or renal impairment.
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Preskorn SH. Drug Development in Psychiatry: The Long and Winding Road from Chance Discovery to Rational Development. Adv Neurobiol 2023; 30:1-18. [PMID: 36928844 DOI: 10.1007/978-3-031-21054-9_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Based extensively on tables and figures, this chapter reviews drug development in psychiatry with an emphasis on antidepressants from the 1950s to the present and then looks forward to the future. It begins with the chance discovery drugs and then moves to through their rational refinement using structure activity relationships to narrow the pharmacological actions of the drugs to those mediating their antidepressant effects and eliminating the effects on targets that mediate adverse effects. This approach yielded newer antidepressants which compared to older antidepressants are safer and better tolerated but nevertheless do still not treat the approximately 40% of patients with major depression (MD) which is unresponsive to biogenic amine mechanisms of action. This form of MD is commonly referred to as treatment resistant depression. Esketamine is an antidepressant which has a novel mechanism of action: blockade of the glutamate NMDA receptor. These studies coupled with earlier studies with other NMDA drugs suggest approximately 60% of patient with TRD are rapidly and robustly responsive to this mechanism of action. Thus, there appears to be three forms of MD based on pharmacological responsiveness: (a) 60% responsive to biogenic amine mechanisms of action, (b) 24% (i.e., 40 × 60%) responsive to NMDA but not to biogenic amine mechanisms of action, and (c) 16% (i.e., 40-24%) not responsive to either of these mechanisms of action. Scientific investigation of these three groups may yield important information about the pathophysiology and/or pathoetiology of these different forms of MD. This information coupled with studies into the neurobiology (e.g., imaging studies, connectomes to name a few approaches being used) and genetics of MD should provide the fundamental knowledge which will permit a rational search for and discovery of newer antidepressant drugs and other somatic and psychotherapeutic approaches to the treatment of patients with different forms of MD based on pathophysiology and pathoetiology. Examples are given of how such discovery and development have occurred in other areas of medicine and even in central nervous system (CNS) space including six novel mechanisms of action CNS drugs which have been successfully developed and marketed over the last 25 years.
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Affiliation(s)
- Sheldon H Preskorn
- Department of Psychiatry and Behavioral Science, Kansas University School of Medicine-Wichita Campus, Wichita, KS, USA.
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Schwasinger-Schmidt T, Preskorn SH. Discovery of New Transmitter Systems and Hence New Drug Targets. Adv Neurobiol 2023; 30:181-193. [PMID: 36928850 DOI: 10.1007/978-3-031-21054-9_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
The development of medications used to treat psychiatric conditions has largely proceeded through serendipity, where a potential drug to treat mental illness is identified by chance. This approach is based on a limited understanding of the underlying pathophysiology of mental illness and brain disorders. Identification of novel neurotransmitter systems has allowed for new molecular-based approaches for drug development that identify specific receptor targets to treat a specific symptom. An example of this approach includes the development of suvorexant, which is a dual orexin receptor antagonist FDA approved in 2014 for the treatment of insomnia. This chapter will discuss challenges in psychiatric drug development; the importance of identifying discrete neurotransmitter systems that target a specific symptom, not a syndrome; the orexin pathway and targets within this pathway that can be used to modulate sleep; and a high-throughput approach to streamlining drug development.
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Affiliation(s)
| | - Sheldon H Preskorn
- Department of Psychiatry and Behavioral Science, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
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Preskorn SH. Comparative Pharmacology of the 3 Marketed Dual Orexin Antagonists-Daridorexant, Lemborexant, and Suvorexant: Part 1: Pharmacokinetic Profiles. J Psychiatr Pract 2022; 28:478-480. [PMID: 36355586 DOI: 10.1097/pra.0000000000000672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This first column in a 2-part series focuses on the pharmacokinetics of the 3 Food and Drug Administration-approved dual orexin receptor antagonists, daridorexant, lemborexant, and suvorexant, specifically as they relate to their use as sleep medications. Although other classes of sleep medications are not discussed, the same pharmacokinetic principles also apply to them.
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Citrome L, Preskorn SH, Lauriello J, Krystal JH, Kakar R, Finman J, De Vivo M, Yocca FD, Risinger R, Rajachandran L. Sublingual Dexmedetomidine for the Treatment of Acute Agitation in Adults With Schizophrenia or Schizoaffective Disorder: A Randomized Placebo-Controlled Trial. J Clin Psychiatry 2022; 83. [PMID: 36198061 DOI: 10.4088/jcp.22m14447] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Objective: Determine if sublingual dexmedetomidine, a selective α2 adrenergic receptor agonist, reduces symptoms of acute agitation associated with schizophrenia or schizoaffective disorder. Methods: This phase 3, randomized, double-blind, placebo-controlled study was conducted in adults diagnosed with schizophrenia or schizoaffective disorder per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. The study was conducted at 15 US sites between January 23, 2020, and May 8, 2020. Participants were randomized to sublingual dexmedetomidine 180 μg, 120 μg, or matching placebo. The primary efficacy endpoint was mean change from baseline in the Positive and Negative Syndrome Scale-Excited Component (PEC) total score at 2 hours postdose. Results: Altogether, 380 participants (mean age 45.6 years, 63.4% identifying as male, 77.9% identifying as Black or African American) were randomized; 380 (100%) self-administered study medication, and 372 (97.9%) completed the study. The mean PEC total score at baseline (17.6) indicated mild to moderate agitation. At 2 hours postdose, the least squares mean changes (SE) from baseline were -10.3 (0.4) for sublingual dexmedetomidine 180 μg, -8.5 (0.4) for 120 μg, and -4.8 (0.4) for placebo. Least squares mean differences (97.5% confidence intervals) in the sublingual dexmedetomidine groups were -5.5 (-6.7 to -4.3) for 180 μg and -3.7 (-4.9 to -2.5) for 120 μg (both P < .001 vs placebo). The most commonly encountered adverse events with dexmedetomidine (incidence ≥ 5% and ≥ 2× rate observed with placebo) were somnolence, dry mouth, and hypotension for the 120 μg dose, and somnolence, dizziness, orthostatic hypotension, and oral hypoesthesia for the 180 μg dose. Conclusions: Treatment with sublingual dexmedetomidine 180 μg or 120 μg was more efficacious than placebo in reducing acute agitation associated with schizophrenia as measured by PEC scores at 2 hours postdose. Trial Registration: ClinicalTrials.gov identifier: NCT04268303.
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Affiliation(s)
- Leslie Citrome
- Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla, New York.,Corresponding author: Leslie Citrome, MD, MPH, 11 Medical Park Drive, Ste 102, Pomona, NY 10970
| | | | - John Lauriello
- Department of Psychiatry and Human Behavior, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - John H Krystal
- Department of Psychiatry, Yale University, New Haven, Connecticut
| | | | - Jeffrey Finman
- Jupiter Point Pharma Consulting, LLC, Groton, Connecticut
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Williamson DJ, Gogate JP, Kern Sliwa JK, Manera LS, Preskorn SH, Winokur A, Starr HL, Daly EJ. Longitudinal Course of Adverse Events With Esketamine Nasal Spray: A Post Hoc Analysis of Pooled Data From Phase 3 Trials in Patients With Treatment-Resistant Depression. J Clin Psychiatry 2022; 83. [PMID: 36149841 DOI: 10.4088/jcp.21m14318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Objective: To describe the tolerability of esketamine nasal spray based on the adverse event profile observed during treatment sessions occurring early and later over the course of treatment. Methods: In 2 long-term, phase 3 studies (NCT02493868, October 1, 2015-February 16, 2018; NCT02497287, September 30, 2015-October 28, 2017), patients with treatment-resistant major depressive disorder (per DSM-5) and nonresponse to ≥ 2 oral antidepressants received esketamine nasal spray (56 or 84 mg) twice weekly during a 4-week induction phase, weekly for weeks 5-8, and weekly or every 2 weeks thereafter as maintenance treatment, in conjunction with a new oral antidepressant. A post hoc analysis using descriptive statistics evaluated occurrence (incidence, frequency, severity) and recurrence (incidence and severity) of events of specific interest. Results: In patients treated with esketamine nasal spray plus a newly initiated oral antidepressant (n = 928), spontaneously reported adverse events of dizziness, nausea, sedation, vertigo, and increased blood pressure were more likely to recur after the first week of treatment if they occurred more frequently (twice > once > none) during the first week. The same pattern was observed when these events were assessed by structured instruments. Incidences of dizziness, dissociation, increased blood pressure, nausea, vertigo, and sedation were highest in week 1 of treatment (20.6%, 16.7%, 4.3%, 14.0%, 12.1%, and 3.8%, respectively) and decreased thereafter. Initial occurrences and subsequent recurrences of events were mostly mild or moderate in severity. Conclusions: Adverse events during treatment with esketamine nasal spray plus an oral antidepressant generally become less frequent with ongoing treatment, and the majority are mild or moderate in severity. Trial Registration: ClinicalTrials.gov identifiers: NCT02493868; NCT02497287.
