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治疗药物监测(Therapeutic drug monitoring,TDM),如通过定量测定血清或血浆药物浓度指导用药剂量优化,已经成为对患者进行精神药物治疗的很有价值的工具。在患者用药依从性难以判断、药物耐受性不佳、治疗剂量下无效以及可能存在药代动力学药物-药物相互作用等情况下,测定药物浓度是很有用的。在精神科,有可能明显获益于TDM的主要患者群体包括儿童、孕妇、老年患者、智力障碍患者、涉及司法的患者、已知或怀疑携带药代动力学相关基因变异的患者,以及合并躯体疾病影响药代动力学的患者。然而,只有将TDM充分整合到临床治疗过程中去,才能发挥其优化药物治疗的潜在优势。为了促进TDM的合理应用,神经精神药理学与药物精神病学协会(Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie,AGNP)的TDM专家组在2004年发表了精神药物治疗药物监测指南。之后,随着知识不断更新,又有许多可能需要进行TDM的新药上市。因此,本次更新将神经精神药物的种类扩展到了128种,并将其TDM必要性划分为从“强烈推荐”到“可能有用”的四个等级。经过大量细致且全面的文献检索与分门别类的汇总整理,将基于循证医学理念的“治疗参考浓度范围”和“剂量相关参考浓度范围”呈现给大家。本共识指南引入了“实验室警戒浓度”的新概念,即实验室需要马上告知治疗医生的药物浓度上限。本共识指南还给出了诸如药物作为细胞色素P450酶的底物和抑制剂的性质,代谢物与母药浓度比值的常见范围,以及与结果解释相关的内容,还提供了何时将TDM与遗传药理学检测相结合的建议。遵循本指南,有助于改善许多患者精神药物治疗的效果,特别是那些存在药代动力学异常的患者。TDM是一门交叉学科,有时针对看起来不一致的数据,需要多学科坦诚地讨论,只有这样,患者才能从这种合作中获益。
Therapeutic drug monitoring (TDM), which has been optimized for psychoactive drug treatment in patients, for example, by optimizing dosages of drugs for the measurement of serum or plasma drug concentrations. It is useful to determine the drug concentration in cases where the patient’s medication adherence is difficult to determine, poorly tolerated, ineffective at therapeutic doses, and possibly pharmacokinetic drug-drug interactions. In psychiatry, the major patient population likely to benefit significantly from TDM includes children, pregnant women, the elderly, people with mental retardation, patients involved in the administration of justice, patients with known or suspected genetic variants associated with pharmacokinetics, and patients with combined body Disease affects pharmacokinetics in patients. However, the potential benefits of optimizing drug therapy can only be demonstrated by fully integrating TDM into clinical practice. In order to promote the rational use of TDM, the TDM expert group of the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) published guidelines for the psychotropic drug treatment in 2004. Later, as knowledge continues to evolve, there are many new drugs that may require TDM. As a result, this update extends the list of neuropsychiatric drugs to 128 and classifies their TDM necessity into four levels from “strongly recommended” to “potentially useful”. After a large number of meticulous and comprehensive literature search and classification of the summary, will be based on the concept of evidence-based medicine “reference concentration range” and “dose-related reference concentration range” presented to everyone. This Consensus Guide introduces a new concept of “laboratory alert concentration”, which is the laboratory’s immediate need to inform the treating physician of the maximum drug concentration. This Consensus Guide also gives information such as the nature of the drug as a substrate and inhibitor of cytochrome P450 enzymes, a common range of metabolite to parent drug concentration ratios, and content related to interpretation of results, and provides information on when TDM is linked to Recommendations for the combination of genetic and pharmacological tests. Following this guideline will help to improve the effectiveness of psychotropic medication in many patients, especially those with pharmacokinetic abnormalities. TDM is an interdisciplinary and sometimes multidisciplinary, frank discussion of what appears to be inconsistent data. Only in this way can patients benefit from this collaboration.