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Yada Y, Kitagawa K, Sakamoto S, Ozawa A, Nakada A, Kashiwagi H, Okahisa Y, Takao S, Takaki M, Kishi Y, Yamada N. The relationship between plasma clozapine concentration and clinical outcome: a cross-sectional study. Acta Psychiatr Scand 2021; 143:227-237. [PMID: 33274435 DOI: 10.1111/acps.13264] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/24/2020] [Accepted: 11/29/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE There is no report that statistically evaluates the therapeutic reference (350-600 ng/ml) and adverse drug reaction (ADR) range (>1000 ng/ml) of clozapine (CLZ) recommended by the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) consensus guidelines in an isolated and large sampling study. METHODS We administered CLZ to 131 Japanese patients with treatment-resistant schizophrenia in a multicenter cross-sectional study. Plasma CLZ concentrations were assayed by high-performance liquid chromatography using trough sampling. The Brief Psychiatric Rating Scale (BPRS) and severe dose-dependent ADR (sedation, myoclonus, and seizures) were analyzed statistically after adjusting for possible confounders. RESULTS The daily CLZ dosage showed a moderately positive relationship with the plasma concentration (r = 0.49, p < 0.001). Every 100 ng/ml increase in plasma CLZ concentration improved the total BPRS score 1.95% (95% CI: 0.89-3.01, p < 0.001) and the odds ratio (OR) 1.38 (95% CI: 1.14-1.66, p = 0.001) for BPRS response. Compared with concentrations below 350 ng/ml CLZ, 350-600 ng/ml (11.12%; 95% CI: 2.52-19.72, p = 0.012) and 600-1000 ng/ml (11.05%; 95% CI: 2.40-19.71, p = 0.013) showed significant improvement in the total BPRS score. Dosages above 1000 ng/ml showed greater improvement (25.36%; 95% CI: 13.08-37.64, p < 0.001) of the total BPRS score but more severe ADRs than dosages below 1000 ng/ml (OR: 31.72; 95% CI: 1.04-968.81, p = 0.048). CONCLUSION The AGNP therapeutic reference range (350-600 ng/ml) is useful, and a dose above 1000 ng/ml is potentially more effective but carries the risk of severe ADRs in the central nervous system.
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Affiliation(s)
- Yuji Yada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.,Okayama Psychiatric Medical Center, Okayama, Japan
| | | | - Shinji Sakamoto
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | | | - Hiroko Kashiwagi
- Department of Forensic Psychiatry, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yuko Okahisa
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Soshi Takao
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Manabu Takaki
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | - Norihito Yamada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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A descriptive study of 10-year clozapine use from the nationwide database in Japan. Psychiatry Res 2021; 297:113764. [PMID: 33567393 DOI: 10.1016/j.psychres.2021.113764] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/24/2021] [Indexed: 12/17/2022]
Abstract
This survey was conducted to identify the actual usage of clozapine and changes required to increase the number of patients with schizophrenia who would benefit from clozapine. We obtained Clozaril® Patient Monitoring Service (CPMS) data for 8,263 patients that received clozapine between July 2009 and January 2020. Patients were divided into the early (n=3,696 cases, which have been analyzed previously) and late groups (n=4,567 cases) according to the date of the treatment initiation. In total, 417 facilities offered the drug, with a surge in cases in the late group (40.0 hospitals/year, 568.6 cases/year vs. 39.3 hospitals/year, 1,141.8 cases/year). We found a significant between-group difference in the mean dosage during treatment (early group: 309.1 mg/day; late group: 247.9 mg/day). The treatment continuation rates at 1 and 4 years in all study participants were 77.2% and 65.1%, respectively. The incidences of granulocytopenia and agranulocytosis were 5.5% and 1.0%, respectively. The discontinuation rate because of granulocytopenia was significantly lower in the late group. There were no differences in the discontinuation rate because of glucose intolerance between the groups. An assessment of the current CPMS regulations may be required to further examine the clozapine use effectiveness.
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Martini F, Spangaro M, Buonocore M, Bechi M, Cocchi F, Guglielmino C, Bianchi L, Sapienza J, Agostoni G, Mastromatteo A, Bosia M, Cavallaro R. Clozapine tolerability in Treatment Resistant Schizophrenia: exploring the role of sex. Psychiatry Res 2021; 297:113698. [PMID: 33440269 DOI: 10.1016/j.psychres.2020.113698] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/28/2020] [Indexed: 12/20/2022]
Abstract
Clozapine is the only evidence-based drug indicated for Treatment Resistant Schizophrenia but it is largely underprescribed, partially due to its life-threatening adverse effects (AEs). However, clozapine treatment is burdened by other common AEs as constipation, hypersalivation, postural hypotension, tachycardia and metabolic abnormalities. Few studies have investigated sex-related differences in clozapine's tolerability, reporting women to experience more frequently weight gain, hyperglycemia and constipation, while men hypertension and dyslipidemia. Based on these premises, we investigated clinical, psychopathological and metabolic sex-related differences among 147 treatment-resistant patients treated with clozapine, with a specific focus on non-life-threatening AEs. We observed significant higher prevalence of tachycardia in men, and of orthostatic hypotension and constipation in women. Concerning metabolic alterations, we observed significant lower levels of HDL-cholesterol and higher prevalence of hypertriglyceridemia among men, whereas females showed higher prevalence of abdominal obesity. Consistently with previous studies, our data confirm the presence of sex-related differences in clozapine tolerability, with a main effect of sex especially for tachycardia, postural hypotension and constipation. Although non-life-threatening, these common AEs significantly affect patients' quality of life, undermine compliance and cause treatment discontinuation. A better understanding of this topic could contribute to tailor therapeutic approaches, thus improving tolerability, compliance and clinical stability.
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Affiliation(s)
- Francesca Martini
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Marco Spangaro
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Mariachiara Buonocore
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Margherita Bechi
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federica Cocchi
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carmelo Guglielmino
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Bianchi
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | | | - Antonella Mastromatteo
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marta Bosia
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Cavallaro
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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Ford E, Curlewis K, Squires E, Griffiths LJ, Stewart R, Jones KH. The Potential of Research Drawing on Clinical Free Text to Bring Benefits to Patients in the United Kingdom: A Systematic Review of the Literature. Front Digit Health 2021; 3:606599. [PMID: 34713089 PMCID: PMC8521813 DOI: 10.3389/fdgth.2021.606599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The analysis of clinical free text from patient records for research has potential to contribute to the medical evidence base but access to clinical free text is frequently denied by data custodians who perceive that the privacy risks of data-sharing are too high. Engagement activities with patients and regulators, where views on the sharing of clinical free text data for research have been discussed, have identified that stakeholders would like to understand the potential clinical benefits that could be achieved if access to free text for clinical research were improved. We aimed to systematically review all UK research studies which used clinical free text and report direct or potential benefits to patients, synthesizing possible benefits into an easy to communicate taxonomy for public engagement and policy discussions. Methods: We conducted a systematic search for articles which reported primary research using clinical free text, drawn from UK health record databases, which reported a benefit or potential benefit for patients, actionable in a clinical environment or health service, and not solely methods development or data quality improvement. We screened eligible papers and thematically analyzed information about clinical benefits reported in the paper to create a taxonomy of benefits. Results: We identified 43 papers and derived five themes of benefits: health-care quality or services improvement, observational risk factor-outcome research, drug prescribing safety, case-finding for clinical trials, and development of clinical decision support. Five papers compared study quality with and without free text and found an improvement of accuracy when free text was included in analytical models. Conclusions: Findings will help stakeholders weigh the potential benefits of free text research against perceived risks to patient privacy. The taxonomy can be used to aid public and policy discussions, and identified studies could form a public-facing repository which will help the health-care text analysis research community better communicate the impact of their work.
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Affiliation(s)
- Elizabeth Ford
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Keegan Curlewis
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Emma Squires
- Swansea Medical School, University of Swansea, Swansea, United Kingdom
| | - Lucy J. Griffiths
- Swansea Medical School, University of Swansea, Swansea, United Kingdom
| | - Robert Stewart
- King's College London, London, United Kingdom
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Kerina H. Jones
- Swansea Medical School, University of Swansea, Swansea, United Kingdom
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Bhattacharya R, White L, Pisaneschi L. Clozapine prescribing: comparison of clozapine dosage and plasma levels between White British and Bangladeshi patients. BJPsych Bull 2021; 45:22-27. [PMID: 32605689 PMCID: PMC8058897 DOI: 10.1192/bjb.2020.59] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
AIMS AND METHOD To compare differences in clozapine doses and plasma levels between Bangladeshi and White British patients. Following ethical approval we identified all current Bangladeshi and White British patients on clozapine maintenance in an east London clinic. We carried out univariate and multivariate regression analyses to examine associations between clozapine doses and ethnicity, age, gender, smoking status and weight. We also compared plasma clozapine levels of the two groups. RESULTS On univariate analysis White British patients had on average 85 mg higher doses than Bangladeshi patients (P = 0.004). Older age, male gender and smoking were also associated with higher dose. On multivariate analysis only age and smoking status remained significant. A greater proportion of Bangladeshi patients had high plasma clozapine levels compared with White British (30.76% v. 20.75%), although the difference was not statistically significant. CLINICAL IMPLICATIONS Our findings point to the need for the broadening of data collection on ethnic differences in clozapine prescribing within big data-sets such as Prescribing Observatory for Mental Health (POM-UK). Ethnopharmacological variations can inform more person-centred guidance on prescribing.
