Optimisation of pharmacotherapy in psychiatry through therapeutic drug monitoring, molecular brain imaging and pharmacogenetic tests: focus on antipsychotics.

BACKGROUND: For psychotic disorders (i.e. schizophrenia), pharmacotherapy plays a key role in controlling acute and long-term symptoms. To find the optimal individual dose and dosage strategy, specialized tools are used. Three tools have been proven useful to personalize drug treatments: therapeutic drug monitoring (TDM) of drug levels, pharmacogenetic testing (PG), and molecular neuroimaging. METHODS: In these Guidelines, we provide an in-depth review of pharmacokinetics, pharmacodynamics, and pharmacogenetics for 50 antipsychotics. Over 30 international experts in psychiatry selected studies that have measured drug concentrations in the blood (TDM), gene polymorphisms of enzymes involved in drug metabolism, or receptor/transporter occupancies in the brain (positron emission tomography (PET)). RESULTS: Study results strongly support the use of TDM and the cytochrome P450 (CYP) genotyping and/or phenotyping to guide drug therapies. Evidence-based target ranges are available for titrating drug doses that are often supported by PET findings. CONCLUSION: All three tools discussed in these Guidelines are essential for drug treatment. TDM goes well beyond typical indications such as unclear compliance and polypharmacy. Despite its enormous potential to optimize treatment effects, minimize side effects and ultimately reduce the global burden of diseases, personalized drug treatment has not yet become the standard of care in psychiatry.

The role of COMT polymorphism in modulation of prefrontal activity during verbal fluency in bipolar disorder.

OBJECTIVE: Verbal fluency (VF) impairment is a strong predictor of social functioning in bipolar disorder (BPD). The enzyme catechol-O- methyltransferase (COMT) has a critical role in cognitive responses by modulating dopaminergic activity in the prefrontal cortex (PFC). Here, we investigated the role of COMT polymorphism (i) in VF performance as well as (ii) in modulation of PFC activity during a VF-task in euthymic BPD patients. METHODS: 30 subjects with remitted BPD-I and 23 healthy controls (HCs) were genotyped for COMT Val158Met (rs4680) polymorphism and were compared in a VF-task. PFC activity was measured by 24-Channel Functional Near Infrared Spectroscopy. RESULTS: Bipolar subjects displayed lower VF performance than HCs. During the VF-task, BPD-group displayed higher activity than HCs in the Brocca's area, Premotor-cortex and supplementary motor area (SMA). In the index group, Val/Met polymorphism was associated with higher activity in the left- frontopolar and dorsolateral PFC (DLPFC) during the VF-task. LIMITATIONS: Antipsychotic use may have interfered with the results. CONCLUSIONS: Increased activity in the Brocca's area may represent compensation of low VF performance, whereas hyperactivity in premotor-cortex and SMA may be associated with increased behavioral intention and/or restlessness in BPD. Higher activity in left-frontopolar and DLPC among Val/Met individuals compared to Met-homozygotes may represent less effective prefrontal dopaminergic signaling in Val/Met individuals with BPD.

The impact of CYP2C19 polymorphisms on citalopram metabolism in patients with major depressive disorder.

WHAT IS KNOWN AND OBJECTIVE: Genetic variations in drug-metabolizing enzyme genes change drug pharmacokinetics and response. CYP2C19 is a clinically important enzyme that metabolizes citalopram (CIT). The objective of this study was to determine CYP2C19 genetic polymorphisms and to evaluate the impact of these polymorphisms on the metabolism of citalopram in a sample of the Turkish population. We also assessed *17 polymorphism in healthy subjects in this population. METHODS: The CYP2C19 genotypes were determined by polymerase chain reaction-restriction fragment length polymorphism method (209 healthy individuals and 50 patients for CIT metabolism), and the plasma concentrations of CIT and demethylcitalopram (DCIT) were quantified by high-performance liquid chromatography. RESULTS AND DISCUSSION: The CYP2C19*1 and *17 allele frequencies for the patient group and the healthy group were 71·0%, 18·0% and 81·1%, 18·9%, respectively. There was no significant difference between the two groups (P > 0·05). The mean plasma concentrations and the mean dose-corrected (C/D) plasma levels of DCIT were significantly higher in patients with the CYP2C19*1/*1 genotype compared to patients with CYP2C19*1/*2 and CYP2C19*2/*2 genotypes (P < 0·05). Furthermore, the mean metabolic ratio (MR, CIT/DCIT) was also significantly higher in the CYP2C19*1/*2 + CYP2C19*2/*2 genotypes (P < 0·05). On the other hand, plasma CIT, DCIT concentrations and M/R value in the CYP2C19*1/*1 genotypes were no different to those of the CYP2C19*1/*17 genotypes (P > 0·05). WHAT IS NEW AND CONCLUSION: Our data suggest that CYP2C19*17 polymorphism does not have a significant effect on CIT metabolism. In contrast CYP2C19*2 polymorphism has a prominent role and is likely to contribute to interindividual variability in CIT metabolism in vivo at therapeutic doses.

