The AGNP-TDM Expert Group Consensus Guidelines: focus on therapeutic monitoring of antidepressants

Figures & data

Table I. General pharmacokinetic properties (absorption, distribution, metabolism, and elimination [ADME]) of antidepressants.^11,20

Figure 1. Summary of the therapeutic drug monitoring (TDM) process for optimization of the pharmacotherpy of psychiatric patients. Routine monitoring should be restricted to psychoactive drugs with established therapeutic ranges and who levels of recommendation to use TDM are at least 2 (Table IV). Specific requests may be useful for any psychoactive drug and many indications (Table I), even without well-established therapeutic ranges.¹¹

Table IV. Recommended target plasma concentration ranges for antidepressant drugs and levels of recommendation for routine monitoring.¹¹ Therapeutic ranges indicate trough concentrations of drugs in serum or plasma of patients under steady-state medication. Level of recommendation: 1. Strongly recommended (for lithium TDM should be a standard of care): established therapeutic range; 2. Recommended: suggested therapeutic ranges obtained from plasma concentrations at therapeutically effective doses (fixed dose studies); 3. Useful: suggested therapeutic ranges are plasma concentrations at therapeutically effective doses obtained from steady-state pharmacokinetic studies; 4. Probably useful: suggested therapeutic ranges from steady-state pharmacokinetic studies at therapeutically effective doses; 5. Not recommended. SPC, Summary of Product Characteristics.

Table II. General indications for therapeutic drug monitoring (TDM) of antidepressants.¹¹

Table III. Dose-related steady-state plasma concentrations of antidepressants.¹¹ Generally, arithmetic means ± standarad deviations are given; numbers in parentheses indicate ranges. md_# median value; gm, geometric mean; m, males; f, females. ^*Extensive metabolizers (CYP 2D6). ^†Doxepin + desmethyldoxepin. ^‡Patients were treated with 20 mg/day citalopram, and S-citalopram and its metabolite were measured. ^§Nonsmokers. ^"Smokers. ^¶Concentrations given in ng.kg/mL.mg, in extensive metabolizers (CYP 2D6). ^#Concentrations show very little differences when given 50 mg/day tid.

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