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Affiliation(s)
- Rahul Bhattacharya
- Tower Hamlets Community Services, East London NHS Foundation Trust; and Barts and the London School of Medicine, UK
| | | | - Laura Pisaneschi
- Tower Hamlets Clozapine Clinic, East London NHS Foundation Trust, UK
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Toyoda K, Hata T, Yamauchi S, Kinoshita S, Nishihara M, Uchiyama K, Inada K, Kanazawa T. Clozapine Is Better Tolerated in Younger Patients: Risk Factors for Discontinuation from a Nationwide Database in Japan. Psychiatry Investig 2021; 18:101-109. [PMID: 33460532 PMCID: PMC7960752 DOI: 10.30773/pi.2020.0376] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/11/2019] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE The effectiveness of clozapine is clearly superior to other antipsychotics in the treatment of refractory schizophrenia. Clozapine leads to various side effects, and therefore many patients are forced to discontinue. In this study, we analyzed the registry database of all cases in Japan to identify risk factors for discontinuation of clozapine. METHODS The Clozaril patient monitoring service® (CPMS) database from July 31, 2009 to January 26, 2020 was acquired. We defined the following exclusion criteria: patients who had ever taken clozapine by a non-CPMS method, such as an individual import or clinical trial, patients who did not receive clozapine after being enrolled in CPMS, and patients with initial doses other than 12.5 mg (outside the current protocol). Therefore, all patients in this study are new users. Multivariate Cox regression analysis was used to investigate independent risk factors associated with time to discontinuation of clozapine. RESULTS We identified 8,263 patients as the study population. Clozapine discontinuation was significantly associated with age 40 and older [hazard ratio (HR)=1.66, p<0.001], intolerance to olanzapine (HR=1.31, p=0.018), previous treatment with clozapine (HR=1.30, p=0.001), and leukocyte counts <6,000/mm3 (HR=1.24, p<0.001). The Kaplan-Meier curves for clozapine discontinuation by age group revealed that older age at the time of clozapine introduction tended to have lower continuation rates. CONCLUSION Careful administration is important because patients with these factors have a high risk of discontinuation. In addition, the initiation of clozapine during the younger period was more effective and more tolerated.
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Affiliation(s)
- Katsunori Toyoda
- Department of Neuropsychiatry, Osaka Medical College, Osaka, Japan
| | - Takeo Hata
- Department of Pharmacy, Osaka Medical College Hospital, Osaka, Japan
| | - Shigeru Yamauchi
- Department of Neuropsychiatry, Osaka Medical College, Osaka, Japan
| | - Shinya Kinoshita
- Department of Neuropsychiatry, Osaka Medical College, Osaka, Japan
| | - Masami Nishihara
- Department of Pharmacy, Osaka Medical College Hospital, Osaka, Japan
| | - Kazuhisa Uchiyama
- Department of Pharmacy, Osaka Medical College Hospital, Osaka, Japan
| | - Ken Inada
- Department of Psychiatry, Tokyo Women's Medical University, Tokyo, Japan
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Griffiths K, Millgate E, Egerton A, MacCabe JH. Demographic and clinical variables associated with response to clozapine in schizophrenia: a systematic review and meta-analysis. Psychol Med 2021; 51:376-386. [PMID: 33602358 DOI: 10.1017/s0033291721000246] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Clozapine is the only licensed pharmacotherapy for treatment-resistant schizophrenia. However, response to clozapine is variable. Understanding the demographic and clinical features associated with response to clozapine may be useful for patient stratification for clinical trials or for identifying patients for earlier initiation of clozapine. We systematically reviewed the literature to investigate clinical and demographic factors associated with variation in clozapine response in treatment-resistant patients with schizophrenia spectrum disorders. Subsequently, we performed a random-effects meta-analysis to evaluate differences in duration of illness, age at clozapine initiation, age of illness onset, body weight and years of education between clozapine responders and non-responders. Thirty-one articles were eligible for qualitative review and 17 of these were quantitatively reviewed. Shorter duration of illness, later illness onset, younger age at clozapine initiation, fewer hospitalisations and fewer antipsychotic trials prior to clozapine initiation showed a trend to be significantly associated with a better response to clozapine. Meta-analysis of seven studies, totalling 313 subjects, found that clozapine responders had a significantly shorter duration of illness compared to clozapine non-responders [g = 0.31; 95% confidence interval (CI) 0.06-0.56; p = 0.01]. The results imply that a delay in clozapine treatment may result in a poorer response and that a focus on prompt treatment with clozapine is warranted.
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Affiliation(s)
- Kira Griffiths
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Edward Millgate
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Alice Egerton
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - James H MacCabe
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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Jilka S, Odoi CM, Meran S, MacCabe JH, Wykes T. Investigating Patient Acceptability of Stratified Medicine for Schizophrenia: A Mixed Methods Study. SCHIZOPHRENIA BULLETIN OPEN 2021; 2:sgab016. [PMID: 34901864 PMCID: PMC8650064 DOI: 10.1093/schizbullopen/sgab016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Health services have advocated a stratified medicine approach in mental health, but little is known about whether service users would accept this approach. AIMS To explore service users' views of the acceptability of stratified medicine for treatment-resistant schizophrenia compared to the traditional "trial-and-error" approach. METHODS A mixed methods observational study that explored questionnaire responses on acceptability and whether these responses were affected by demographic or clinical variables. We also investigated whether treatment responsiveness or experience of invasive tests (brain scans and blood tests) affected participants' responses. Questionnaire generated qualitative data were analyzed thematically. Participants (N108) were aged 18-65, had a diagnosis of schizophrenia, and were adherent to antipsychotic medication. RESULTS Acceptability of a stratified approach was high, even after participants had experienced invasive tests. Most rated it as safer (62% vs 43%; P < .01 [CI: -1.69 to 2.08]), less risky (77% vs 44%; P < .01 [CI: -1.75 to 1.10]), and less painful (90% vs 73%; P < 0.01 [CI: -0.84 to 0.5]) and this was not affected by treatment responsiveness or test experience. Although not statistically significant, treatment nonresponders were more willing to undergo invasive tests. Qualitatively, all participants raised concerns about the risks, discomfort, and potential side effects associated with the invasive tests. CONCLUSIONS Service users were positive about a stratified approach for choosing treatments but were wary of devolving clinical decisions to purely data-driven algorithms. These results reinforce the value of service user perspectives in the development and evaluation of novel treatment approaches.
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Affiliation(s)
- Sagar Jilka
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Clarissa Mary Odoi
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Sazan Meran
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - James H MacCabe
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Til Wykes
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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Ignjatovic Ristic D, Cohen D, Ristic I. Prescription attitudes and practices regarding clozapine among Serbian psychiatrists: results of a nationwide survey. Ther Adv Psychopharmacol 2021; 11:20451253211020235. [PMID: 34104415 PMCID: PMC8165825 DOI: 10.1177/20451253211020235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/05/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Despite clozapine being the most effective treatment for treatment-resistant schizophrenia (TRS), a clear explanation as to why it is underutilized and why its initiation is delayed remains unclear. The first aim of the study was to conduct a nation-wide assessment of both the psychiatrists' attitudes of the obstacles for prescribing clozapine as well as their prescription practices. The second aim was to make recommendations, based on the results obtained, for improving the Serbian clozapine guidelines. METHODS A questionnaire was conducted consisting of two parts. One regarded the clinical characteristics of the psychiatrists, while the second contained questions about indications for clozapine initiation, clozapine prescribing tendencies, and barriers to clozapine use. The questionnaire was sent to 302 Serbian psychiatrists. RESULTS With 161 out of the 302 psychiatrists returning the questionnaires, the response rate was 53.3%. Nearly 60% of the psychiatrists treated 10 or more patients with clozapine, with TRS being the most common indication. Only four psychiatrists (2.5%) had no patients currently on clozapine. Psychiatrists indicated that their fear of agranulocytosis (68%) constituted the greatest obstacle for clozapine prescription, followed closely by weight gain (56%), and sedation (39%). Despite their fear of agranulocytosis, only 83.9% of the psychiatrists monitored leukocytes regularly. CONCLUSION In general, psychiatrists in Serbia seem to be confident in prescribing clozapine, even in the absence of clear monitoring guidelines and the possibility of therapeutic drug monitoring. In order to reduce obstacles for clozapine prescription, monitoring laxity, and an overreliance on personal experience, we recommend three modifications of the existing clozapine guideline.
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Affiliation(s)
- Dragana Ignjatovic Ristic
- Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovića 69, Kragujevac, 34000, Serbia
| | - Dan Cohen
- Mental Health Organization North-Holland North, Heerhugowaard, The Netherlands
| | - Ivan Ristic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Absolute and Dose-Adjusted Serum Concentrations of Clozapine in Patients Switching vs. Maintaining Treatment: An Observational Study of 1979 Patients. CNS Drugs 2021; 35:999-1008. [PMID: 34417726 PMCID: PMC8408068 DOI: 10.1007/s40263-021-00847-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Clozapine is an effective drug for the management of schizophrenia that has not responded to other agents, but some patients experience insufficient or adverse effects and discontinue treatment. OBJECTIVE We investigated a potential association between clozapine serum concentrations and switching to other antipsychotics in a large real-world patient population from a therapeutic drug monitoring service. METHODS Absolute and dose-adjusted serum concentrations (concentration-to-dose ratios [C/D ratios]) of clozapine during dosing between 100 and 1000 mg/day were measured in 1979 Norwegian patients during the period 2005-2019. These variables were compared in patients switching to other antipsychotic drugs versus maintaining clozapine treatment using linear mixed models. Smoking habits were known for 49% of the patients. To prevent potential nonadherence affecting clozapine switching, only patients with serum concentrations above 50% of the lower reference range were included. RESULTS In total, 190 patients (9.6%) switched from clozapine to another antipsychotic drug during the study period, whereas the remaining patients were not detected as switchers and were interpreted as maintaining treatment. Patients switching treatment had 23.5% lower absolute concentrations (954 vs. 1245 nmol/L; p < 0.001) and 15.7% lower daily doses (305 vs. 362 mg/day; p < 0.001) of clozapine than did nonswitchers, making the clozapine C/D ratio 9.7% lower in switchers than in nonswitchers after correcting for smoking habits (2.80 vs. 3.10 nmol/L/mg/day; p = 0.032). CONCLUSIONS The present study suggests that decreased absolute and dose-adjusted serum concentrations of clozapine were associated with clozapine discontinuation. The significantly reduced clozapine concentrations regardless of prescribed dose in switchers versus nonswitchers may indicate a pharmacokinetic mechanism underlying the risk of clozapine discontinuation.
