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Using Evidence-Based Models to Improve Clinical Care For Patients Taking Lithium
Dr Vincent Millischer, MD, PhD, discussed key findings from his study "Improving Lithium Dose Prediction Using Population Pharmacokinetics and Pharmacogenomics: a Cohort Genome-Wide Association Study in Sweden," recently published in The Lancet.
Clinicians treating patients with bipolar disorder frequently encounter the challenge of lithium clearance. In the second part of this Q&A, Dr Millischer explains the potential applications for his findings about lithium clearance, including how to approach the search for the correct lithium dosage in patients and plans for a smartphone app that would aid clinicians in determining the ideal dosage.
Read Part 1: Demystifying the Lithium Clearance Challenge here!
Psych Congress Network: How have these study findings reshaped the way you think about the use of lithium to treat bipolar disorder in a clinical setting? What are some practical applications of your findings for clinicians treating patients with lithium for bipolar disorder?
Vincent Millischer, MD, PhD: Given that a large part of the variance is explained by our model, we think it is important to see whether such evidence-based models could improve clinical care. It is true that experienced clinicians would adapt the lithium dosage to individual patients (e.g., give more to a young, tall man than an elderly lady), but given that the variables (age, sex, eGFR, …) are easily measured and well known, it might be good to keep them even more in mind when starting patients on lithium.
Psych Congress Network: Please tell us more about the proposed digital app that is in development pending the results of your model applied in a clinical trial.
Dr Millischer: To begin, we have to validate our model, first in a retrospective way, then eventually in a prospective way. If we see that the model holds up, and might lead to better outcomes (e.g., reaching therapeutic drug levels faster or having fewer side effects), we would plan to establish an easy-to-use app where you could input the clinical variables of a patient and get an estimate of how much lithium will be needed.
Psych Congress Network: Until the next phase of your research is completed, how can practitioners immediately incorporate your study’s findings into their daily clinical routines when using lithium to treat bipolar disorder?
Dr Millischer: As mentioned above, thinking about the personal background of each patient, i.e. how old is he, how is the kidney function, what level of lithium do I want to reach, what body structure does he have, to get an idea what the final amount of lithium will be, could eventually reduce the time needed to reach therapeutic concentrations. However, until we have validated our models, we cannot recommend any change to the titration method and regular therapeutic drug monitoring that is currently recommended by the guidelines.
Psych Congress Network: What new questions has this study inspired in yours and your colleagues’ minds for future research?
Dr Millischer: The integration of genetic and clinical data a very exciting field, one which we would like to pursue from these findings. Regarding lithium treatment, we are also currently exploring new methods to measure lithium at home to improve access to lithium for people who might not have an easy access to therapeutic drug monitoring, which is currently still a prerequisite for lithium treatment.
Psych Congress Network: What else should health care professionals know about the implications of this study that we haven’t touched on yet?
Dr Millischer: Large data sets with good phenotypes are extremely important for academic research. Even if can be a bit difficult to include this type of data collection in the clinical routine, it can be extremely rewarding to have good cooperation between research and clinic. We are extremely thankful for the very supportive clinical environment at SLSO that allowed us to perform this study.
Reference
Vincent Millischer, MD, PhD, studied medicine in Vienna and Paris from 2008-2014. He continued on to complete his PhD in medical science at Karolinska Institutet in Stockholm Sweden in 2015. After defending in 2020, he returned to Vienna to do his residency in psychiatry. Dr. Millischer's main research interests include psychiatric genetics and inflammation.