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Affiliation(s)
- David J Williamson
- Field-Based Medical Affairs, Janssen Scientific Affairs, LLC, Titusville, New Jersey.,Drs Williamson and Daly and Mr Manera were affiliated with Janssen Scientific Affairs, LLC, at the time the trial was conducted.,Corresponding author: David J. Williamson, PhD, University of South Alabama College of Medicine, 2450 Old Shell Rd, Ste A, Mobile, AL 36607
| | - Jagadish P Gogate
- Statistics and Decision Sciences, Janssen Research & Development, LLC, Titusville, New Jersey
| | - Jennifer K Kern Sliwa
- Neuroscience Medical Information, Janssen Scientific Affairs, LLC, Titusville, New Jersey
| | - Lewis S Manera
- Janssen Medical Information, Janssen Scientific Affairs, LLC, Titusville, New Jersey.,Drs Williamson and Daly and Mr Manera were affiliated with Janssen Scientific Affairs, LLC, at the time the trial was conducted
| | - Sheldon H Preskorn
- Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine, Wichita, Kansas
| | - Andrew Winokur
- Department of Psychiatry, UConn Health, Farmington, Connecticut
| | - H Lynn Starr
- Clinical Development, Janssen Scientific Affairs, LLC, Titusville, New Jersey
| | - Ella J Daly
- Field-Based Medical Affairs, Janssen Scientific Affairs, LLC, Titusville, New Jersey.,Drs Williamson and Daly and Mr Manera were affiliated with Janssen Scientific Affairs, LLC, at the time the trial was conducted
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Preskorn SH. Building a Comprehensive Biopsychosocial Database to Identify Underlying Causes of Suicide and Improve Suicide Prevention. J Psychiatr Pract 2022; 28:391-395. [PMID: 36074108 DOI: 10.1097/pra.0000000000000653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In June, 2022, the United States Department of Veterans Affairs (VA) announced an initiative to reduce death due to suicide in US Veterans. This column is based on a proposal written for that initiative, as well as on an earlier psychopharmacology column in this journal that reviewed the statistics and the genetics of suicide, and the US medicolegal death investigation system. This system is composed of 3137 county coroner or medical examiner offices across the country that are responsible under state and local law for investigating deaths that are not explained by natural causes and are suspicious and/or unattended. Thus, this system gathers data concerning all deaths due to suicide. Currently this death investigation system costs US taxpayers ∼$660 million per year, and it has determined that ∼45,000 Americans die from suicide each year. In the conduct of these investigations, a large amount of data is collected, including biological samples. While the demographic data are reported to the Centers for Disease Control (CDC), little-if anything-is done with the collected biological material beyond its use in determining the cause of death of the individual. The earlier column on this topic advocated for the establishment of a central database to retain and utilize this information to further understand the biopsychosocial causes of suicide, with the goal of preventing suicides. This column describes a proposal submitted to the VA system for how such a system could initially be piloted in a small group of VA medical centers and then expanded to the entire system. This initial effort could then, in turn, serve as a model for expanding such data gathering to the entire US medicolegal death investigation system.
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Preskorn SH, Risinger R, Kakar R. Sublingual Dexmedetomidine vs Placebo and Acute Agitation Associated With Bipolar Disorder-Reply. JAMA 2022; 328:214-215. [PMID: 35819427 DOI: 10.1001/jama.2022.8349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Preskorn SH. How an Understanding of the Function of the Locus Coeruleus Led to Use of Dexmedetomidine to Treat Agitation in Bipolar Disorder: Example of Rational Development of Psychiatric Medications. J Psychiatr Pract 2022; 28:227-233. [PMID: 35511098 DOI: 10.1097/pra.0000000000000634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This column reviews >50 years of research on the functions subsumed by the locus coeruleus (LC) (also called the central adrenergic system). A major role of the LC is monitoring acid-base balance in the brain and responding by regulating blood-brain permeability to water and other small molecules and cerebral blood flow. The LC, through its downward projections, also regulates and coordinates respiratory and cardiac functions. Through its effect regionally or more globally depending on the stimulus and its magnitude, the LC can regulate the extracellular space in the brain, which in turn can alter ionic concentrations and thus the sensitivity of neurons to signaling. As a result of these far-reaching effects, the LC has been implicated in brain functions ranging from sleep and wakefulness to psychiatric conditions such as hyperarousal/hypervigilance, fear, agitation, anxiety, and panic attacks. This understanding of the brain functions subsumed by the LC has, in turn, led to the most recent development in the use of dexmedetomidine, an alpha-2 adrenergic agonist, to treat agitation in patients with bipolar disorder. This column also illustrates a theme discussed in a series of previous columns concerning the successful development of novel psychiatric/central nervous system drugs on the basis of an understanding of relatively simple circuits or mechanisms that underlie pathologic behavior.
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Abstract
This column presents a real-life case of a patient who developed severe and prolonged Parkinsonism secondary to the loading dose strategy recommended in the prescribing information (package insert) for paliperidone palmitate (Invega Sustenna). This column presents 2 major points. First, the case illustrates what the practitioner must do before following the general guidelines for a loading dose approach to the administration of paliperidone palmitate as outlined in the package insert to decrease the likelihood of a serious and potentially fatal consequence. Second, the case illustrates how therapeutic drug monitoring can be useful in assessing and managing patients who develop an untoward reaction. In this case, therapeutic drug monitoring was done using serum prolactin levels because the available laboratory could not measure the level of the drug itself in plasma, and the case highlights some limitations to keep in mind when using plasma prolactin levels to do such monitoring. To put this case in context, a review of the literature was conducted which identified 3 related cases. The author also refers readers to previous articles on therapeutic drug monitoring and pharmacokinetic considerations that arise when using depot (long-acting injectable) antipsychotics.