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Blackman G, Oloyede E. Clozapine discontinuation withdrawal symptoms in schizophrenia. Ther Adv Psychopharmacol 2021; 11:20451253211032053. [PMID: 34552710 PMCID: PMC8450618 DOI: 10.1177/20451253211032053] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/23/2021] [Indexed: 12/14/2022] Open
Abstract
Clozapine is an atypical antipsychotic used in treatment-resistant schizophrenia. Whilst clozapine is highly effective, there are some clinical scenarios, such as the emergence of severe side effects, that necessitate its discontinuation. There is an emerging literature suggesting that discontinuing antipsychotics, in particular clozapine, can cause an array of withdrawal symptoms. We review the evidence for the existence of clozapine-induced withdrawal symptoms, and in particular focus on withdrawal-associated psychosis, cholinergic rebound, catatonia and serotonergic discontinuation symptoms. To date, there has been surprisingly little clinical guidance on how to minimise the likeliness of withdrawal symptoms in patients who are stopped on clozapine abruptly or gradually. We discuss the key outstanding questions in this area and why there is a need for guidance on the management of withdrawal symptoms associated with clozapine discontinuation.
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Affiliation(s)
- Graham Blackman
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, Camberwell, London, SE5 8AF, UK
| | - Ebenezer Oloyede
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Flanagan RJ, Lally J, Gee S, Lyon R, Every-Palmer S. Clozapine in the treatment of refractory schizophrenia: a practical guide for healthcare professionals. Br Med Bull 2020; 135:73-89. [PMID: 32885238 PMCID: PMC7585831 DOI: 10.1093/bmb/ldaa024] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/18/2020] [Accepted: 06/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clozapine remains the only medication licensed for treating refractory schizophrenia. However, it remains underutilized in part due to concerns regarding adverse events. SOURCES OF DATA Published literature. AREAS OF AGREEMENT Common adverse events during clozapine treatment include sedation, hypersalivation, postural hypotension, dysphagia, gastrointestinal hypomotility, weight gain, diabetes mellitus and dyslipidaemia. Rare but serious events include agranulocytosis, cardiomyopathy, myocarditis, pneumonia, paralytic ileus and seizure. AREAS OF CONTROVERSY It remains unclear how best to minimize clozapine-induced morbidity/mortality (i) during dose titration, (ii) from hypersalivation and (iii) from gastrointestinal hypomotility. It is also unclear how clozapine pharmacokinetics are affected by (i) gastrointestinal hypomotility, (ii) systemic infection and (iii) passive exposure to cigarette smoke. Whether monthly haematological monitoring needs to continue after 12 months of uninterrupted therapy is also a subject of debate. GROWING POINTS There is a need for better management of serious clozapine-related adverse events in addition to agranulocytosis. There is also a need for better education of patients and carers, general practitioners, A&E and ITU staff and others of the problems posed in using clozapine safely. AREAS TIMELY FOR DEVELOPING RESEARCH There is a need for more research on assessing clozapine dosage (i) as patients get older, (ii) with respect to exposure to cigarette smoke and (iii) optimizing response if adverse events or other factors limit dosage.
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Affiliation(s)
- R J Flanagan
- Precision Medicine, Networked Services, Bessemer Wing, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK.,Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK
| | - J Lally
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK.,Department of Psychiatry, Mater Misericordiae University Hospital, 63 Eccles Street, Dublin 7, Ireland.,Department of Psychiatry, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland
| | - S Gee
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, Denmark Hill, London SE5 8AZ, UK
| | - R Lyon
- Department of Pharmacy, Sussex Partnership NHS Foundation Trust, Chichester Centre, Graylingwell Drive, Chichester, West Sussex PO19 6GS UK
| | - S Every-Palmer
- Department of Psychological Medicine, University of Otago, Wellington, PO Box 7343, Newtown, Wellington 6242, NZ
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63
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Ponsford MJ, Steven R, Bramhall K, Burgess M, Wijetilleka S, Carne E, McGuire F, Price CR, Moody M, Zouwail S, Tahir T, Farewell D, El-Shanawany T, Jolles SRA. Clinical and laboratory characteristics of clozapine-treated patients with schizophrenia referred to a national immunodeficiency clinic reveals a B-cell signature resembling common variable immunodeficiency (CVID). J Clin Pathol 2020; 73:587-592. [PMID: 32094276 PMCID: PMC7476264 DOI: 10.1136/jclinpath-2019-206235] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 01/05/2023]
Abstract
AIMS An association between antibody deficiency and clozapine use in individuals with schizophrenia has recently been reported. We hypothesised that if clozapine-associated hypogammaglobulinaemia was clinically relevant this would manifest in referral patterns. METHODS Retrospective case note review of patients referred and assessed by Immunology Centre for Wales (ICW) between January 2005 and July 2018 with extraction of clinical and immunological features for individuals with diagnosis of schizophrenia-like illness. RESULTS 1791 adult patients were assessed at ICW during this period; 23 patients had a psychiatric diagnosis of schizophrenia or schizoaffective disorder. Principal indications for referral were findings of low calculated globulin and immunoglobulins. Clozapine was the single most commonly prescribed antipsychotic (17/23), disproportionately increased relative to reported use in the general schizophrenia population (OR 6.48, 95% CI: 1.79 to 23.5). Clozapine therapy was noted in 6/7 (86%) of patients subsequently requiring immunoglobulin replacement therapy (IgRT). Marked reduction of class-switched memory B cells (CSMB) and plasmablasts were observed in clozapine-treated individuals relative to healthy age-matched controls. Clozapine duration is associated with CSMB decline. One patient discontinued clozapine, with gradual recovery of IgG levels without use of IgRT. CONCLUSIONS Our findings are consistent with enrichment of clozapine-treatment within schizophrenic individuals referred for ICW assessment over the last 13 years. These individuals displayed clinical patterns closely resembling the primary immunodeficiency common variable immunodeficiency, however appears reversible on drug cessation. This has diagnostic, monitoring and treatment implications for psychiatry and immunology teams and directs prospective studies to address causality and the wider implications for this patient group.
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Affiliation(s)
- Mark James Ponsford
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
- Tenovus Institute, Division of Infection & Immunity, Cardiff University, Cardiff, UK
| | - Rachael Steven
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Kathyrn Bramhall
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Mathew Burgess
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Sonali Wijetilleka
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Emily Carne
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Frances McGuire
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Colin R Price
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Mo Moody
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Soha Zouwail
- Department of Medical Biochemistry, University Hospital of Wales, Cardiff, UK
- Department of Medical Biochemistry, Medical School, Alexandria University, Alexandria, Egypt
| | - Tayyeb Tahir
- Liaison Psychiatry, University Hospital of Wales, Cardiff, UK
| | - Daniel Farewell
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Tariq El-Shanawany
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Stephen R A Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
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64
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Casetta C, Oloyede E, Whiskey E, Taylor DM, Gaughran F, Shergill SS, Onwumere J, Segev A, Dzahini O, Legge SE, MacCabe JH. A retrospective study of intramuscular clozapine prescription for treatment initiation and maintenance in treatment-resistant psychosis. Br J Psychiatry 2020; 217:506-513. [PMID: 32605667 DOI: 10.1192/bjp.2020.115] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Clozapine is uniquely effective in treatment-resistant psychosis but remains underutilised, partly owing to psychotic symptoms leading to non-adherence to oral medication. An intramuscular formulation is available in the UK but outcomes remain unexplored. AIMS This was a retrospective clinical effectiveness study of intramuscular clozapine prescription for treatment initiation and maintenance in treatment-resistant psychosis over a 3-year period. METHOD Successful initiation of oral clozapine after intramuscular prescription was the primary outcome. Secondary outcomes included all-cause clozapine discontinuation 2 years following initiation, and 1 year after discharge. Discontinuation rates were compared with a cohort prescribed only oral clozapine. Propensity scores were used to address confounding by indication. RESULTS Among 39 patients prescribed intramuscular clozapine, 19 received at least one injection, whereas 20 accepted oral clozapine when given an enforced choice between the two. Thirty-six (92%) patients successfully initiated oral clozapine after intramuscular prescription; three never transitioned to oral. Eight discontinued oral clozapine during the 2-year follow-up, compared with 83 out of 162 in the comparator group (discontinuation rates of 24% and 50%, respectively). Discontinuation rates at 1-year post-discharge were 21%, compared with 44% in the comparison group. Intramuscular clozapine prescription was associated with a non-significantly lower hazard of discontinuation 2 years after initiation (hazard ratio 0.39, 95% CI 0.14-1.06) and 1 year after discharge (hazard ratio 0.37, 95% CI 0.11-1.24). The only reported adverse event specific to the intramuscular formulation was injection site pain and swelling. CONCLUSIONS Intramuscular clozapine prescription allowed transition to oral maintenance in an initially non-adherent cohort. Discontinuation rates were similar to patients only prescribed oral clozapine and comparable to existing literature.
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Affiliation(s)
- Cecilia Casetta
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London; and National Psychosis Service, South London and Maudsley NHS Foundation Trust, UK
| | - Ebenezer Oloyede
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London; and Pharmacy Dept, South London and Maudsley NHS Foundation Trust, UK
| | - Eromona Whiskey
- Pharmacy Dept, South London and Maudsley NHS Foundation Trust, UK
| | | | - Fiona Gaughran
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London; and National Psychosis Service, South London and Maudsley NHS Foundation Trust, UK
| | - Sukhi S Shergill
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London; and National Psychosis Service, South London and Maudsley NHS Foundation Trust, UK
| | - Juliana Onwumere
- National Psychosis Service, South London and Maudsley NHS Foundation Trust; and Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Aviv Segev
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK; and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Olubanke Dzahini
- Pharmacy Dept, South London and Maudsley NHS Foundation Trust, UK
| | - Sophie E Legge
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, UK
| | - James Hunter MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London; and National Psychosis Service, South London and Maudsley NHS Foundation Trust, UK
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65
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Abstract
Wider use of clozapine, one of the most effective antipshychotic drugs, is precluded by its propensity to cause agranulocytosis. Currently, clozapine is used for treatment-resistant schizophrenia, with mandatory blood count monitoring for the duration of treatment. Agranulocytosis occurs in up to 0.8% of patients and presents a significant medical challenge, despite decreasing mortality rates. In this paper, we review the epidemiology of clozapine-induced agranulocytosis (CLIA), advances in identifying genetic risk factors, and the preventive measures to reduce the risk of CLIA. We discuss the pathogenesis of CLIA, which, despite receiving considerable scientific attention, has not been fully elucidated. Finally, we address the clinical management and suggest the approach to clozapine re-challenge in patients with a previous episode of neutropenia. With a significant proportion of clozapine recipients in Western hemisphere being Black, we comment on the importance of recognizing benign ethnic neutropenia as a potential impediment to clozapine administration. This review aims to aid haematologists and psychiatrists to jointly manage neutropenia and agranulocytosis caused by clozapine.
