Therapeutic Drug Monitoring of Antidepressants: An Underused but Potentially Valuable Tool in Primary Care

Piacentino, Daria; Bianchi, Esperia; Donatis, Domenico De; Florio, Vincenzo De; Conca, Andreas

doi:10.3389/fpsyt.2022.867840

Cited by 7 publications

(5 citation statements)

References 39 publications

(35 reference statements)

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“…TDM for antidepressant medications can improve treatment optimization in order to monitor treatment adherence and avoid or limit ADRs or toxicity; however, the use of TDM for this wildly used class of drugs is limited compared to other drugs, such as mood stabilizers or antipsychotic medications [140]. TDM currently applies to numerous antidepressants, and serum drug concentrations might represent a better index than drug dosage [141].…”

Section: Tdm and Antidepressant Medicationsmentioning

confidence: 99%

Therapeutic Drug Monitoring in Psychiatry: Enhancing Treatment Precision and Patient Outcomes

Biso,

Aringhieri,

Carli

et al. 2024

Pharmaceuticals

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Psychiatric disorders often require pharmacological interventions to alleviate symptoms and improve quality of life. However, achieving an optimal therapeutic outcome is challenging due to several factors, including variability in the individual response, inter-individual differences in drug metabolism, and drug interactions in polytherapy. Therapeutic drug monitoring (TDM), by measuring drug concentrations in biological samples, represents a valuable tool to address these challenges, by tailoring medication regimens to each individual. This review analyzes the current landscape of TDM in psychiatric practice, highlighting its significance in optimizing drug dosages, minimizing adverse effects, and improving therapeutic efficacy. The metabolism of psychiatric medications (i.e., mood stabilizers, antipsychotics, antidepressants) often exhibits significant inter-patient variability. TDM can help address this variability by enhancing treatment personalization, facilitating early suboptimal- or toxic-level detection, and allowing for timely interventions to prevent treatment failure or adverse effects. Furthermore, this review briefly discusses technological advancements and analytical methods supporting the implementation of TDM in psychiatric settings. These innovations enable quick and cost-effective drug concentration measurements, fostering the widespread adoption of TDM as a routine practice in psychiatric care. In conclusion, the integration of TDM in psychiatry can improve treatment outcomes by individualizing medication regimens within the so-called precision medicine.

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Section: Tdm and Antidepressant Medicationsmentioning

confidence: 99%

Therapeutic Drug Monitoring in Psychiatry: Enhancing Treatment Precision and Patient Outcomes

Biso,

Aringhieri,

Carli

et al. 2024

Pharmaceuticals

View full text Add to dashboard Cite

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“…Furthermore, blood levels should be monitored in non-responding persons receiving some TCAs (i.e., imipramine, desip ramine, nortriptyline), as therapeutic levels/win dows have been established for these agents [175][176][177] .…”

Section: Pharmacogenomic Testing and Evaluating Antidepressant Blood ...mentioning

confidence: 99%

Treatment‐resistant depression: definition, prevalence, detection, management, and investigational interventions

McIntyre,

Alsuwaidan,

Baune

et al. 2023

World Psychiatry

124

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Treatment‐resistant depression (TRD) is common and associated with multiple serious public health implications. A consensus definition of TRD with demonstrated predictive utility in terms of clinical decision‐making and health outcomes does not currently exist. Instead, a plethora of definitions have been proposed, which vary significantly in their conceptual framework. The absence of a consensus definition hampers precise estimates of the prevalence of TRD, and also belies efforts to identify risk factors, prevention opportunities, and effective interventions. In addition, it results in heterogeneity in clinical practice decision‐making, adversely affecting quality of care. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have adopted the most used definition of TRD (i.e., inadequate response to a minimum of two antidepressants despite adequacy of the treatment trial and adherence to treatment). It is currently estimated that at least 30% of persons with depression meet this definition. A significant percentage of persons with TRD are actually pseudo‐resistant (e.g., due to inadequacy of treatment trials or non‐adherence to treatment). Although multiple sociodemographic, clinical, treatment and contextual factors are known to negatively moderate response in persons with depression, very few factors are regarded as predictive of non‐response across multiple modalities of treatment. Intravenous ketamine and intranasal esketamine (co‐administered with an antidepressant) are established as efficacious in the management of TRD. Some second‐generation antipsychotics (e.g., aripiprazole, brexpiprazole, cariprazine, quetiapine XR) are proven effective as adjunctive treatments to antidepressants in partial responders, but only the olanzapine‐fluoxetine combination has been studied in FDA‐defined TRD. Repetitive transcranial magnetic stimulation (TMS) is established as effective and FDA‐approved for individuals with TRD, with accelerated theta‐burst TMS also recently showing efficacy. Electroconvulsive therapy is regarded as an effective acute and maintenance intervention in TRD, with preliminary evidence suggesting non‐inferiority to acute intravenous ketamine. Evidence for extending antidepressant trial, medication switching and combining antidepressants is mixed. Manual‐based psychotherapies are not established as efficacious on their own in TRD, but offer significant symptomatic relief when added to conventional antidepressants. Digital therapeutics are under study and represent a potential future clinical vista in this population.