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Preskorn SH, Zeller S, Citrome L, Finman J, Goldberg JF, Fava M, Kakar R, De Vivo M, Yocca FD, Risinger R. Effect of Sublingual Dexmedetomidine vs Placebo on Acute Agitation Associated With Bipolar Disorder: A Randomized Clinical Trial. JAMA 2022; 327:727-736. [PMID: 35191924 PMCID: PMC8864508 DOI: 10.1001/jama.2022.0799] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Acute agitation is common in patients with bipolar disorder and requires urgent management to relieve distress and to prevent escalation to aggressive behavior. OBJECTIVE To evaluate the effect of orally absorbed, sublingual dexmedetomidine, a selective α2A-adrenergic receptor agonist on symptoms of acute agitation in patients with bipolar disorder. DESIGN, SETTING, AND PARTICIPANTS Phase 3, randomized, double-blind, placebo-controlled trial conducted in 15 sites in the US with enrollment between February 24, 2020, and April 27, 2020, and final follow-up on May 21, 2020. A total of 380 adults with bipolar I or II disorder were randomized and 362 completed the study. INTERVENTIONS Participants were randomized to 3 groups: sublingual dexmedetomidine 180 μg (n = 127), sublingual dexmedetomidine 120 μg (n = 127), or placebo (n = 126). MAIN OUTCOMES AND MEASURES The primary efficacy end point was the mean change from baseline at 2 hours for the Positive and Negative Syndrome Scale-Excited Component (PEC) total score. The range of possible total scores is 5 (absence of agitation) to 35 (extremely severe). The secondary end point was the earliest time of a statistically significant change in PEC total score from baseline for the drug vs placebo. On the primary efficacy end point, to account for multiplicity associated with comparing 2 sublingual dexmedetomidine doses with placebo, the 2-sided significance level for each dose vs placebo was set at .025. RESULTS Of 380 patients randomized (mean age, 45.6 years; 54.8% women; and 56.1% Black individuals), 378 (99.5%) self-administered the study medication and completed the study. Baseline agitation was mild to moderate, with an overall mean PEC total score of 18.0. Two hours after taking the medication, the mean changes from baseline in PEC total score were -10.4 for sublingual dexmedetomidine 180 μg, -9.0 for sublingual dexmedetomidine 120 μg, and -4.9 for placebo. Least-square mean differences from placebo in the sublingual dexmedetomidine groups at 2 hours were -5.4 (97.5% CI, -6.6 to -4.2) for 180 μg and -4.1 (97.5% CI, -5.3 to -2.9) for 120 μg (both doses P < .001 vs placebo). Treatment effects began 20 minutes after taking the medication among patients in the sublingual dexmedetomidine groups (least-square mean difference for 180 μg, -1.1 [97.5% CI, -2.0 to -0.2]; P = .007; for 120 μg, -1.0 [97.5% CI, -1.9 to -0.1]; P = .009). Adverse events occurred in 35.7% of patients taking 180 μg of dexmedetomidine, 34.9% taking 120 μg, and 17.5% taking placebo. The most common adverse events (≥5%) in the respective 180 μg, 120 μg, and placebo groups were somnolence (21.4% and 20.6% vs 4.8%); dry mouth (4.8% and 7.1% vs 0.8%); hypotension (6.3% and 4.8% vs 0%); and dizziness (5.6% and 5.6% vs 0.8%). CONCLUSIONS AND RELEVANCE Among patients with mild to moderate agitation associated with bipolar disorder, treatment with a sublingual film formulation of dexmedetomidine 120 μg or 180 μg, compared with placebo, resulted in significantly greater reduction in the agitation score at 2 hours. Further research is needed to understand the spectrum of patients for whom this treatment would be effective and feasible and to better understand the clinical importance of the observed effect size. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04276883.
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Affiliation(s)
| | - Scott Zeller
- Department of Psychiatry, University of California-Riverside School of Medicine, Riverside
| | - Leslie Citrome
- Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla
| | - Jeffrey Finman
- Jupiter Point Pharma Consulting, LLC, Groton, Connecticut
| | - Joseph F. Goldberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Maurizio Fava
- Massachusetts General Hospital and Harvard Medical School, Boston
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Preskorn SH. Subtypes of Major Depressive Disorder Based on Pharmacological Responsiveness. J Psychiatr Pract 2021; 27:448-452. [PMID: 34768267 DOI: 10.1097/pra.0000000000000591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Major depressive disorder (MDD) is a descriptive, syndromic diagnosis which will likely be discovered to be more than a single disorder when understood from a pathobiological or pathoetiological perspective. To date, attempts to divide this disorder into more homogenous phenotypes on the basis of signs and symptoms have not yielded more information on the pathobiological or pathoetiological factors that can cause a major depressive episode. This column proposes a new way of dividing MDD into 3 subtypes based on responsiveness to pharmacological treatments that are pharmacologically quite different from each other: type 1, which is responsive to treatment with biogenic amine antidepressants; type 2, which is not responsive to treatment with biogenic amine antidepressants but is responsive to antidepressants that work on the glutamine neurotransmitter system via the N-methyl-D-aspartate receptor; and type 3, which is not responsive to either of these 2 types of antidepressants. The goal of this formulation is to develop biologically meaningful subtypes that can be further studied to understand the pathobiology underlying these 3 types of MDD with the goal of developing newer treatments and earlier ways of diagnosing these conditions.
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Preskorn SH. Fundamental Pharmacokinetic Concepts and Their Clinical Relevance: Clearance, Zero Versus First Order and Nonlinear Pharmacokinetics. J Psychiatr Pract 2021; 27:380-383. [PMID: 34529604 DOI: 10.1097/pra.0000000000000570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In response to a question posed by a valued colleague, this column will discuss 4 fundamental pharmacokinetic concepts: (1) What does the term clearance encompass? (2) What do the terms first order and second order pharmacokinetics mean? (3) What does the term nonlinear pharmacokinetics mean and is it just a synonym for zero order pharmacokinetics? (4) What is the clinical relevance, if any, of these concepts and why? In addition, this column cites several earlier columns that are relevant to aspects of each of the answers. Thus, readers interested in more details can refer to these earlier publications that include case examples and figures that further illustrate various points. In considering the clinical relevance of these pharmacokinetic concepts, this column discusses relative binding affinity for targets and the concept of selective versus nonselective drugs, which are foundational cornerstones for understanding and optimally using currently available psychopharmaceutical agents.
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Abstract
Therapeutic drug monitoring (TDM) results are a biological measure of the ability of the patient to clear a drug as long as the patient is adhering to the prescribed dosage. If the patient is not adherent, then TDM can provide evidence of such nonadherence. To properly interpret TDM results, several variables must be considered. First and foremost is the dose the patient is supposed to be taking. The second variable is whether the patient should have achieved a steady-state condition, which means that the amount of drug the patient is taking in a day is equal to the amount the patient is eliminating in the same day so that the level will not change unless changes occur in either the dosing rate or the ability of the patient to clear the drug. For drugs with a half-life of 24 hours, steady state typically occurs when the patient has been taking the same dose for 5 to 7 days (ie, 5 x the half-life). The third variable is the time between when the last dose was taken and the sample was obtained. Ideally, for most drugs, that desired interval is 10 to 12 hours after the last dose was taken assuming the patient is taking the dose daily as different rules apply for depot medications. There are 2 reasons for this stipulation. First, this interval will best reflect the average concentration that the patient achieves over the daily dosing interval on that drug. Second, for most orally administered drugs, the value that is obtained 10 to 12 hours after the last dose will not be influenced by differences in the absorption of the drug. In contrast, if the sample is obtained during the absorption phase, the plasma concentration can be both much higher and less predictable than is the case when absorption is complete. Therefore, these 3 variables must be included when recording TDM results in the chart. As explained in this column, the TDM result without this information is not optimally interpretable. Parenthetically, TDM results do not need to be repeated (unless specific concerns arise as explained in this column), because these results are a measure of the ability of the patient to clear the drug. For depot medications (eg, antipsychotics), the results should be obtained at the end of the dosing cycle just before the administration of the drug and after the patient has ideally received 4 to 5 injections at equal intervals (eg, monthly) to be near steady-state. Parenthetically, TDM at the appropriate fixed interval (usually monthly) with depot medications is much less sensitive to timing issues than TDM of orally administered drugs. This column explains the rationale for obtaining TDM results, principally focusing on orally administered drugs and how to optimally chart and disseminate these results.
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Abstract
This column reviews the development of intranasal esketamine with particular emphasis on the consistency of the clinical trial results. In the process, it illustrates methodological issues important in the approval process by an agency such as the United States Food and Drug Administration. Topics covered include the importance of study design, the nature of the comparator, and the prespecified statistical analysis plan. The column also discusses what is considered a positive versus a supportive study and the differences between phase 2 and phase 3 studies and the rationale for including both in the development process. While this information is particularly germane to intranasal esketamine, it also serves as a more general example of the drug development and approval process.
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Abstract
Based extensively on tables and figures, this chapter reviews drug development in psychiatry with an emphasis on antidepressants from 1950s to the present and then looks forward to the future. It begins with the chance discovery drugs and then moves to through their rational refinement using structure activity relationships to narrow the pharmacological actions of the drugs to those mediating their antidepressant effects and eliminating the effects on targets that mediate adverse effects. This approach yielded newer antidepressants which compared to older antidepressants are safer and better tolerated but nevertheless do still not treat the approximately 40% of patients with major depression (MD) which is unresponsive to biogenic amine mechanisms of action. This form of MD is commonly referred to as treatment resistant depression. Esketamine is an investigational antidepressant which has a novel mechanism of action: blockade of the glutamate NMDA receptor. Positive trials reported this year for esketamine make it likely this drug will be approved next year in the USA. These studies coupled with earlier studies with other NMDA drugs suggest approximately 60% of patient with TRD are rapidly and robustly responsive to this mechanism of action. Thus, there appears to be three forms of MD based on pharmacological responsiveness: (a) 60% responsive to biogenic amine mechanisms of action, (b) 24% (i.e., 40 × 60%) responsive to NMDA but not to biogenic amine mechanisms of action, and (c) 16% (i.e., 40 - 24%) not responsive to either of these mechanisms of action. Scientific investigation of these three groups may yield important information about the pathophysiology and/or pathoetiology of these different forms of MD. This information coupled with studies into the neurobiology (e.g., imaging studies, connectomes to name a few approaches being used) and genetics of MD should provide the fundamental knowledge which will permit a rational search for and discovery of newer antidepressant drugs and other somatic and psychotherapeutic approaches to the treatment of patients with different forms of MD based on pathophysiology and pathoetiology. Examples are given of how such discovery and development has occurred in other areas of medicine and even in central nervous system (CNS) space including six novel mechanisms of action CNS drugs which have been successfully developed and marketed over the last 25 years.