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Affiliation(s)
- Aleksandar Mijovic
- Department of Haematological Medicine, King's College Hospital, London, SE5 9RS, UK.
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66
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Kitagawa K, So R, Nomura N, Mizuno Y, Misawa F, Kodama M, Uchida H, Mimura M, Takeuchi H. Reliability of the Glasgow Antipsychotic Side-effects Scale for Clozapine Japanese version (GASS-C-J). PLoS One 2020; 15:e0234864. [PMID: 32555706 PMCID: PMC7302491 DOI: 10.1371/journal.pone.0234864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 06/03/2020] [Indexed: 11/18/2022] Open
Abstract
The purpose of this study was to develop the Glasgow Antipsychotic Side effects Scale for Clozapine Japanese version (GASS-C-J) and examine its reliability to assess clozapine-related side effects. We developed the GASS-C-J using forward and backward translation. Semantic equivalence of the GASS-C-J to the GASS-C was confirmed by the original author. We then administered the GASS-C-J twice to 109 patients on clozapine treatment at two psychiatric hospitals in Japan. We assessed the internal consistency and test-retest reliability of the GASS-C-J using Cronbach's alpha and weighted kappa coefficient, respectively. We also examined if discrepancies in each GASS-C-J item score between the first and second rating were correlated with items of the Brief Evaluation of Psychosis Symptom Domains (BE-PSD). The Cronbach's alpha coefficient of the GASS-C-J at the first and second rating was 0.78 (95% CI: 0.72 to 0.84) and 0.82 (95% CI: 0.76 to 0.88), respectively. The weighted kappa coefficient of individual and total GASS-C-J item scores ranged from 0.45 to 0.88. Some symptom domains were correlated with discrepancies in specific items of the GASS-C-J: psychotic symptoms and nausea/vomiting (rs = 0.27), thirst (rs = 0.31), and appetite/weight gain (rs = 0.27); disorganized thinking and urinary incontinence (rs = 0.26); depression/anxiety and myoclonus (rs = 0.25), hypersalivation (rs = -0.27), and blurred vision (rs = -0.22). These findings demonstrate that the GASS-C-J can be used in clinical and research settings as a reliable scale to assess clozapine-related side effects.
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Affiliation(s)
- Kohei Kitagawa
- Department of Neuropsychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Ryuhei So
- Department of Neuropsychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Nobuyuki Nomura
- Department of Neuropsychiatry, Yamanashi Prefectural Kita Hospital, Yamanashi, Japan
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Yuya Mizuno
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, United Kingdom
| | - Fuminari Misawa
- Department of Neuropsychiatry, Yamanashi Prefectural Kita Hospital, Yamanashi, Japan
| | - Masafumi Kodama
- Department of Neuropsychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Yamanashi Prefectural Kita Hospital, Yamanashi, Japan
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
- * E-mail:
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67
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Morrison AP, Pyle M, Gumley A, Schwannauer M, Turkington D, MacLennan G, Norrie J, Hudson J, Bowe S, French P, Hutton P, Byrne R, Syrett S, Dudley R, McLeod HJ, Griffiths H, Barnes TR, Davies L, Shields G, Buck D, Tully S, Kingdon D. Cognitive-behavioural therapy for clozapine-resistant schizophrenia: the FOCUS RCT. Health Technol Assess 2020; 23:1-144. [PMID: 30806619 DOI: 10.3310/hta23070] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clozapine (clozaril, Mylan Products Ltd) is a first-choice treatment for people with schizophrenia who have a poor response to standard antipsychotic medication. However, a significant number of patients who trial clozapine have an inadequate response and experience persistent symptoms, called clozapine-resistant schizophrenia (CRS). There is little evidence regarding the clinical effectiveness of pharmacological or psychological interventions for this population. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of cognitive-behavioural therapy (CBT) for people with CRS and to identify factors predicting outcome. DESIGN The Focusing on Clozapine Unresponsive Symptoms (FOCUS) trial was a parallel-group, randomised, outcome-blinded evaluation trial. Randomisation was undertaken using permuted blocks of random size via a web-based platform. Data were analysed on an intention-to-treat (ITT) basis, using random-effects regression adjusted for site, age, sex and baseline symptoms. Cost-effectiveness analyses were carried out to determine whether or not CBT was associated with a greater number of quality-adjusted life-years (QALYs) and higher costs than treatment as usual (TAU). SETTING Secondary care mental health services in five cities in the UK. PARTICIPANTS People with CRS aged ≥ 16 years, with an International Classification of Diseases, Tenth Revision (ICD-10) schizophrenia spectrum diagnoses and who are experiencing psychotic symptoms. INTERVENTIONS Individual CBT included up to 30 hours of therapy delivered over 9 months. The comparator was TAU, which included care co-ordination from secondary care mental health services. MAIN OUTCOME MEASURES The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months and the primary secondary outcome was PANSS total score at the end of treatment (9 months post randomisation). The health benefit measure for the economic evaluation was the QALY, estimated from the EuroQol-5 Dimensions, five-level version (EQ-5D-5L), health status measure. Service use was measured to estimate costs. RESULTS Participants were allocated to CBT (n = 242) or TAU (n = 245). There was no significant difference between groups on the prespecified primary outcome [PANSS total score at 21 months was 0.89 points lower in the CBT arm than in the TAU arm, 95% confidence interval (CI) -3.32 to 1.55 points; p = 0.475], although PANSS total score at the end of treatment (9 months) was significantly lower in the CBT arm (-2.40 points, 95% CI -4.79 to -0.02 points; p = 0.049). CBT was associated with a net cost of £5378 (95% CI -£13,010 to £23,766) and a net QALY gain of 0.052 (95% CI 0.003 to 0.103 QALYs) compared with TAU. The cost-effectiveness acceptability analysis indicated a low likelihood that CBT was cost-effective, in the primary and sensitivity analyses (probability < 50%). In the CBT arm, 107 participants reported at least one adverse event (AE), whereas 104 participants in the TAU arm reported at least one AE (odds ratio 1.09, 95% CI 0.81 to 1.46; p = 0.58). CONCLUSIONS Cognitive-behavioural therapy for CRS was not superior to TAU on the primary outcome of total PANSS symptoms at 21 months, but was superior on total PANSS symptoms at 9 months (end of treatment). CBT was not found to be cost-effective in comparison with TAU. There was no suggestion that the addition of CBT to TAU caused adverse effects. Future work could investigate whether or not specific therapeutic techniques of CBT have value for some CRS individuals, how to identify those who may benefit and how to ensure that effects on symptoms can be sustained. TRIAL REGISTRATION Current Controlled Trials ISRCTN99672552. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 7. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Anthony P Morrison
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Melissa Pyle
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Andrew Gumley
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Matthias Schwannauer
- Department of Clinical Psychology, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Douglas Turkington
- Academic Psychiatry, Northumberland, Tyne and Wear NHS Foundation Trust, Centre for Ageing and Vitality, Newcastle General Hospital, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Clinical Trials Unit, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Jemma Hudson
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Samantha Bowe
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK
| | - Paul French
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Paul Hutton
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Rory Byrne
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Suzy Syrett
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Robert Dudley
- School of Psychology, Newcastle University, Newcastle upon Tyne, UK
| | - Hamish J McLeod
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Helen Griffiths
- Department of Clinical Psychology, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | | | - Linda Davies
- Division of Population Health, University of Manchester, Manchester, UK
| | - Gemma Shields
- Division of Population Health, University of Manchester, Manchester, UK
| | - Deborah Buck
- Division of Population Health, University of Manchester, Manchester, UK
| | - Sarah Tully
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - David Kingdon
- Department of Psychiatry, University of Southampton, Academic Centre, Southampton, UK
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68
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Tareen FK, Shah KU, Ahmad N, Ur Rehman A, Shah SU, Ullah N. Proniosomes as a Carrier System for Transdermal Delivery of Clozapine. Drug Dev Ind Pharm 2020; 46:1-24. [PMID: 32362194 DOI: 10.1080/03639045.2020.1764020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 03/16/2020] [Accepted: 04/26/2020] [Indexed: 12/19/2022]
Abstract
The current study aimed to formulate the clozapine (CLZ) loaded proniosomal gel (PN) and evaluate it's in vitro release, ex vivo permeation and gel properties. CLZ is a BCS class II drug with low bioavailability of 27% and severe adverse drug reactions (ADRs) due to frequent dosing. Proniosomes offer a versatile pro-vesicular approach with potential in transdermal drug delivery. PN-CLZ gel was prepared by the coacervation phase separation method utilizing span-60, cholesterol and lecithin. Optimization of PN gel was done by hit & trial method and the formulations were characterized for particle size, entrapment efficiency (EE), polydispersity index (PDI) and zeta potential (ZP). The optimized formulation had the highest entrapment efficiency of 90% and the average particle size of approx. 325 nm. PDI reflected homogeneity in the formulation. ZP was -59.76 mV, high enough to indicate a stable formulation. The in vitro release studies manifested a sustained release behavior of clozapine from the proniosomal gel. The ex vivo permeation showed noteworthy permeation of the drug through stratum corneum with a steady state flux of 18.26 ug/cm2/hr. The optimized gel was analyzed for pH, spreadability, bioadhesion and rheology. The results suggested that clozapine could be effectively loaded into proniosomal gel for administration through skin.
