Systematic review and meta-analysis on the therapeutic reference range for escitalopram: Blood concentrations, clinical effects and serotonin transporter occupancy.

Introduction: A titration within a certain therapeutic reference range presupposes a relationship between the blood concentration and the therapeutic effect of a drug. However, this has not been systematically investigated for escitalopram. Furthermore, the recommended reference range disagrees with mean steady state concentrations (11-21 ng/ml) that are expected under the approved dose range (10-20 mg/day). This work systematically investigated the relationships between escitalopram dose, blood levels, clinical effects, and serotonin transporter occupancy. Methods: Following our previously published methodology, relevant articles were systematically searched and reviewed for escitalopram. Results: Of 1,032 articles screened, a total of 30 studies met the eligibility criteria. The included studies investigated escitalopram blood levels in relationship to clinical effects (9 studies) or moderating factors on escitalopram metabolism (12 studies) or serotonin transporter occupancy (9 studies). Overall, the evidence for an escitalopram concentration/effect relationship is low (level C). Conclusion: Based on our findings, we propose a target range of 20-40 ng/ml for antidepressant efficacy of escitalopram. In maintenance treatment, therapeutic response is expected, when titrating patients above the lower limit. The lower concentration threshold is strongly supported by findings from neuroimaging studies. The upper limit for escitalopram's reference range rather reflects a therapeutic maximum than a tolerability threshold, since the incidence of side effects in general is low. Concentrations above 40 ng/ml should not necessarily result in dose reductions in case of good clinical efficacy and tolerability. Dose-related escitalopram concentrations in different trials were more than twice the expected concentrations from guideline reports. Systematic review registration: [https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=215873], identifier [CRD42020215873].

Established amyloid-ß pathology is unaffected by chronic treatment with the selective serotonin reuptake inhibitor paroxetine.

INTRODUCTION: Treatment with selective serotonin reuptake inhibitors has been suggested to mitigate amyloid-ß (Aß) pathology in Alzheimer's disease, in addition to an antidepressant mechanism of action. METHODS: We investigated whether chronic treatment with paroxetine, a selective serotonin reuptake inhibitor, mitigates Aß pathology in plaque-bearing double-transgenic amyloid precursor protein (APP)swe/presenilin 1 (PS1)ΔE9 mutants. In addition, we addressed whether serotonin depletion affects Aß pathology. Treatments were assessed by measurement of serotonin transporter occupancy and high-performance liquid chromatography. The effect of paroxetine on Aß pathology was evaluated by stereological plaque load estimation and Aß42/Aß40 ratio by enzyme-linked immunosorbent assay. RESULTS: Contrary to our hypothesis, paroxetine therapy did not mitigate Aß pathology, and depletion of brain serotonin did not exacerbate Aß pathology. However, chronic paroxetine therapy increased mortality in APPswe/PS1ΔE9 transgenic mice. DISCUSSION: Our results question the ability of selective serotonin reuptake inhibitor therapy to ameliorate established Aß pathology. The severe adverse effect of paroxetine may discourage its use for disease-modifying purposes in Alzheimer's disease.