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Goldberg JF, Rosenblat JD, McIntyre RS, Preskorn SH, de Leon J. Letter to the Editor: Clinical versus statistical significance of pharmacogenomic-guided antidepressant therapy: What's really being measured and marketed? J Psychiatr Res 2019; 114:208-209. [PMID: 31064655 DOI: 10.1016/j.jpsychires.2019.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 03/10/2019] [Accepted: 04/02/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Joseph F Goldberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sheldon H Preskorn
- Department of Psychiatry, Kansas University School of Medicine-Wichita, Wichita, KS, USA
| | - Jose de Leon
- University of Kentucky Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA; Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain
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Abstract
This column begins a series exploring drug-drug interactions (DDIs) with a special emphasis on psychiatric medications. As explained in this column, this topic is important for multiple reasons. First, a large percentage of the population is receiving psychiatric medications. Second, these patients are likely to be on multiple medications which means that they are at risk for an adverse DDI. Third, DDIs may occur but not be recognized even though they have significant health care consequences for the patient. Fourth, these consequences can range from a catastrophic outcome to more everyday clinical problems involving a myriad of presentations as enumerated in this column. Also discussed in this column is the fact that all drugs, including psychiatric medications, interact on the basis of their pharmacodynamics and pharmacokinetics rather than their therapeutic use. Therefore, psychiatric medications may interact with medications prescribed for nonpsychiatric reasons as well as with other psychiatric medications. Tables are included that explain reasons for multiple medication use and principles to follow to minimize the risk of adverse DDIs.
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Savitz JB, Teague TK, Misaki M, Macaluso M, Wurfel BE, Meyer M, Drevets D, Yates W, Gleason O, Drevets WC, Preskorn SH. Treatment of bipolar depression with minocycline and/or aspirin: an adaptive, 2×2 double-blind, randomized, placebo-controlled, phase IIA clinical trial. Transl Psychiatry 2018; 8:27. [PMID: 29362444 PMCID: PMC5802452 DOI: 10.1038/s41398-017-0073-7] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 11/01/2017] [Indexed: 12/27/2022] Open
Abstract
Given evidence of chronic inflammation in bipolar disorder (BD), we tested the efficacy of aspirin and minocycline as augmentation therapy for bipolar depression. Ninety-nine depressed outpatients with BD were enrolled in a 6 week, double-blind, placebo-controlled trial, and randomized to one of four groups: active minocycline (100 mg b.i.d.) + active aspirin (81 mg b.i.d.) (M + A); active minocycline + placebo aspirin (M + P); placebo-minocycline + active aspirin (A + P); and placebo-minocycline + placebo aspirin (P + P). A blinded interim analysis mid-way through the study led to the dropping of the M + P and A + P arms from further enrollment giving numbers per group who were included in the final analysis of: 30 (M + A), 18 (M + P), 19 (A + P), and 28 (P + P). When the study started, there were three primary outcome measures. Based on the results of the interim analysis, the primary outcome variable, response to treatment as defined by >50% decrease in Montgomery-Äsberg Depression Rating Scale (MADRS) score was maintained. The other two (i.e., the change in mean MADRS score from baseline to end of study and the remission rate, with remission being defined as a score of <11 on the MADRS) were reduced to exploratory outcome measures because the interim analysis indicated that the study was adequately powered to test differences in response rate but not the mean change in MADRS scores or remission rates. CRP and IL-6 were assayed to measure inflammation. Urinary thromboxane B2 (11-D-TXB2) concentrations, which were significantly increased at baseline in the combined BD sample (n = 90) vs. a healthy control group (n = 27), served as an indirect marker of cyclooxygenase (COX) activity. In a two-group analysis, the M + A group showed a greater response rate than the P + P group (p(one-tailed) = 0.034, OR = 2.93, NNT = 4.7). When all four arms were included in the analysis, there was a main effect of aspirin on treatment response that was driven by both the M + A and the A + P groups (p(two-tailed) = 0.019, OR = 3.67, NNT = 4.0). Additionally, there was a significant 3-way interaction between aspirin, minocycline, and IL-6, indicating that response to minocycline was significantly greater in participants in the M + P group with higher IL-6 concentrations. Further, participants in the M + P group who responded to treatment had significantly greater decreases in IL-6 levels between baseline and visit 7 vs. non-responders. Regarding the exploratory outcomes, there was a main effect for aspirin on the remission rate (χ12 = 4.14, p(2t) = 0.04, OR = 2.52, NNT = 8.0). There was no significant main effect of aspirin or minocycline on the mean change in MADRS score across visits. Aspirin and minocycline may be efficacious adjunctive treatments for bipolar depression. Given their potential import, additional studies to confirm and extend these findings are warranted.
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Affiliation(s)
- Jonathan B. Savitz
- 0000 0004 0512 8863grid.417423.7Laureate Institute for Brain Research, Tulsa, OK USA ,0000 0001 2160 264Xgrid.267360.6Faculty of Community Medicine, University of Tulsa, Tulsa, OK USA
| | - T. Kent Teague
- 0000 0004 0447 0018grid.266900.bDepartment of Surgery, University of Oklahoma College of Medicine, Tulsa, OK USA ,0000 0004 0447 0018grid.266900.bDepartment of Psychiatry, University of Oklahoma College of Medicine, Tulsa, OK USA ,0000 0004 0447 0018grid.266900.bDepartment of Pharmaceutical Sciences, University of Oklahoma College of Pharmacy, Tulsa, OK USA ,0000 0004 0542 825Xgrid.261367.7Department of Biochemistry and Microbiology, Oklahoma State University Center for Health Sciences, Tulsa, OK USA
| | - Masaya Misaki
- 0000 0004 0512 8863grid.417423.7Laureate Institute for Brain Research, Tulsa, OK USA
| | - Matt Macaluso
- 0000 0001 2106 0692grid.266515.3Department of Psychiatry and Clinical Trials Unit, University of Kansas School of Medicine, Wichita, Kansas USA
| | - Brent E. Wurfel
- 0000 0004 0512 8863grid.417423.7Laureate Institute for Brain Research, Tulsa, OK USA
| | - Matt Meyer
- 0000 0004 0512 8863grid.417423.7Laureate Institute for Brain Research, Tulsa, OK USA
| | - Douglas Drevets
- 0000 0001 2179 3618grid.266902.9Department of Medicine, Oklahoma University Health Sciences Center, and Oklahoma City VAMC, Oklahoma City, Oklahoma USA
| | - William Yates
- 0000 0004 0512 8863grid.417423.7Laureate Institute for Brain Research, Tulsa, OK USA
| | - Ondria Gleason
- 0000 0004 0447 0018grid.266900.bDepartment of Psychiatry, University of Oklahoma College of Medicine, Tulsa, OK USA
| | - Wayne C. Drevets
- 0000 0004 0512 8863grid.417423.7Laureate Institute for Brain Research, Tulsa, OK USA ,grid.417429.dJanssen Research and Development, LLC of Johnson and Johnson, Inc., Titusville, NJ USA
| | - Sheldon H. Preskorn
- 0000 0004 0512 8863grid.417423.7Laureate Institute for Brain Research, Tulsa, OK USA ,0000 0001 2106 0692grid.266515.3Department of Psychiatry and Clinical Trials Unit, University of Kansas School of Medicine, Wichita, Kansas USA
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Affiliation(s)
- Sheldon H Preskorn
- Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine-Wichita, Wichita, KS
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Young KD, Preskorn SH, Victor T, Misaki M, Bodurka J, Drevets WC. The Effect of Mineralocorticoid and Glucocorticoid Receptor Antagonism on Autobiographical Memory Recall and Amygdala Response to Implicit Emotional Stimuli. Int J Neuropsychopharmacol 2016; 19:pyw036. [PMID: 27207909 PMCID: PMC5043643 DOI: 10.1093/ijnp/pyw036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 04/16/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Acutely elevated cortisol levels in healthy humans impair autobiographical memory recall and alter hemodynamic responses of the amygdala to emotionally valenced stimuli. It is hypothesized that the effects of the cortisol on cognition are influenced by the ratio of mineralocorticoid receptor to glucocorticoid receptor occupation. The current study examined the effects of acutely blocking mineralocorticoid receptors and glucocorticoid receptors separately on 2 processes known to be affected by altering levels of cortisol: the specificity of autobiographical memory recall, and the amygdala hemodynamic response to sad and happy faces. METHODS We employed a within-subjects design in which 10 healthy male participants received placebo, the mineralocorticoid receptor antagonist spironolactone (600mg) alone, and the glucocorticoid receptor antagonist mifepristone (600mg) alone in a randomized, counter-balanced order separated by 1-week drug-free periods. RESULTS On autobiographical memory testing, mineralocorticoid receptor antagonism impaired, while glucocorticoid receptor antagonism improved, recall relative to placebo, as evinced by changes in the percent of specific memories recalled. During fMRI, the amygdala hemodynamic response to masked sad faces was greater under both mineralocorticoid receptor and glucocorticoid receptor antagonism relative to placebo, while the response to masked happy faces was attenuated only during mineralocorticoid receptor antagonism relative to placebo. CONCLUSIONS These data suggest both mineralocorticoid receptor and glucocorticoid receptor antagonism (and potentially any deviation from the normal physiological mineralocorticoid receptor/glucocorticoid receptor ratio achieved under the circadian pattern) enhances amygdala-based processing of sad stimuli and may shift the emotional processing bias away from the normative processing bias and towards the negative valence. In contrast, autobiographical memory was enhanced by conditions of reduced glucocorticoid receptor occupancy.