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Affiliation(s)
- Fahad Khan Tareen
- Department of Pharmacy, Quaid-i-Azam University Islamabad, 45320, Pakistan
| | - Kifayat Ullah Shah
- Department of Pharmacy, Quaid-i-Azam University Islamabad, 45320, Pakistan
| | - Naveed Ahmad
- Department of Pharmacy, Quaid-i-Azam University Islamabad, 45320, Pakistan
| | - Asim Ur Rehman
- Department of Pharmacy, Quaid-i-Azam University Islamabad, 45320, Pakistan
| | - Shefaat Ullah Shah
- Deaprtment of Pharmaceutics, Faculty of Pharmacy, Gomal University, D.I.Khan, Pakistan
| | - Naseem Ullah
- Department of Pharmacy, Quaid-i-Azam University Islamabad, 45320, Pakistan
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69
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Ponsford MJ, Steven R, Bramhall K, Burgess M, Wijetilleka S, Carne E, McGuire F, Price CR, Moody M, Zouwail S, Tahir T, Farewell D, El-Shanawany T, Jolles SRA. Clinical and laboratory characteristics of clozapine-treated patients with schizophrenia referred to a national immunodeficiency clinic reveals a B-cell signature resembling common variable immunodeficiency (CVID). J Clin Pathol 2020. [PMID: 32094276 DOI: 10.1136/jclinpath‐2019‐206235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS An association between antibody deficiency and clozapine use in individuals with schizophrenia has recently been reported. We hypothesised that if clozapine-associated hypogammaglobulinaemia was clinically relevant this would manifest in referral patterns. METHODS Retrospective case note review of patients referred and assessed by Immunology Centre for Wales (ICW) between January 2005 and July 2018 with extraction of clinical and immunological features for individuals with diagnosis of schizophrenia-like illness. RESULTS 1791 adult patients were assessed at ICW during this period; 23 patients had a psychiatric diagnosis of schizophrenia or schizoaffective disorder. Principal indications for referral were findings of low calculated globulin and immunoglobulins. Clozapine was the single most commonly prescribed antipsychotic (17/23), disproportionately increased relative to reported use in the general schizophrenia population (OR 6.48, 95% CI: 1.79 to 23.5). Clozapine therapy was noted in 6/7 (86%) of patients subsequently requiring immunoglobulin replacement therapy (IgRT). Marked reduction of class-switched memory B cells (CSMB) and plasmablasts were observed in clozapine-treated individuals relative to healthy age-matched controls. Clozapine duration is associated with CSMB decline. One patient discontinued clozapine, with gradual recovery of IgG levels without use of IgRT. CONCLUSIONS Our findings are consistent with enrichment of clozapine-treatment within schizophrenic individuals referred for ICW assessment over the last 13 years. These individuals displayed clinical patterns closely resembling the primary immunodeficiency common variable immunodeficiency, however appears reversible on drug cessation. This has diagnostic, monitoring and treatment implications for psychiatry and immunology teams and directs prospective studies to address causality and the wider implications for this patient group.
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Affiliation(s)
- Mark James Ponsford
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK .,Tenovus Institute, Division of Infection & Immunity, Cardiff University, Cardiff, UK
| | - Rachael Steven
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Kathyrn Bramhall
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Mathew Burgess
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Sonali Wijetilleka
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Emily Carne
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Frances McGuire
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Colin R Price
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Mo Moody
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Soha Zouwail
- Department of Medical Biochemistry, University Hospital of Wales, Cardiff, UK.,Department of Medical Biochemistry, Medical School, Alexandria University, Alexandria, Egypt
| | - Tayyeb Tahir
- Liaison Psychiatry, University Hospital of Wales, Cardiff, UK
| | - Daniel Farewell
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Tariq El-Shanawany
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Stephen R A Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
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70
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Barnes TR, Drake R, Paton C, Cooper SJ, Deakin B, Ferrier IN, Gregory CJ, Haddad PM, Howes OD, Jones I, Joyce EM, Lewis S, Lingford-Hughes A, MacCabe JH, Owens DC, Patel MX, Sinclair JM, Stone JM, Talbot PS, Upthegrove R, Wieck A, Yung AR. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2020; 34:3-78. [PMID: 31829775 DOI: 10.1177/0269881119889296] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.
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Affiliation(s)
- Thomas Re Barnes
- Emeritus Professor of Clinical Psychiatry, Division of Psychiatry, Imperial College London, and Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Richard Drake
- Clinical Lead for Mental Health in Working Age Adults, Health Innovation Manchester, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Carol Paton
- Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Stephen J Cooper
- Emeritus Professor of Psychiatry, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Bill Deakin
- Professor of Psychiatry, Neuroscience & Psychiatry Unit, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - I Nicol Ferrier
- Emeritus Professor of Psychiatry, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine J Gregory
- Honorary Clinical Research Fellow, University of Manchester and Higher Trainee in Child and Adolescent Psychiatry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Peter M Haddad
- Honorary Professor of Psychiatry, Division of Psychology and Mental Health, University of Manchester, UK and Senior Consultant Psychiatrist, Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Oliver D Howes
- Professor of Molecular Psychiatry, Imperial College London and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ian Jones
- Professor of Psychiatry and Director, National Centre of Mental Health, Cardiff University, Cardiff, UK
| | - Eileen M Joyce
- Professor of Neuropsychiatry, UCL Queen Square Institute of Neurology, London, UK
| | - Shôn Lewis
- Professor of Adult Psychiatry, Faculty of Biology, Medicine and Health, The University of Manchester, UK, and Mental Health Academic Lead, Health Innovation Manchester, Manchester, UK
| | - Anne Lingford-Hughes
- Professor of Addiction Biology and Honorary Consultant Psychiatrist, Imperial College London and Central North West London NHS Foundation Trust, London, UK
| | - James H MacCabe
- Professor of Epidemiology and Therapeutics, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and Honorary Consultant Psychiatrist, National Psychosis Service, South London and Maudsley NHS Foundation Trust, Beckenham, UK
| | - David Cunningham Owens
- Professor of Clinical Psychiatry, University of Edinburgh. Honorary Consultant Psychiatrist, Royal Edinburgh Hospital, Edinburgh, UK
| | - Maxine X Patel
- Honorary Clinical Senior Lecturer, King's College London, Institute of Psychiatry, Psychology and Neuroscience and Consultant Psychiatrist, Oxleas NHS Foundation Trust, London, UK
| | - Julia Ma Sinclair
- Professor of Addiction Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James M Stone
- Clinical Senior Lecturer and Honorary Consultant Psychiatrist, King's College London, Institute of Psychiatry, Psychology and Neuroscience and South London and Maudsley NHS Trust, London, UK
| | - Peter S Talbot
- Senior Lecturer and Honorary Consultant Psychiatrist, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Rachel Upthegrove
- Professor of Psychiatry and Youth Mental Health, University of Birmingham and Consultant Psychiatrist, Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Angelika Wieck
- Honorary Consultant in Perinatal Psychiatry, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Alison R Yung
- Professor of Psychiatry, University of Manchester, School of Health Sciences, Manchester, UK and Centre for Youth Mental Health, University of Melbourne, Australia, and Honorary Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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Verdoux H, Quiles C, de Leon J. Clinical determinants of fever in clozapine users and implications for treatment management: A narrative review. Schizophr Res 2019; 211:1-9. [PMID: 31378552 DOI: 10.1016/j.schres.2019.07.040] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/25/2019] [Accepted: 07/25/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To identify the clinical determinants of fever in clozapine users and their impact on management of clozapine treatment. METHODS Articles published in English or French identified with a MEDLINE, Web of Sciences, Cochrane Library and PsycINFO search, from inception through February 2019, using the term "clozapine" in combination with "fever" OR "hyperthermia" OR "body temperature" OR "pyrexia" OR "febrile" OR "heat" OR "thermoregulation". Information extracted for each medical condition were frequency, time to onset after initiation of clozapine treatment, characteristics of fever, associated symptoms, laboratory tests used for diagnosis, course, lethality, discontinuation of clozapine. Data were synthesized narratively. RESULTS Our search yielded 394 unique hits published from 1993 to 2018. We included 73 articles in the review: two meta-analyses, 14 reviews, six epidemiological studies, 11 clinical studies and 40 case reports. During clozapine initiation, fever is most frequently benign and transient but should be closely monitored as it may be the first stage of potentially life-threatening adverse drug reactions (ADR) (agranulocytosis, neuroleptic malignant syndrome myocarditis, hepatitis, pancreatitis, nephritis, colitis, etc.). Other ADR associated with fever are independent of duration of exposure to clozapine (heat stroke, pneumonia, pulmonary embolism, necrotizing colitis). If fever is due to intercurrent infection, therapeutic drug monitoring is recommended to adjust clozapine daily dosage. CONCLUSION Benign causes of fever are much more frequent than life-threatening ADR during clozapine treatment. Discontinuation should not be considered as automatic in the event of fever, especially during the early phase of clozapine initiation.
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Affiliation(s)
- Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France; Centre Hospitalier Charles Perrens, F-33000 Bordeaux, France.
| | - Clélia Quiles
- Centre Hospitalier Charles Perrens, F-33000 Bordeaux, France
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY and Psychiatry and Neurosciences Research Group (CTS-549), USA; Institute of Neurosciences, University of Granada, Granada, Spain; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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72
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Chan CYW, Abdin E, Seow E, Subramaniam M, Liu J, Peh CX, Tor PC. Clinical effectiveness and speed of response of electroconvulsive therapy in treatment-resistant schizophrenia. Psychiatry Clin Neurosci 2019; 73:416-422. [PMID: 31026106 DOI: 10.1111/pcn.12855] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 04/12/2019] [Accepted: 04/25/2019] [Indexed: 11/29/2022]
Abstract
AIM Although electroconvulsive therapy (ECT) has been shown to be efficacious for patients with treatment-resistant schizophrenia, there has been limited evidence on the rate of response, cognition, and quality-of-life outcomes. The primary aims of the present study were thus to examine the effectiveness and speed of response to ECT in a naturalistic retrospective cohort in patients with treatment-resistant schizophrenia. METHODS We performed a retrospective database analysis. The primary effectiveness outcome was defined as an improvement of ≥40% from pretreatment scores based on the Brief Psychiatric Rating Scale (BPRS) Psychotic Symptom subscale. Data were included for analysis for all patients with a primary DSM-5 diagnosis of schizophrenia that was treatment-resistant and who had had an acute course of ECT initiated for the treatment of schizophrenia between 1 July 2016 and 1 December 2016. RESULTS A total of 50 inpatients were included for analysis. The present study revealed that 50% of patients showed at least a 40% reduction in BPRS Psychotic Symptom subscale scores after completion of ECT and that 16.7% of patients responded after the first three sessions, 39.3% after six sessions, 46.4% after nine sessions, and 50% after 12 sessions. The greatest improvement in BPRS scores was between the third and sixth ECT sessions. BPRS scores, Clinical Global Impression, Montreal Cognitive Assessment, and Global Assessment of Functioning showed significant improvement. There was no significant difference in quality-of-life outcomes. CONCLUSION Utilizing modern techniques in treatment-resistant schizophrenia, this study demonstrates the real-world effectiveness and rate of response of patients receiving ECT.
