Drug Blood Concentrations and Clinical Response

For none of the SSRIs has a plasma concentration—clinical effectiveness relationship been evinced.23,58,59 Consequently, therapeutic monitoring is limited to indications such as: lack of compliance, non-response despite adequate doses, or the response in 'special populations' such as the elderly (see below). While, for most SSRIs, several studies have been carried out, none have been reported for the widely introduced sertraline. Also, only limited data have been published on the plasma concentrations of SSRIs in the clinical context.23,60 Furthermore, there is a lack of published studies on the relationship between plasma concentration and clinical response to fluoxetine or citalopram which take account of their enantiomers. As reviewed recently,61 pharmacokinetic studies have shown that in some 'special populations', SSRI doses should be modified. For instance, lower doses of citalopram, fluoxetine and sertraline should be used in patients suffering from liver disease. With paroxetine, a drug eliminated mainly by the kidney, the dose should be carefully adapted in patients suffering from renal disease. Finally, in elderly subjects, it is advisable to decrease the recommended doses of citalopram, paroxetine and sertraline but, generally, controlled studies of this group of patients are lacking.

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