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Affiliation(s)
- Kymberly D Young
- University of Pittsburgh School of Medicine, Pittsburgh, PA (Dr Young) Laureate Institute for Brain Research, Tulsa, OK (Drs Young, Preskorn, Victor, Misaki, Bodurka, and Drevets); Kansas University School of Medicine, Wichita, KS (Dr Preskorn); Biomedical Engineering Center, University of Oklahoma College of Engineering, Norman, OK (Dr Bodurka); Janssen Research and Development, LLC, of Johnson & Johnson, Inc., New Brunswick, NJ (Dr Drevets).
| | - Sheldon H Preskorn
- University of Pittsburgh School of Medicine, Pittsburgh, PA (Dr Young) Laureate Institute for Brain Research, Tulsa, OK (Drs Young, Preskorn, Victor, Misaki, Bodurka, and Drevets); Kansas University School of Medicine, Wichita, KS (Dr Preskorn); Biomedical Engineering Center, University of Oklahoma College of Engineering, Norman, OK (Dr Bodurka); Janssen Research and Development, LLC, of Johnson & Johnson, Inc., New Brunswick, NJ (Dr Drevets)
| | - Teresa Victor
- University of Pittsburgh School of Medicine, Pittsburgh, PA (Dr Young) Laureate Institute for Brain Research, Tulsa, OK (Drs Young, Preskorn, Victor, Misaki, Bodurka, and Drevets); Kansas University School of Medicine, Wichita, KS (Dr Preskorn); Biomedical Engineering Center, University of Oklahoma College of Engineering, Norman, OK (Dr Bodurka); Janssen Research and Development, LLC, of Johnson & Johnson, Inc., New Brunswick, NJ (Dr Drevets)
| | - Masaya Misaki
- University of Pittsburgh School of Medicine, Pittsburgh, PA (Dr Young) Laureate Institute for Brain Research, Tulsa, OK (Drs Young, Preskorn, Victor, Misaki, Bodurka, and Drevets); Kansas University School of Medicine, Wichita, KS (Dr Preskorn); Biomedical Engineering Center, University of Oklahoma College of Engineering, Norman, OK (Dr Bodurka); Janssen Research and Development, LLC, of Johnson & Johnson, Inc., New Brunswick, NJ (Dr Drevets)
| | - Jerzy Bodurka
- University of Pittsburgh School of Medicine, Pittsburgh, PA (Dr Young) Laureate Institute for Brain Research, Tulsa, OK (Drs Young, Preskorn, Victor, Misaki, Bodurka, and Drevets); Kansas University School of Medicine, Wichita, KS (Dr Preskorn); Biomedical Engineering Center, University of Oklahoma College of Engineering, Norman, OK (Dr Bodurka); Janssen Research and Development, LLC, of Johnson & Johnson, Inc., New Brunswick, NJ (Dr Drevets)
| | - Wayne C Drevets
- University of Pittsburgh School of Medicine, Pittsburgh, PA (Dr Young) Laureate Institute for Brain Research, Tulsa, OK (Drs Young, Preskorn, Victor, Misaki, Bodurka, and Drevets); Kansas University School of Medicine, Wichita, KS (Dr Preskorn); Biomedical Engineering Center, University of Oklahoma College of Engineering, Norman, OK (Dr Bodurka); Janssen Research and Development, LLC, of Johnson & Johnson, Inc., New Brunswick, NJ (Dr Drevets)
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Wehler CA, Preskorn SH. High false-positive rate of a putative biomarker test to aid in the diagnosis of schizophrenia. J Clin Psychiatry 2016; 77:e451-6. [PMID: 27137429 DOI: 10.4088/jcp.14m09686] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 05/05/2015] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The current study determined the ability of a 51-analyte immunoassay panel to discriminate between subjects with chronic schizophrenia and healthy control subjects in an American population. METHODS Serum samples were collected from 25 subjects with a DSM-IV-TR diagnosis of schizophrenia and 50 healthy control subjects. Blinded samples were sent to the RulesBaseMedicine (RBM) laboratory, which analyzed the 51 biomarkers and converted the results into the VeriPsych score by the application of RBM-determined decision rules and returned these scores to the investigators. The VeriPsych score yields a conditional probability ranging from strongly positive to strongly negative that the sample was from someone who had schizophrenia. Sensitivity and specificity were calculated for these data. The study was conducted between February 27, 2010, and August 31, 2011. RESULTS On the basis of this test, the conditional probability of having schizophrenia ranged from 35% to 98% in the subjects previously diagnosed with schizophrenia and ranged from < 12% to 99% in the healthy control subjects. The sensitivity of this 51-plex biomarker was 89% in this study, while the specificity was 34%. CONCLUSIONS The current study confirms that the 51-plex test performs as expected in individuals with chronic schizophrenia (sensitivity = 89%), indicating that the abnormalities in this multiple biomarker test persist and are not affected by the number of years this illness has been present or by its treatment. However, there was a high false-positive rate in healthy control subjects in our sample, leading to a low specificity rate of 34%. Due to the high false-positive rate in our normal controls, this biomarker test was not able to discriminate between healthy control subjects and subjects with chronic schizophrenia in our sample.
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Affiliation(s)
- Cheryl A Wehler
- Department of Psychiatry and Behavioral Sciences, The University of Kansas School of Medicine-Wichita, 1010 N Kansas, Wichita, KS 67214
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Abstract
In both clinical trials and daily practice, there can be substantial inter- and even intraindividual variability in response--whether beneficial or adverse--to antidepressants and antipsychotic medications. So far, no tools have become available to predict the outcome of these treatments in specific patients. This is because the causes of such variability are often not known, and when they are, there is no way of predicting the effects of their various potential combinations in an individual. Given this background, this paper presents a conceptual framework for understanding known factors and their combinations so that eventually clinicians can better predict what medication(s) to select and at what dose they can optimize the outcome for a given individual. This framework is flexible enough to be readily adaptable as new information becomes available. The causes of variation in patient response are grouped into four categories: (i) genetics; (ii) age; (iii) disease; and (iv) environment (internal). Four cases of increasing complexity are used to illustrate the applicability of this framework in a clinically relevant way In addition, this paper reviews tools that the clinician can use to assess for and quantify such inter- and intraindividual variability. With the information gained, treatment can be adjusted to compensate for such variability, in order to optimize outcome. Finally, the limitations of existing antidepressant and antipsychotic therapy and the way they reduce current ability to predict response is discussed.