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Affiliation(s)
| | | | - Esmond Seow
- Research Division, Institute of Mental Health, Singapore
| | | | - Jianlin Liu
- Research Division, Institute of Mental Health, Singapore
| | - Chao Xu Peh
- Research Division, Institute of Mental Health, Singapore
| | - Phern Chern Tor
- Department of General Psychiatry, Institute of Mental Health, Singapore
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73
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Pardiñas AF, Nalmpanti M, Pocklington AJ, Legge SE, Medway C, King A, Jansen J, Helthuis M, Zammit S, MacCabe J, Owen MJ, O'Donovan MC, Walters JTR. Pharmacogenomic Variants and Drug Interactions Identified Through the Genetic Analysis of Clozapine Metabolism. Am J Psychiatry 2019; 176:477-486. [PMID: 30922102 DOI: 10.1176/appi.ajp.2019.18050589] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Clozapine is the only effective medication for treatment-resistant schizophrenia, but its worldwide use is still limited because of its complex titration protocols. While the discovery of pharmacogenomic variants of clozapine metabolism may improve clinical management, no robust findings have yet been reported. This study is the first to adopt the framework of genome-wide association studies (GWASs) to discover genetic markers of clozapine plasma concentrations in a large sample of patients with treatment-resistant schizophrenia. METHODS The authors used mixed-model regression to combine data from multiple assays of clozapine metabolite plasma concentrations from a clozapine monitoring service and carried out a genome-wide analysis of clozapine, norclozapine, and their ratio on 10,353 assays from 2,989 individuals. These analyses were adjusted for demographic factors known to influence clozapine metabolism, although it was not possible to adjust for all potential mediators given the available data. GWAS results were used to pinpoint specific enzymes and metabolic pathways and compounds that might interact with clozapine pharmacokinetics. RESULTS The authors identified four distinct genome-wide significant loci that harbor common variants affecting the metabolism of clozapine or its metabolites. Detailed examination pointed to coding and regulatory variants at several CYP* and UGT* genes as well as corroborative evidence for interactions between the metabolism of clozapine, coffee, and tobacco. Individual effects of single single-nucleotide polymorphisms (SNPs) fine-mapped from these loci were large, such as the minor allele of rs2472297, which was associated with a reduction in clozapine concentrations roughly equivalent to a decrease of 50 mg/day in clozapine dosage. On their own, these single SNPs explained from 1.15% to 9.48% of the variance in the plasma concentration data. CONCLUSIONS Common genetic variants with large effects on clozapine metabolism exist and can be found via genome-wide approaches. Their identification opens the way for clinical studies assessing the use of pharmacogenomics in the clinical management of patients with treatment-resistant schizophrenia.
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Affiliation(s)
- Antonio F Pardiñas
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Mariana Nalmpanti
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Andrew J Pocklington
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Sophie E Legge
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Christopher Medway
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Adrian King
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - John Jansen
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Marinka Helthuis
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Stanley Zammit
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - James MacCabe
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Michael J Owen
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Michael C O'Donovan
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - James T R Walters
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
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The impact of clozapine initiation and cessation on psychiatric hospital admissions and bed days: a mirror image cohort study. Psychopharmacology (Berl) 2019; 236:1931-1935. [PMID: 30715572 DOI: 10.1007/s00213-019-5179-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/23/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Clozapine is the most effective medication for the positive symptoms of treatment-refractory schizophrenia. Although clozapine use is associated with fewer admissions, less is known about the impact of clozapine cessation on hospitalisation. AIMS The aims of this study were to investigate whether clozapine-reduced psychiatric inpatient admissions and bed days, and investigate patient factors associated with these changes from a sample of 1906 people commenced on clozapine. METHODS All people commencing clozapine during an acute hospitalisation over a 10-year period in Queensland, Australia, were included in this retrospective cohort study. A mirror image design was used to compare psychiatric bed days and hospitalisations 2 years before and after clozapine treatment, and the impact of clozapine continuation or early cessation. Changes in psychiatric bed days and hospitalisations were analysed using linear regression, adjusting for the duration on clozapine, sex, age, indigenous status, country of origin and time to clozapine commencement. RESULTS/OUTCOMES There was a significant reduction in bed days (29.55 days vs 24.46 days, p < 0.001) and admissions (2.27 vs 1.87 < 0.001) associated with clozapine commencement. This remained significant among clozapine continuers, but not among those with early cessation. Longer duration on clozapine was associated with greater reductions in psychiatric bed days and admissions. Age, sex and time to clozapine commencement, indigeneity and country of origin did not impact outcomes. CONCLUSION/INTERPRETATION Longer clozapine therapy led to a greater reduction in psychiatric bed days and hospitalisations. Early cessation was associated with a return to pre-clozapine levels of bed days and admissions.
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75
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Ucok A, Yağcıoğlu EA, Yıldız M, Kaymak SU, Saka MC, Taşdelen R, Danacı AE, Şenol ŞH. Reasons for clozapine discontinuation in patients with treatment-resistant schizophrenia. Psychiatry Res 2019; 275:149-154. [PMID: 30908979 DOI: 10.1016/j.psychres.2019.01.110] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/16/2019] [Accepted: 01/17/2019] [Indexed: 01/10/2023]
Abstract
Although clozapine is more effective than other antipsychotics in the treatment of schizophrenia, the rate of its discontinuation is also high. The aim of this retrospective chart-review study was to investigate the causes of clozapine discontinuation in patients with treatment-resistant schizophrenia. This study included a total of 396 patients with schizophrenia, 240 still on clozapine therapy and 156 who discontinued clozapine, and compared their clinical characteristics. Those who discontinued clozapine had a longer history of illness and more hospitalizations before clozapine and tended to be older. Inadequate response was more common among clozapine discontinuers compared to continuers. The most common reason for discontinuation was the side-effects associated with clozapine (49%). Discontinuation from patient decision or by the psychiatrist due to noncompliance was the second (29.7%) and discontinuation due to lack of efficacy was the third most frequent reason (21.3%). The patients who discontinued clozapine because of cardiac side effects were younger, had shorter duration of clozapine use, and had lower maximum clozapine dose compared to the other discontinuers. Our findings point out the importance of enhancing psychiatrists' ability to handle manageable side effects to minimize discontinuations and maximize the benefits of clozapine in patients with treatment-resistant schizophrenia.
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Affiliation(s)
- Alp Ucok
- Istanbul University, Istanbul Faculty of Medicine, Department of Psychiatry, Istanbul, Turkey.
| | - Elif Anıl Yağcıoğlu
- Hacettepe University, Hacettepe Faculty of Medicine, Department of Psychiatry, Ankara, Turkey
| | - Mustafa Yıldız
- Kocaeli University, Faculty of Medicine, Department of Psychiatry, Kocaeli, Turkey
| | - Semra Ulusoy Kaymak
- Ataturk Research and Training Hospital, Department of Psychiatry, Ankara, Turkey
| | - Meram Can Saka
- Ankara University, Ankara Faculty of Medicine, Department of Psychiatry, Ankara, Turkey
| | - Rümeysa Taşdelen
- Marmara University, Faculty of Medicine, Department of Psychiatry, Istanbul, Turkey
| | - Ayşen Esen Danacı
- Celal Bayar University, Faculty of Medicine, Department of Psychiatry, Manisa, Turkey
| | - Şevin Hun Şenol
- Sanliurfa Research and Training Hospital, Psychiatry Clinic, Urfa, Turkey
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76
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Roméo B, Petillion A, Martelli C, Benyamina A. Failure of rechallenge clozapine after agranulocytosis: A case report. Encephale 2019; 45:449-450. [PMID: 30878138 DOI: 10.1016/j.encep.2019.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 01/19/2019] [Accepted: 02/11/2019] [Indexed: 10/27/2022]
Affiliation(s)
- B Roméo
- Department of psychiatry and addictology, Paul Brousse hospital, AP-HP, 12, avenue Paul Vaillant Couturier, 94800 Villejuif, France; Faculté de médecine, Paris Sud university, Le Kremlin-Bicetre, 94270 Île-de-France, France; Institut national de la santé et de la recherche médicale U 1178, 91190 Paris, France.
| | - A Petillion
- Department of psychiatry and addictology, Paul Brousse hospital, AP-HP, 12, avenue Paul Vaillant Couturier, 94800 Villejuif, France
| | - C Martelli
- Department of psychiatry and addictology, Paul Brousse hospital, AP-HP, 12, avenue Paul Vaillant Couturier, 94800 Villejuif, France; Institut national de la santé et de la recherche médicale U1000, Research unit, NeuroImaging and Psychiatry, Paris Sud university-Paris Saclay University, Paris Descartes University, Digiteo Labs, Bâtiment 660, Gif-sur-Yvette, France
| | - A Benyamina
- Department of psychiatry and addictology, Paul Brousse hospital, AP-HP, 12, avenue Paul Vaillant Couturier, 94800 Villejuif, France; Faculté de médecine, Paris Sud university, Le Kremlin-Bicetre, 94270 Île-de-France, France; Institut national de la santé et de la recherche médicale U 1178, 91190 Paris, France
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77
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Predicting Unsuccessful Clozapine Treatment After First Use in Adult Patients With Psychotic Disorders. J Clin Psychopharmacol 2018; 38:604-608. [PMID: 30371636 DOI: 10.1097/jcp.0000000000000977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE/BACKGROUND Cessation of clozapine therapy and insufficient response may result in relapse of psychotic symptoms and in clinical admissions. However, discontinuation rates are high. Identifying patients at risk for unsuccessful clozapine use might enable clinicians to direct specific attention to them. METHODS/PROCEDURES Routinely collected data from a large insurance company were used to develop a simple prediction model for unsuccessful clozapine treatment in psychiatric patients 1 year after clozapine was first dispensed by a community pharmacy in the Netherlands. Multivariate logistic regression analyses were performed with the Nagelkerke R statistic as a measure of the predictive value of the model. FINDINGS/RESULTS A total of 937 patients were dispensed clozapine for the first time by their community pharmacy between January 1, 2011, and December 31, 2015 (index date). Of these, 741 patients had started their clozapine treatment in hospital before the index date (inpatient starters); the remaining 196 patients started clozapine as outpatients on the index date (outpatient starters). In 191 patients (20.4%), clozapine treatment was unsuccessful 1 year after the index date. Unsuccessful treatment was more common among outpatient starters than among inpatient starters (32.1% vs 17.3%). Using backward selection of the variables, a model consisting of 61 variables had the best predictive value overall (Nagelkerke R = 0.301), whereas a model consisting of 52 variables had the best predictive value in outpatient starters (Nagelkerke R = 0.676). IMPLICATIONS/CONCLUSIONS The likelihood of unsuccessful clozapine treatment after 1 year was higher among patients who started clozapine as outpatients. Despite the use of a diversity of variables and different statistical approaches, it was not possible to make a simple prediction model for unsuccessful clozapine treatment using relatively easily accessible data.
