Pharmacogenomic (PGx) testing aided by therapeutic drug monitoring (TDM) has the potential to improve medication-related outcomes in some individuals prescribed psychiatric medications. Many commonly prescribed psychiatric medications are metabolized through polymorphic drug metabolizing enzymes such as cytochrome p450 (CYP) 2D6 (CYP2D6) and CYP2C19. Through PGx testing, clinicians can make biologically informed choices when selecting a new medication, and TDM may help inform dose adjustments or assess exposures to current treatments. Herein, we describe 2 complex case reports of individuals with multiple psychiatric diagnoses and extensive histories of medication failures who underwent PGx testing in addition to TDM as part of a pharmacist-led comprehensive medication therapy management evaluation in a community mental health clinic setting.

Hyperprolactinemia is a well-known consequence of conventional antipsychotic therapy. The atypical antipsychotic clozapine is reported to lack this effect. We describe a case of attenuated serum prolactin levels after conversion to clozapine therapy in an adolescent. A 13-year-old female patient developed hyperprolactinemia with galactorrhea and amenorrhea while receiving thioridazine 300 mg daily. These symptoms continued throughout 3 years of treatment with haloperidol 10 mg daily and then fluphenazine 10 mg daily. Subsequently, after an incomplete improvement in her psychiatric symptoms and hyperprolactinemia on thioridazine 150 mg and bromocriptine 15 mg daily, the patient was changed to clozapine at age 16. Clozapine 150 mg twice daily improved her psychiatric status and corrected her serum prolactin concentrations after 2 weeks; bromocriptine was able to be discontinued. We recommend systematic evaluation of atypical neuroleptics as alternative treatments for refractory hyperprolactinemia induced by conventional antipsychotics.

Mental illnesses are common and often necessitate the use of medications to improve symptoms. For most common conditions, many pharmacologic treatment options are available, but there is limited evidence to guide the selection of a specific medication or dose for a given patient. Dose‐related side effects are common, and many patients either drop out of treatment or require multiple medication trials before finding a regimen they can tolerate. This prolongs time to remission, increasing suffering and risk for severe outcomes including disability and suicide. A promising approach to reduce early medication discontinuation or switching is through the strategic application of pharmacogenomics (PGx), which utilizes an individual's genetic information to refine dosing or better select an optimal medication. Extensive research has established how genetic variation may influence to what extent individuals metabolize medications commonly prescribed for mental illnesses. The evidence‐based integration of PGx information into clinical care necessitates a patient‐centered approach that considers many factors. Comprehensive medication management by pharmacists provides an optimal framework to incorporate PGx information to improve treatment precision in mental health.

Acetazolamide (AZD), a sulfa-like moiety, is a potent, nonspecific inhibitor of carbonic anhydrase (CA) enzymes and has been demonstrated to decrease lipogenesis in adipose cells in in vitro cell culture studies. In contrast, topiramate (a sulfamate moiety) appears to inhibit specific (CA) enzymes II and V. Four placebo-controlled trials with topiramate have demonstrated positive results in weight loss. There is only anecdotal evidence that AZD may cause weight loss. The following case is of a 49-year-old African-American woman with a long history of schizoaffective disorder, hypertension, diabetes type II, stress incontinence, and obesity (body mass index, 45.5 kg/m2). Previous trials of topiramate demonstrated temporary but significant weight loss before AZD use. A 4 week washout period occurred before starting AZD, 250 mg twice daily. Significant weight loss of 11.5 lbs was seen over 4 weeks. During washout periods of either topiramate or AZD, her total mean weight was approximately 2 to 7 lbs higher than when she was treated with AZD. Although tolerance and side effects may limit the use of AZD as a safe and effective strategy for medication-related weight gain, the pharmacology may provide research insights into the causes and treatments of obesity.

Determine the percentage of subjects taking antipsychotics who meet criteria for metabolic syndrome based on point-of-care testing analyses. Evaluate pharmacist comprehensive medication management services using point-of-care tests to reduce the mean difference in number of metabolic syndrome risk parameters at 6 and 12 months.This 12-month, prospective, multisite, randomized, controlled study included 120 subjects taking antipsychotics (mean [SD] age of 42.9 [11.3] years) recruited from 3 community mental health clinics in Minnesota. Subjects consented to receive either pharmacist (PCS; n = 60) or no pharmacist (NCS; n = 60) comprehensive medication management services. Data were collected from February 2010 to January 2012.No statistical differences in metabolic syndrome based on point-of-care tests were observed between the 2 groups at baseline (PCS: 85.2%, n = 46 versus NCS: 71.2%, n = 42, P = .073) or at 12 months (PCS: 84.4%, n = 38 versus NCS: 70.2%, n = 33, P = .104). Subjects, overall, screened positive at baseline for dyslipidemia (85.8%, n = 106), hypertension (52.5%, n = 63), and diabetes (22.5%, n = 27) based on point-of-care testing for metabolic risk criteria. After 12 months, a nonsignificant (P = .099) higher adjusted mean number of metabolic syndrome parameters in PCS subjects compared to NCS subjects (mean difference [95% CI] = 0.41 [-0.08 to 0.90]) were found.A relatively high proportion of subjects met criteria for metabolic syndrome, although no significant improvement was observed between the groups after 12 months. Point-of-care test analyses identified a high proportion of subjects meeting criteria for dyslipidemia, hypertension, and diabetes. Utilizing point-of-care tests in mental health settings and fostering interprofessional partnerships with comprehensive medication management pharmacists may improve identification and long-term management of metabolic risks among patients prescribed antipsychotics.ClinicalTrials.gov identifier: NCT02029989.