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Affiliation(s)
- Sheldon H Preskorn
- Professor of Psychiatry, Kansas University School of Medicine, Wichita, Kansas, USA; Professor of Psychiatry, Laureate Institute for Brain Research, Tulsa, Oklahoma, USA
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Macaluso M, Kazanchi H, Preskorn SH. How the pharmacokinetics and receptor-binding profile of lurasidone affect the clinical utility and safety of the drug in the treatment of schizophrenia. Expert Opin Drug Metab Toxicol 2015; 11:1317-27. [DOI: 10.1517/17425255.2015.1059821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Chiu YY, Ereshefsky L, Preskorn SH, Poola N, Loebel A. Lurasidone drug-drug interaction studies: a comprehensive review. ACTA ACUST UNITED AC 2015; 29:191-202. [PMID: 24825095 DOI: 10.1515/dmdi-2014-0005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 03/24/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND To evaluate potential drug-drug interactions with the atypical antipsychotic lurasidone. METHODS Seven phase I studies were conducted to investigate the effects of repeated dosing of ketoconazole, diltiazem, rifampin, or lithium on the pharmacokinetics (PK) of single oral doses of lurasidone, or the effects of repeated dosing of lurasidone on the PK of digoxin, midazolam, or the oral contraceptive norgestimate/ethinyl estradiol. Two 6-week, phase III studies included evaluation of the potential for interaction between lurasidone and lithium or valproate. Maximum serum or plasma concentration (Cmax) and area under the concentration-time curve (AUC) were calculated. RESULTS Concomitant ketoconazole administration resulted in a 6.8-fold increase in lurasidone Cmax and a 9.3-fold increase in lurasidone AUC; concomitant diltiazem administration resulted in 2.1- and 2.2-fold increases, respectively. Rifampin decreased lurasidone Cmax and AUC (one-seventh and one-fifth of lurasidone alone, respectively). Steady-state dosing with lurasidone increased Cmax and AUC0-24 (AUC from time 0 to 24 h postdose) of digoxin by 9% and 13%, respectively, and of midazolam by 21% and 44%, respectively. There were no significant interactions between lurasidone and lithium, valproate, ethinyl estradiol, or norelgestromin (the major active metabolite of norgestimate). CONCLUSIONS Lurasidone PK is altered by strong cytochrome P450 (CYP) 3A4 inhibitors or inducers, and coadministration is contraindicated; whereas moderate CYP3A4 inhibitors have less effect, and lurasidone dosage restrictions are recommended. No dose adjustment for lurasidone is needed when administered with lithium or valproate. Dose adjustment is not required for lithium, valproate, digoxin (a P-glycoprotein substrate), or midazolam or oral contraceptives (CYP3A4 substrates) when coadministered with lurasidone.
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Macaluso M, Nichols AI, Preskorn SH. How the Probability and Potential Clinical Significance of Pharmacokinetically Mediated Drug-Drug Interactions Are Assessed in Drug Development: Desvenlafaxine as an Example. Prim Care Companion CNS Disord 2015; 17:14r01710. [PMID: 26445693 DOI: 10.4088/pcc.14r01710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 10/29/2014] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The avoidance of adverse drug-drug interactions (DDIs) is a high priority in terms of both the US Food and Drug Administration (FDA) and the individual prescriber. With this perspective in mind, this article illustrates the process for assessing the risk of a drug (example here being desvenlafaxine) causing or being the victim of DDIs, in accordance with FDA guidance. DATA SOURCES/STUDY SELECTION DDI studies for the serotonin-norepinephrine reuptake inhibitor desvenlafaxine conducted by the sponsor and published since 2009 are used as examples of the systematic way that the FDA requires drug developers to assess whether their new drug is either capable of causing clinically meaningful DDIs or being the victim of such DDIs. In total, 8 open-label studies tested the effects of steady-state treatment with desvenlafaxine (50-400 mg/d) on the pharmacokinetics of cytochrome (CYP) 2D6 and/or CYP 3A4 substrate drugs, or the effect of CYP 3A4 inhibition on desvenlafaxine pharmacokinetics. The potential for DDIs mediated by the P-glycoprotein (P-gp) transporter was assessed in in vitro studies using Caco-2 monolayers. DATA EXTRACTION Changes in area under the plasma concentration-time curve (AUC; CYP studies) and efflux (P-gp studies) were reviewed for potential DDIs in accordance with FDA criteria. RESULTS Desvenlafaxine coadministration had minimal effect on CYP 2D6 and/or 3A4 substrates per FDA criteria. Changes in AUC indicated either no interaction (90% confidence intervals for the ratio of AUC geometric least-squares means [GM] within 80%-125%) or weak inhibition (AUC GM ratio 125% to < 200%). Coadministration with ketoconazole resulted in a weak interaction with desvenlafaxine (AUC GM ratio of 143%). Desvenlafaxine was not a substrate (efflux ratio < 2) or inhibitor (50% inhibitory drug concentration values > 250 μM) of P-gp. CONCLUSIONS A 2-step process based on FDA guidance can be used first to determine whether a pharmacokinetically mediated interaction occurs and then to assess the potential clinical significance of the DDI. In the case of the drug tested in this series of studies, the potential for clinically meaningful DDIs mediated by CYP 2D6, CYP 3A4, or P-gp was found to be low.
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Affiliation(s)
- Matthew Macaluso
- University of Kansas School of Medicine, Wichita, Kansas (Drs Macaluso and Preskorn); Pfizer Inc, Collegeville, Pennsylvania (Dr Nichols); and Laureate Institute for Brain Research, Tulsa, Oklahoma (Dr Preskorn)
| | - Alice I Nichols
- University of Kansas School of Medicine, Wichita, Kansas (Drs Macaluso and Preskorn); Pfizer Inc, Collegeville, Pennsylvania (Dr Nichols); and Laureate Institute for Brain Research, Tulsa, Oklahoma (Dr Preskorn)
| | - Sheldon H Preskorn
- University of Kansas School of Medicine, Wichita, Kansas (Drs Macaluso and Preskorn); Pfizer Inc, Collegeville, Pennsylvania (Dr Nichols); and Laureate Institute for Brain Research, Tulsa, Oklahoma (Dr Preskorn)
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Preskorn SH. Dr Preskorn replies. J Clin Psychiatry 2013; 74:1025-6. [PMID: 24229758 DOI: 10.4088/jcp.13flr08555a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
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Preskorn SH, Kane CP, Lobello K, Nichols AI, Fayyad R, Buckley G, Focht K, Guico-Pabia CJ. Cytochrome P450 2D6 phenoconversion is common in patients being treated for depression: implications for personalized medicine. J Clin Psychiatry 2013; 74:614-21. [PMID: 23541126 DOI: 10.4088/jcp.12m07807] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 10/25/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Determine the point prevalence of phenoconversion to cytochrome P450 2D6 (CYP2D6) poor metabolizer status in clinical practice. METHOD This multicenter, open-label, single-visit naturalistic study was conducted from October 2008 to July 2009 in adult patients (≥ 18 years) who had been receiving venlafaxine extended-release (ER) (37.5-225 mg/d) treatment for up to 8 weeks. A 15-mL blood sample was drawn 4 to 12 hours after patients' last venlafaxine ER dose. Plasma O-desmethylvenlafaxine and venlafaxine concentrations were determined for each patient. CYP2D6 poor metabolizer phenotype was defined as O-desmethylvenlafaxine to venlafaxine ratio < 1 based on published data. CYP2D6 genotype was determined for each patient; patients were classified as poor metabolizer, intermediate metabolizer, extensive metabolizer, and ultrarapid metabolizer. Agreement between poor metabolizer phenotype and genotype classifications was assessed using the McNemar test. RESULTS Phenoconversion to CYP2D6 poor metabolizer status occurred in 209 of 865 individuals (24%) with a CYP2D6 non-poor metabolizer genotype. The incidence of CYP2D6 poor metabolizer status based on phenotype was almost 7 times higher than that expected based on genotype: only 4% (35/900) of patients were genotypic CYP2D6 poor metabolizers, but 27% (243/900) were phenotypic CYP2D6 poor metabolizers (McNemar test, P < .0001). CONCLUSIONS CYP2D6 phenotype conversion is common in patients being treated for depression. These results are important because differences in CYP2D6 drug metabolic capacity, whether genetically determined or due to phenoconversion, can affect clinical outcomes in patients treated with drugs substantially metabolized by CYP2D6. These results demonstrate that personalized medicine based solely on genetics can be misleading and support the need to consider drug-induced variability as well. TRIAL REGISTRATION ClinicalTrials identifier: NCT00788944.
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Affiliation(s)
- Sheldon H Preskorn
- Kansas University School of Medicine, 1010 North Kansas, Wichita, KS 67214, USA
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Harvey AT, Flockhart D, Gorski JC, Greenblatt DJ, Burke M, Werder S, Preskorn SH. Intramuscular Haloperidol or Lorazepam and QT Intervals in Schizophrenia. J Clin Pharmacol 2013; 44:1173-84. [PMID: 15342619 DOI: 10.1177/0091270004267807] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study was to estimate the effects of intramuscular haloperidol and lorazepam on the QT interval in volunteers with schizophrenia. Intramuscular haloperidol and intramuscular lorazepam are standard treatments in the acute management of agitation and aggression. Although prolongation of the QT interval and sequelae, including torsade de pointes and death, have been reported for haloperidol (but not lorazepam), formal studies have been lacking. Volunteers with schizophrenia (n = 12) were administered a single intramuscular injection of 7.5 mg haloperidol or 4 mg lorazepam in a blinded, randomized, placebo-controlled crossover design. Serial EKGs and concurrent blood samples were obtained over 6 hours following each injection. Changes in the QT interval were evaluated, as were plasma drug and prolactin concentrations. Haloperidol injection increased the heart rate-corrected QT interval an average of 5.1 msec using Bazett's correction (QTb 90% confidence interval [CI]: 0.3, 9.8), 3.6 msec using Fridericia's correction (QTf 90% CI: 0.02, 7.2), and 4.2 msec using an empirically derived "baseline correction" (QT(ii) 90% CI: 0.3, 8.0). Effects of lorazepam on QT were nullified by correction for the heart rate elevation (QTb 3.8 msec, 90% CI: 0.6, 7.1; QTf 0.0 msec, 90% CI: -3.2, 3.4; QTii -2.3 msec, 90% CI: -6.6, 2.0). An association between QT prolongation and occurrence of extrapyramidal symptoms was observed. On average, intramuscular haloperidol led to minimal prolongation of the QT interval. This propensity is of theoretical concern in individuals with risk factors for torsade de pointes but seems unlikely to be a problem in the vast majority of patients.
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Affiliation(s)
- Anne T Harvey
- Psychiatric Research, Institute, Wichita, KS 67214-2878
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Chapel S, Hutmacher MM, Haig G, Bockbrader H, de Greef R, Preskorn SH, Lalonde RL. Exposure-Response Analysis in Patients With Schizophrenia to Assess the Effect of Asenapine on QTc Prolongation. J Clin Pharmacol 2013; 49:1297-308. [DOI: 10.1177/0091270009344855] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Preskorn SH, Hatt CR. How pharmacogenomics (PG) are changing practice: implications for prescribers, their patients, and the healthcare system (PG series part I). J Psychiatr Pract 2013; 19:142-9. [PMID: 23507814 DOI: 10.1097/01.pra.0000428559.01953.73] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
This is the first column of a series discussing how advances in pharmacogenomic information (PGI) and molecular biology are leading to changes in the product labels of existing drugs and providing new targets for drug discovery. This column first introduces the concept of PGI and defines related terminology. The authors then discuss how new information on genetic variations in patient responses to drugs has led to revisions in the product labels of many already marketed drugs. Rapidly expanding PGI has also led to the development of new drugs with novel mechanisms of action. Such drug development has been especially common in oncology, with new agents being developed to target genetically specific forms of cancer. The authors review how genetically determined variations in the pharmacokinetics and pharmacodynamics of a drug in a specific patient can make that patient "sensitive" or "resistant" to the effects of that particular drug. This type of PGI is expanding the concept of "special populations" to include patients with genetically determined differences in pharmacokinetics and/or pharmacodynamics. The second column in this series will explain how increased knowledge of molecular pharmacology and PGI has resulted in the revision of product labels for drugs already on the market, using pimozide as an example. The third column in this series will deal with the discovery of new drugs with novel mechanisms of action, with a focus on oncology drugs. The last column in the series will discuss the need to make this knowledge readily accessible to clinicians at the time and point of therapeutic care.
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Affiliation(s)
- Sheldon H Preskorn
- Department of Psychiatry, University of Kansas School of Medicine-Wichita, USA
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Affiliation(s)
- Sheldon H Preskorn
- Department of Psychiatry and Behaviorial Health, Kansas University School of Medicine-Wichita (KUSM-W) and the KUSM-W Clinicial Trial Unit, Wichita, Kansas, USA.
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Preskorn SH. Changes in the product label for pimozide illustrate both the promises and the challenges of personalized medicine. J Clin Psychiatry 2012; 73:1191-3. [PMID: 23059147 DOI: 10.4088/jcp.12com07963] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 06/20/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Sheldon H Preskorn
- Department of Psychiatry and Behavioral Health and Kansas University, Wichita Clinical Trial Unit, Kansas University School of Medicine, 8911 E Orme, Wichita, KS 67207, USA
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Nichols AI, Focht K, Jiang Q, Preskorn SH, Kane CP. Pharmacokinetics of Venlafaxine Extended Release 75 mg and Desvenlafaxine 50 mg in Healthy CYP2D6 Extensive and Poor Metabolizers. Clin Drug Investig 2011; 31:155-67. [DOI: 10.2165/11586630-000000000-00000] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Lobello KW, Preskorn SH, Guico-Pabia CJ, Jiang Q, Paul J, Nichols AI, Patroneva A, Ninan PT. Cytochrome P450 2D6 phenotype predicts antidepressant efficacy of venlafaxine: a secondary analysis of 4 studies in major depressive disorder. J Clin Psychiatry 2010; 71:1482-7. [PMID: 20441720 DOI: 10.4088/jcp.08m04773blu] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 06/10/2009] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Venlafaxine, a serotonin-norepinephrine reuptake inhibitor antidepressant, is metabolized primarily by the cytochrome P450 2D6 enzyme into O-desmethylvenlafaxine (ODV). The ODV/venlafaxine ratio can be used to distinguish between extensive metabolizers (EMs) and poor metabolizers (PMs). OBJECTIVES To determine the relative efficacy and tolerability of venlafaxine in EM vs PM patients with major depressive disorder (MDD). METHOD Data from 4 double-blind, placebo-controlled studies of patients with MDD were pooled. Blood samples were analyzed for plasma concentrations of venlafaxine, ODV, total venlafaxine + ODV, and ODV/venlafaxine ratio. Patients were classified as EMs or PMs on the basis of ODV/venlafaxine ratios. Changes from baseline in depression scale scores were compared between EMs and PMs using t tests. Rates of response, remission, discontinuation, and adverse events (AEs) were compared for EMs and PMs using Fisher exact tests. RESULTS Compared with PMs, EMs had significantly greater mean changes from baseline on 4 of 5 depression rating scales (all 4 comparisons, P ≤ .020). A significantly greater percentage of EMs achieved response or remission by most measures compared with PMs (4 of 5 comparisons, P ≤ .015). Rates of discontinuation and AEs did not differ significantly between EMs and PMs. Since there were no substantial differences between EMs and PMs in terms of venlafaxine dose or tolerability, these factors are not likely to account for the efficacy findings. CONCLUSIONS Venlafaxine treatment in EMs was associated with greater efficacy in MDD on virtually all measures compared with PMs, with no important tolerability differences.