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Tirupati S. An attempt to discontinue clozapine - Worth a try? Aust N Z J Psychiatry 2018; 52:1003. [PMID: 30191725 DOI: 10.1177/0004867418797433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Srinivasan Tirupati
- Psychiatric Rehabilitation Services, Hunter New England Mental Health Service, Hamilton, NSW, Australia
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Nilsson BM, Lindström L, Mohsen I, Holmlöv K, Bodén R. Persistent tachycardia in clozapine treated patients: A 24-hour ambulatory electrocardiogram study. Schizophr Res 2018; 199:403-406. [PMID: 29602642 DOI: 10.1016/j.schres.2018.03.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 03/09/2018] [Accepted: 03/11/2018] [Indexed: 01/11/2023]
Abstract
Tachycardia is associated with cardiovascular mortality. Tachycardia is also a known clozapine adverse effect. However, whether clozapine-associated tachycardia is persistent is not known. Thirty clozapine-treated patients with clinical tachycardia were investigated with 24-hour ambulatory electrocardiography (ECG). Baseline peripheral heart rate (HR) was 106.7±7.8. The ambulatory ECG 24-hour-HR was 98.7±9.7. Baseline HR and 24-hour-HR correlated strongly (r=0.74, p=0.000003). Daytime HR was 106.4±9.9 and nighttime HR 89.2±12.0. Low dose bisoprolol reduced HR significantly. The high 24-hour-HR indicates a persistent tachycardia. Tachycardia should not discourage from clozapine use but the findings indicate a need of guidelines for detection and treatment of clozapine-associated tachycardia.
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Affiliation(s)
- Björn M Nilsson
- Department of Neuroscience, Psychiatry, Uppsala University, SE-75185 Uppsala, Sweden.
| | - Leif Lindström
- Department of Neuroscience, Psychiatry, Uppsala University, SE-75185 Uppsala, Sweden
| | - Issam Mohsen
- Department of Medical Sciences, Clinical Physiology, Uppsala University, SE-75185 Uppsala, Sweden
| | - Karolina Holmlöv
- Department of Neuroscience, Psychiatry, Uppsala University, SE-75185 Uppsala, Sweden
| | - Robert Bodén
- Department of Neuroscience, Psychiatry, Uppsala University, SE-75185 Uppsala, Sweden
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80
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Shafique MN, Hussain M. Efficacy of Tamsulosin alone versus Tamsulosin Phloroglucinol combination therapy for medical expulsion of lower Ureteral calculi. Pak J Med Sci 2018; 34:393-398. [PMID: 29805415 PMCID: PMC5954386 DOI: 10.12669/pjms.342.14134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To see whether phloroglucinol-added tamsulosin therapy exhibits better efficacy than tamsulosin alone in medical expulsion of lower ureteral stone (LUS). Methods Sixty four consecutive adult patients presented in a urological setting at Sialkot, Pakistan between January 2015 and December 2016 with solitary, unilateral 3-8mm sized lower ureteral stone (reported by noncontrast computed tomography of the kidney-ureter-bladder) were documented. Group either study or control was allotted, randomly. Same 0.4 mg tamsulosin, once daily was given to all the participants. However, additional 40 mg phloroglucinol, thrice daily was advised for study group (n = 32). The therapy terminated on confirmation of stone expulsion otherwise continued for 6 weeks. Patients were asked to use 50 mg diclophenac Na on colic episode. Results Demographic characteristics revealed 81.2% (n = 52) male patients while age statistics as M = 42.3, SD = 5.93 (range 32-60) years. The study group showed higher stone expulsion rate (100%) and time to expulsion (M = 10.34 days) than control. The values were statistically significant (p = .02 and p = .0001; χ2 test in SPSS). Similarly, combination therapy had advantage on mono therapy for reporting statistically lesser numbers of colic episode (p = .03) and consumption of analgesic (p = .02). A marked difference in rate of adverse effects i.e. 68.8 vs. 90.6% was observed in study and control groups. Conclusion Phloroglucinol-added therapy is a better choice for expulsion of LUS than tamsulosin alone with reference to stone expulsion rate and medication time.
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Affiliation(s)
- Muhammad Nadeem Shafique
- Dr. Muhammad Nadeem Shafique, Masters in Surgery (MS) Urology, Department of rology, Sialkot Medical College, Sialkot, Pakistan
| | - Mujahid Hussain
- Dr. Mujahid Hussain, PhD, Department of Biology, FG College, Sialkot Cantt, Pakistan
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Abstract
OBJECTIVE Clozapine is uniquely effective for treatment-resistant schizophrenia, and so treatment continuation is essential. We aimed to identify factors associated with an increased likelihood of clozapine discontinuation in a cohort of patients in South East London. METHODS We gathered demographic and treatment information such as duration of illness and antipsychotic treatment history. t-tests, chi-square tests and binary logistic regression were used to compare patients who continued and discontinued clozapine during the study and to identify predictor variables for discontinuation. RESULTS Out of the study population of 133 patients, 48 discontinued clozapine at least once during the study period. The majority of these (75%) stopped treatment within the first 4 years of clozapine therapy. Age, ethnicity, diagnosis and antipsychotic treatment history were not predictive of the risk of clozapine discontinuation. However, male patients were more likely to stop taking clozapine (χ2 = 6.81, p = 0.009). The odds of discontinuing clozapine were 2.15 times higher for male patients. The most common reason for discontinuation was patient refusal of treatment. CONCLUSION We found that patients who discontinue clozapine are more likely to be male, but no other demographic variable was found to predict treatment cessation. Discontinuation usually occurred due to patient refusal of treatment.
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Affiliation(s)
- Siobhan H Gee
- 1 Pharmacy Department, South London and Maudsley NHS Foundation Trust, UK
| | | | - David M Taylor
- 3 Institute of Pharmaceutical Science, King's College London, UK
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Sodium valproate and clozapine induced neutropenia: A case control study using register data. Schizophr Res 2018; 195:267-273. [PMID: 28882687 DOI: 10.1016/j.schres.2017.08.041] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 08/20/2017] [Accepted: 08/21/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND The use of clozapine is limited due to the occurrence of neutropenia, and the rare but life threatening adverse event of agranulocytosis. There is little epidemiological research into clinical factors that may impact on this risk. We conducted a case control study examining the clinical risk factors for neutropenia patients treated with clozapine. METHOD A case-control study was conducted within a database of anonymised electronic clinical records. All patients who discontinued clozapine due to a neutropenic event were included as cases. Matched controls were selected from patients with a documented clozapine exposure at the time of the clozapine neutropenic event of the case patient, matched by duration of clozapine treatment. RESULTS 136 cases and 136 controls were included. In multivariable analysis, the concurrent use of sodium valproate was associated with neutropenia (Odds Raito (OR) 2.28, 95%CI: 1.27-4.11, p=0.006). There was a dose-response effect, with greater associations for higher doses. Patients who discontinued clozapine due to neutropenia were more likely to be of black ethnicity (OR 2.99, p<0.001), were younger (t=5.86, df=267, p<0.001), and received lower doses of clozapine (t=-2.587, p=0.01) than those who did not develop neutropenia. CONCLUSION We identified an association between the concurrent use of sodium valproate and an increased risk of clozapine associated neutropenia. These results, taken in combination with the results from previous case series, suggest that the risk of clozapine associated neutropenia could be reduced by avoiding concurrent valproate treatment.
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Ignjatović Ristić D, Cohen D, Obradović A, Nikić-Đuričić K, Drašković M, Hinić D. The Glasgow antipsychotic side-effects scale for clozapine in inpatients and outpatients with schizophrenia or schizoaffective disorder. Nord J Psychiatry 2018; 72:124-129. [PMID: 29125018 DOI: 10.1080/08039488.2017.1400097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The inconsistency in clinician and patient ratings of clozapine-induced side effects underscore the need to supplement clinician-based estimates of side effects with patient-reported ones. AIMS The main aims of the study are validation of the Glasgow antipsychotic side-effects scale for clozapine (GASS-C) in Serbian inpatients/outpatients with schizophrenia or schizo-affective disorder and recommendations for its future use, based on common and rare clozapine-associated side-effects. METHODS The GASS-C was administered to 95 outpatients/inpatients diagnosed with schizophrenia, schizoaffective, or chronic psychotic disorder. RESULTS The scale showed good overall reliability, with an internal consistency coefficient of α = 0.84, an average retest coefficient of rho = 0.76, and a Spearman-Brown coefficient of validity of 0.81. Side effects were absent or mild in 64.2% of the patients, moderate in 31.6%, severe in 4.2%; 14% of the subjects considered their symptoms distressing. The most commonly reported side-effects were drowsiness, thirst, frequent urination, and dry mouth. Women reported more side effects than men, and patients not in a relationship reported significantly fewer side effects than patients in a relationship. Results indicate a weak positive correlation (rho = 0.231; p = .025) between severity of side effects and clozapine dose. CONCLUSIONS The GASS-C showed good psychometric characteristics in clinical population of patients on clozapine. In future studies, clozapine serum concentrations should be measured when using the GASS-C to monitor side effects.