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“…Data for venlafaxine suggest increased concentration‐dependent side effects in CYP2D6 PMs ( Table ). The paucity of prospective studies, uncommon clinical use of therapeutic drug monitoring for antidepressants, 38 and the potential that decreasing the dose may compromise medication efficacy was the basis for the optional recommendation to consider alternatives to venlafaxine in CYP2D6 PMs ( Table 2 c ). Moreover, the FDA Table of Pharmacogenetic Associations 39 lists venlafaxine and vortioxetine as drugs warranting dose adjustments in CYP2D6 PMs.…”

Section: Drugs: Serotonin Reuptake Inhibitorsmentioning

confidence: 99%

Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2D6, CYP2C19, CYP2B6, SLC6A4, and HTR2A Genotypes and Serotonin Reuptake Inhibitor Antidepressants

Bousman

Stevenson

Ramsey

et al. 2023

Clin Pharma and Therapeutics

108

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Serotonin reuptake inhibitor antidepressants, including selective serotonin reuptake inhibitors (SSRIs; i.e., citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline), serotonin and norepinephrine reuptake inhibitors (i.e., desvenlafaxine, duloxetine, levomilnacipran, milnacipran, and venlafaxine), and serotonin modulators with SSRI-like properties (i.e., vilazodone and vortioxetine) are primary pharmacologic treatments for major depressive and anxiety disorders. Genetic variation in CYP2D6, CYP2C19, and CYP2B6 influences the metabolism of many of these antidepressants, which may potentially affect dosing, efficacy, and tolerability. In addition, the pharmacodynamic genes SLC6A4 (serotonin transporter) and HTR2A (serotonin-2A receptor) have been examined in relation to efficacy and side effect profiles of these drugs. This guideline updates and expands the 2015 Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for CYP2D6 and CYP2C19 genotypes and SSRI dosing and summarizes the impact of CYP2D6, CYP2C19, CYP2B6, SLC6A4, and HTR2A genotypes on antidepressant dosing, efficacy, and tolerability. We provide recommendations for using CYP2D6, CYP2C19, and CYP2B6 genotype results to help inform prescribing these antidepressants and describe the existing data for SLC6A4 and HTR2A, which do not support their clinical use in antidepressant prescribing.This document updates and expands the 2015 Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for CYP2D6 and CYP2C19 genotypes and selective serotonin reuptake inhibitor (SSRI) antidepressants. 1 The current guideline includes updated evidence reviews for SSRIs, as well as evidence reviews for serotonin and norepinephrine reuptake inhibitors

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Therapeutic Drug Monitoring of Antidepressants: An Underused but Potentially Valuable Tool in Primary Care

Cited by 7 publications

References 39 publications

Therapeutic Drug Monitoring in Psychiatry: Enhancing Treatment Precision and Patient Outcomes

Therapeutic Drug Monitoring in Psychiatry: Enhancing Treatment Precision and Patient Outcomes

Treatment‐resistant depression: definition, prevalence, detection, management, and investigational interventions

Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2D6, CYP2C19, CYP2B6, SLC6A4, and HTR2A Genotypes and Serotonin Reuptake Inhibitor Antidepressants

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