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Chen ML, Shah VP, Ganes D, Midha KK, Caro J, Nambiar P, Rocci ML, Thombre AG, Abrahamsson B, Conner D, Davit B, Fackler P, Farrell C, Gupta S, Katz R, Mehta M, Preskorn SH, Sanderink G, Stavchansky S, Temple R, Wang Y, Winkle H, Yu L. Challenges and opportunities in establishing scientific and regulatory standards for assuring therapeutic equivalence of modified release products: workshop summary report. AAPS J 2010; 12:371-7. [PMID: 20440588 DOI: 10.1208/s12248-010-9201-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 03/25/2010] [Indexed: 11/30/2022]
Abstract
Modified release products are complex dosage forms designed to release drug in a controlled manner to achieve desired efficacy and safety. Inappropriate control of drug release from such products may result in reduced efficacy or increased toxicity. This workshop provided an opportunity for pharmaceutical scientists from academia, industry, and regulatory agencies to discuss current industry practices and regulatory expectations for demonstrating pharmaceutical equivalence and bioequivalence of MR products, further facilitating the establishment of regulatory standards for ensuring therapeutic equivalence of these products.
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Affiliation(s)
- Mei-Ling Chen
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA.
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Gandelman K, Alderman JA, Glue P, Lombardo I, LaBadie RR, Versavel M, Preskorn SH. The impact of calories and fat content of meals on oral ziprasidone absorption: a randomized, open-label, crossover trial. J Clin Psychiatry 2009; 70:58-62. [PMID: 19026256 DOI: 10.4088/jcp.08m04104] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Accepted: 07/24/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Food is known to increase the bioavailability of ziprasidone. Therefore, we evaluated the effects of meals of differing caloric and fat content on steady-state ziprasidone exposure in a stable, treated group of subjects with DSM-IV diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder, or psychotic disorder (not otherwise specified) who were already receiving oral ziprasidone as their standard therapy. METHOD Patients took ziprasidone under 6 meal conditions in randomized sequences (fasted, low calorie/low fat, low calorie/high fat, medium calorie/high fat, high calorie/low fat, and high calorie/high fat); each crossover period was separated by at least 3 days for washout of the previous meal condition. Serial blood samples were obtained over the 12 hours postdose. The study was conducted from July 27 to September 28 of 2006. RESULTS Maximum ziprasidone exposures in this study were observed with high-calorie meals (1000 kcal), which were nearly twice those observed under fasting conditions. The medium-calorie meal (500 kcal) was associated with exposures similar to the high-calorie meals. Low-calorie meals (250 kcal) were associated with exposures that were approximately 60% to 90% lower than those of medium- and high-calorie meals, and approached exposures seen under fasting conditions. Fat content of the meal had no significant effect on ziprasidone absorption. The ziprasidone exposures observed with medium- and high-calorie meals had less variability than those with low-calorie meals and under fasting conditions. CONCLUSIONS These results confirm that ziprasidone should be taken with food and that a meal equal to or greater than 500 kcal, irrespective of fat content, is required for optimal and reproducible bioavailability of the administered dose.
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Affiliation(s)
- Kuan Gandelman
- Clinical Pharmacology, Pfizer Inc, New York, NY 10017, USA.
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Abstract
BACKGROUND The cytochrome P450 2D6 (CYP2D6) enzyme is responsible for metabolizing approximately 25% of pharmaceutical agents. Individuals with impaired CYP2D6 metabolism and those concomitantly receiving agents that inhibit CYP2D6 can have variations in concentrations of such medications and their metabolites. METHODS Five studies assessing the interaction between desvenlafaxine and CYP2D6 are reviewed. Study 1 compared desvenlafaxine area under the plasma concentration-versus-time curve (AUC) in CYP2D6 extensive metabolizers (EMs) and poor metabolizers (PMs) after administration of 100 mg of desvenlafaxine or 75 mg of venlafaxine extended release (ER). Studies 2 to 5 assessed the effect of concomitant administration of desvenlafaxine 100 mg (studies 2, 4, and 5) or 400 mg (study 3), paroxetine (20 mg, study 4), and duloxetine (30 mg twice daily; study 5) on the CYP2D6 probe desipramine. RESULTS In study 1, there was no significant difference in mean desvenlafaxine AUC between the CYP2D6 EMs and PMs (-11%; P=0.641) who were administered desvenlafaxine. However, PMs receiving venlafaxine ER had significantly higher venlafaxine and lower desvenlafaxine AUCs compared with EMs (+350% and -74%, respectively; P<0.001 for each). In studies 2, 4, and 5, the mean increases in desipramine AUC with concomitant administration of desvenlafaxine 100 mg ranged from 17% to 36%; the increase with concomitant administration of desvenlafaxine 400 mg (study 3) was 90%. Paroxetine and duloxetine produced increases in mean desipramine AUC of 419% and 122%, respectively, which were significantly greater than the increases seen with desvenlafaxine 100 mg (P<0.001 for each comparison). CONCLUSIONS Based on the findings presented here, desvenlafaxine is expected to have a low risk for variability in efficacy and safety/tolerability resulting from CYP2D6 polymorphisms or drug-drug interactions when coadministered with CYP2D6 substrates or inhibitors.
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Affiliation(s)
- Sheldon H Preskorn
- Clinical Research Institute and University of Kansas School of Medicine, Wichita, KS 67211, USA.
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Affiliation(s)
- Sheldon H Preskorn
- Department of Psychiatry, University of Kansas School of Medicine-Wichita, Kansas, USA
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Weiden PJ, Preskorn SH, Fahnestock PA, Carpenter D, Ross R, Docherty JP. Translating the psychopharmacology of antipsychotics to individualized treatment for severe mental illness: a Roadmap. J Clin Psychiatry 2007; 68 Suppl 7:1-48. [PMID: 17650057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
OBJECTIVES The goal of the Roadmap is to provide guidance on how to use currently available antipsychotics to achieve best outcomes for patients with serious mental illness. The Roadmap orientation is that clinicians often make treatment decisions based on their underlying model of the illness. The Roadmap therefore begins with a review of two theoretical models often used by clinicians who treat patients with severe mental illness (Section II). The "maintenance model" emphasizes achieving clinical stability; once the patient is stable, this model gives priority to relapse prevention and maintenance of stability. The "recovery model" also aims for achieving stability, but it places more emphasis on achieving further gains in physical and emotional health once stability is achieved. While a simplification, these models are based on different assumptions about the course and outcome of schizophrenia and the potential risks and benefits of different pharmacologic treatment options. These treatment models serve as the framework for the Roadmap recommendations, which are based on the clinical and psychopharmacologic research literature as well as expert consensus on questions not definitively answered in that literature. METHODS On the basis of results of an initial survey and a roundtable meeting, a panel of 10 experts developed a list of psychopharmacologic topics not adequately addressed by the evidence-based literature, but which clinicians who use antipsychotic medications need to understand. These questions were posed in a survey to a larger panel of 32 experts, 27 (84%) of whom responded. Results of this survey and data from the literature were then used to develop recommendations for applying psychopharmacologic principles to individualize treatment for patients with severe mental illness. RESULTS Recommendations are presented to help clinicians make informed decisions about choice of medication, dosing, and switching strategies, based on the pharmaco-dynamic and pharmacokinetic properties of different antipsychotics (Section III); diagnosis, prominent symptoms, and treatment history (Section IV); the patient's age, gender, and psychosocial characteristics (Section V); and the patient's medical conditions whether related to antipsychotic treatment or not (Section VI). The final section illustrates how to apply the principles presented in the first six sections in real-world clinical situations. CONCLUSIONS The experts reached a high level of consensus on many key questions about treatment strategies. The Roadmap recommendations provide guidance for clinicians on how to fine-tune their psychopharmacologic strategies with antipsychotics to achieve the best outcomes for each individual patient.
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Affiliation(s)
- Sheldon H Preskorn
- Department of Psychiatry, University of Kansas School of Medicine-Wichita, KS, USA
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Cascade EF, Kalali AH, Preskorn SH. Emsam: the first year. Psychiatry (Edgmont) 2007; 4:19-21. [PMID: 20711332 PMCID: PMC2921248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
We investigated the use of EMSAM in the first year post-launch in the US-April of 2006 through March of 2007. According to our data, EMSAM represents <0.1 percent of total prescriptions for antidepressants in the US and is prescribed most often by psychiatrists (83%of prescriptions). The impact of the product on the MAO inhibitor class, however, has been significant. We found that EMSAM now represents 30 percent of all MAO inhibitor use and has been a catalyst for growth in the overall MAO inhibitor class. An expert commentary is provided on the data.
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Affiliation(s)
- Elisa F Cascade
- Ms. Cascade is Vice President, Strategic Research and Safety, Quintiles Inc., Falls Church, Virginia
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