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Affiliation(s)
- Dragana Ignjatović Ristić
- a Psychiatric Clinic, Clinical Center Kragujevac and Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Dan Cohen
- b Department of Community Mental Health , Mental Health Care North-Holland North , Heerhugowaard , Netherlands
| | - Andrea Obradović
- a Psychiatric Clinic, Clinical Center Kragujevac and Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Katarina Nikić-Đuričić
- a Psychiatric Clinic, Clinical Center Kragujevac and Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Marija Drašković
- a Psychiatric Clinic, Clinical Center Kragujevac and Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Darko Hinić
- c Faculty of Science and Faculty of Philology and Arts , University of Kragujevac , Kragujevac , Serbia
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Mayerova M, Ustohal L, Jarkovsky J, Pivnicka J, Kasparek T, Ceskova E. Influence of dose, gender, and cigarette smoking on clozapine plasma concentrations. Neuropsychiatr Dis Treat 2018; 14:1535-1543. [PMID: 29950838 PMCID: PMC6011879 DOI: 10.2147/ndt.s163839] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Therapeutic drug monitoring (TDM) of clozapine is a very useful method for verifying both the correct intake and the interindividual variability of its metabolism, thereby avoiding the risk of toxicity. The purposes of this paper were to discover how many patients using clozapine in common clinical practice have clozapine plasma concentration (PC) levels in the proposed reference range and to identify factors that influence clozapine PC levels. METHODS Our study included 100 inpatients (diagnosed with schizophrenia or schizoaffective disorder) taking standard doses of clozapine (100-700 mg/day). Clozapine concentration was measured by high-performance liquid chromatography. Correlations between doses and PC levels and the influence of smoking and gender on clozapine PC levels were calculated. RESULTS A large number of the patients (67%) had PC levels outside the proposed reference range. The clozapine PC levels were influenced by dose, gender, and cigarette smoking. CONCLUSION The correlations between dose, gender, and cigarette smoking and clozapine PC levels highlighted by our study overlap other research. It was surprising to find such a large number of patients with clozapine PC levels outside the therapeutic range. This result suggests the importance of clozapine TDM due to misunderstood inter- and/or intraindividual variability or misestimated partial therapeutic compliance.
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Affiliation(s)
- Michaela Mayerova
- Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Psychiatry, University Hospital Brno, Brno, Czech Republic.,CEITEC - Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Libor Ustohal
- Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Psychiatry, University Hospital Brno, Brno, Czech Republic.,CEITEC - Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Jiri Jarkovsky
- Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic
| | - Jan Pivnicka
- Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Institute of Forensic Medicine, St. Anne's University Hospital, Masaryk University, Brno, Czech Republic
| | - Tomas Kasparek
- Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Psychiatry, University Hospital Brno, Brno, Czech Republic
| | - Eva Ceskova
- Faculty of Medicine, Masaryk University, Brno, Czech Republic.,CEITEC - Central European Institute of Technology, Masaryk University, Brno, Czech Republic
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Bachmann CJ, Aagaard L, Bernardo M, Brandt L, Cartabia M, Clavenna A, Coma Fusté A, Furu K, Garuoliené K, Hoffmann F, Hollingworth S, Huybrechts KF, Kalverdijk LJ, Kawakami K, Kieler H, Kinoshita T, López SC, Machado-Alba JE, Machado-Duque ME, Mahesri M, Nishtala PS, Piovani D, Reutfors J, Saastamoinen LK, Sato I, Schuiling-Veninga CCM, Shyu YC, Siskind D, Skurtveit S, Verdoux H, Wang LJ, Zara Yahni C, Zoëga H, Taylor D. International trends in clozapine use: a study in 17 countries. Acta Psychiatr Scand 2017; 136:37-51. [PMID: 28502099 DOI: 10.1111/acps.12742] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE There is some evidence that clozapine is significantly underutilised. Also, clozapine use is thought to vary by country, but so far no international study has assessed trends in clozapine prescribing. Therefore, this study aimed to assess clozapine use trends on an international scale, using standardised criteria for data analysis. METHOD A repeated cross-sectional design was applied to data extracts (2005-2014) from 17 countries worldwide. RESULTS In 2014, overall clozapine use prevalence was greatest in Finland (189.2/100 000 persons) and in New Zealand (116.3/100 000), and lowest in the Japanese cohort (0.6/100 000), and in the privately insured US cohort (14.0/100 000). From 2005 to 2014, clozapine use increased in almost all studied countries (relative increase: 7.8-197.2%). In most countries, clozapine use was highest in 40-59-year-olds (range: 0.6/100 000 (Japan) to 344.8/100 000 (Finland)). In youths (10-19 years), clozapine use was highest in Finland (24.7/100 000) and in the publicly insured US cohort (15.5/100 000). CONCLUSION While clozapine use has increased in most studied countries over recent years, clozapine is still underutilised in many countries, with clozapine utilisation patterns differing significantly between countries. Future research should address the implementation of interventions designed to facilitate increased clozapine utilisation.
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Affiliation(s)
| | - L Aagaard
- Life Science Team, Bech-Bruun Law Firm, Copenhagen, Denmark
| | - M Bernardo
- Barcelona Clinic Schizophrenia Unit, Neuroscience Institute, and Hospital Clínic, Department of Medicine, Barcelona University, and Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - L Brandt
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Cartabia
- Pharmacoepidemiology Unit, Department of Public Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - A Clavenna
- Pharmacoepidemiology Unit, Department of Public Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - A Coma Fusté
- Pharmacy Department of Barcelona Health Region, Catalan Health Service (CatSalut), Barcelona, Spain
| | - K Furu
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - K Garuoliené
- Medicines Reimbursement Department, National Health Insurance Fund of the Republic of Lithuania, Vilnius, Lithuania.,Faculty of Medicine, Department of Pathology, Forensic Medicine and Pharmacology, Vilnius University, Vilnius, Lithuania
| | - F Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - S Hollingworth
- School of Pharmacy, University of Queensland, Woolloongabba, Qld, Australia
| | - K F Huybrechts
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - L J Kalverdijk
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, the Netherlands
| | - K Kawakami
- Department of Pharmacoepidemiology and Clinical Research Management, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - H Kieler
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - T Kinoshita
- Department of Pharmacoepidemiology and Clinical Research Management, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - S C López
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira - Audifarma S.A., Pereira, Colombia
| | - J E Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira - Audifarma S.A., Pereira, Colombia
| | - M E Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira - Audifarma S.A., Pereira, Colombia
| | - M Mahesri
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - P S Nishtala
- New Zealand's National School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - D Piovani
- Pharmacoepidemiology Unit, Department of Public Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - J Reutfors
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - L K Saastamoinen
- Kela Research, The Social Insurance Institution, Helsinki, Finland
| | - I Sato
- Department of Pharmacoepidemiology and Clinical Research Management, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - C C M Schuiling-Veninga
- Unit of Pharmacotherapy, -Epidemiology and -Economics, Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Y-C Shyu
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan.,Institute of Molecular Biology, Academia Sinica, Taipei, Qld, Taiwan.,Department of Nutrition, Chang Gung University of Science and Technology, Kwei-Shan, Taiwan
| | - D Siskind
- School of Medicine, University of Queensland, Woolloongabba, Qld, Australia
| | - S Skurtveit
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - H Verdoux
- University Bordeaux, INSERM, Bordeaux Population Health Research Center, team Pharmaco-epidemiology, UMR 1219, F-33000, Bordeaux, France
| | - L-J Wang
- Department of Child & Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C Zara Yahni
- Pharmacy Department of Barcelona Health Region, Catalan Health Service (CatSalut), Barcelona, Spain
| | - H Zoëga
- Bordeaux Population Health Research Center, INSERM, Univ. Bordeaux, team Pharmaco-epidemiology, UMR 1219, Bordeaux, France
| | - D Taylor
- South London and Maudsley NHS Foundation Trust, London, UK.,Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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Rimessi A, Pavan C, Ioannidi E, Nigro F, Morganti C, Brugnoli A, Longo F, Gardin C, Ferroni L, Morari M, Vindigni V, Zavan B, Pinton P. Protein Kinase C β: a New Target Therapy to Prevent the Long-Term Atypical Antipsychotic-Induced Weight Gain. Neuropsychopharmacology 2017; 42:1491-1501. [PMID: 28128334 PMCID: PMC5436118 DOI: 10.1038/npp.2017.20] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 01/03/2017] [Accepted: 01/21/2017] [Indexed: 12/21/2022]
Abstract
Antipsychotic drugs are currently used in clinical practice for a variety of mental disorders. Among them, clozapine is the most effective medication for treatment-resistant schizophrenia and is most helpful in controlling aggression and the suicidal behavior in schizophrenia and schizoaffective disorder. Although clozapine is associated with a low likelihood of extrapyramidal symptoms and other neurological side effects, it is well known for the weight gain and metabolic side effects, which expose the patient to a greater risk of cardiovascular disorders and premature death, as well as psychosocial issues, leading to non-adherence to therapy. The mechanisms underlying these iatrogenic metabolic disorders are still controversial. We have therefore investigated the in vivo effects of the selective PKCβ inhibitor, ruboxistaurin (LY-333531), in a preclinical model of long-term clozapine-induced weight gain. Cell biology, biochemistry, and behavioral tests have been performed in wild-type and PKCβ knockout mice to investigate the contribution of endogenous PKCβ and its pharmacological inhibition to the psychomotor effects of clozapine. Finally, we also shed light on a novel aspect of the mechanism underlying the clozapine-induced weight gain, demonstrating that the clozapine-dependent PKCβ activation promotes the inhibition of the lipid droplet-selective autophagy process. This paves the way to new therapeutic approaches to this serious complication of clozapine therapy.
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Affiliation(s)
- Alessandro Rimessi
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Ferrara, Italy
| | - Chiara Pavan
- Unit of Psychiatry, Department of Neurosciences NPSRR, University of Padua, Padua, Italy
| | - Elli Ioannidi
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Ferrara, Italy
| | - Federica Nigro
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Ferrara, Italy
| | - Claudia Morganti
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Ferrara, