Case report: Major depression and Therapeutic Drug Monitoring in patient with CYP2C19 genetic polymorphism

Introduction Several CYP2C19 genetic polymorphisms are described to be associated with ultrarapid (UM) or poor drug metabolism (PM), inducing treatment resistance and/or adverse drug events, and might therefore be related to pharmacoresistant severe mental health disease.

This case report presents a female 61-year old, in-patient, suffered from drug resistant severe major depression (ICD-10, F33.2). Antidepressant drugs like mirtazapine, duloxetine were changed before. Low serum levels of sertraline in steady-state were monitored during psychiatric care.

Methods Clinical course documentation, therapeutic drug monitoring with low-serum level concentration of sertraline in steady-state and dose related, medical imaging (cMRT, EEG).

Results Low-serum level sertraline were<4,88 µg/ml (10–150 therapeutic range), desmethylsertraline 22,8 µg/l, ratio N.N (1,7–3,4) after four weeks, and two weeks later sertraline were 5,4 µg/l, desmethylsertraline 26,8, ratio 4,96 (1,7–3,4). In the clinical documentation the patient suffered from resistant-symptoms of major depression like anhedonia and apathy.

Gene duplication associated with UM has been found at CYP2C19 (duplet of allels CYP2C19*17/*17).

Conclusion In this case report we demonstrate consequent therapeutic drug monitoring as an option to identify high-risk patients with genetic polymorphisms.

Nevertheless, knowledge of individual metabolism and in particular CYP2C19 genotyping should be considered for clinical workup and therapy adjustment in resistant patients in adolescent psychiatry and might permit better treatment outcome, increased treatment adherence and diminished adverse drug events.

Publication History

Article published online:
16 May 2022