TYMS and DPYD polymorphisms in a Turkish population.

OBJECTIVE: The thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD) enzymes affect the outcome of 5-fluorouracil (5-FU)-based chemotherapy. Genetic polymorphisms of the thymidylate synthase (TYMS) and dihydropyrimidine dehydrogenase (DPYD) genes that may affect chemotherapy are described. The aim of this study was to determine the frequencies of TYMS and DPYD polymorphisms in healthy Turkish individuals. METHODS: Genotyping analyses of the promoter enhancer region of TYMS (TSER) and the exon 14-skipping mutation of the DPYD (DPYD*2A) genes were conducted in 250 unrelated, healthy volunteers from the central region of Turkey using a PCR-based assay. RESULTS: The distribution of the TSER*2/*2, *2/*3 and *3/*3 genotypes were 17.6%, 48.8%, and 33.6%, respectively. The frequencies of the TSER*2 and *3 alleles in the Turkish population were 0.42 and 0.58, respectively. No individuals with the variant DPYD*2A allele were identified in the study group. CONCLUSION: The frequency of the TSER*3 allele among members of the Turkish population was similar to frequencies observed in other Caucasian populations but was lower than those found in Japanese and Chinese populations.

Correlation between lead exposure indicators and sister chromatid exchange (SCE) frequencies in lymphocytes from inorganic lead exposed workers.

Inorganic lead exposure was studied in 31 volunteers employed in storage battery plant. The genotoxicity of lead was measured in terms of sister chromatid exchange (SCE). Erythrocyte delta-aminolevulinic acid dehydrogenase (ALAD) activity, urinary delta-aminolevulinic acid (U-ALA), and blood lead levels (PbBs) were also determined to evaluate some possible relations between these lead exposure indicators and the observed SCE frequencies. Blood lead concentration of 36.31 microg/dl was determined as an average level in the workers. Consequently decreased ALAD activity in erythrocytes and increased U-ALA excretion was observed in statistically higher PbBs when compared with the control group. A statistically significant correlation was observed between the PbBs and SCE frequencies (p < 0.05). Moreover, the correlation between U-ALA excretion and SCE frequencies (p < 0.01) was relatively higher than the correlation between PbBs and SCE frequencies. These results might indicate a possible mechanism of ALA mediation in the genotoxic effects of lead.

The restriction site mutation assay: a review of the methodology development and the current status of the technique.

The restriction site mutation (RSM) assay has been employed in our laboratory, as a mutation detection system, since its first description in 1990. In principle the technique is capable of detecting mutations in ubiquitous restriction enzyme sites and is, therefore, readily applicable to any sequenced gene and/or organism. The RSM assay has been applied in our laboratory in various species, detecting rare mutations induced in mouse, rat, Xenopus, flatfish and human cells and tissues. This paper reviews the data accumulated by the RSM methodology in our hands and charts the developmental processes which have steadily improved the technique such that it is now applicable as a sensitive genotypic mutation detection system. This paper also includes PCR primer sequences and restriction enzymes employed in mutational analyses performed in the various species studied. We detail a variety of problems associated with the assay and the steps taken to solve them. The specific hurdles which have been overcome include the lack of quantitative data, the question of the contribution of DNA adducts to the induced mutation profile and the presence of false positives. Finally, the methods which have been developed to increase the sensitivity of the assay are also detailed. This paper describes our recommended RSM methodology, as it is routinely employed in our laboratory, which enables the analyses of mutations induced by chemical exposures and spontaneous endogenous processes. Our aim in presenting the developmental data on the RSM assay is to provide other researchers with sufficient information about the RSM methodology to facilitate its application in mutation analysis in other genes and organisms.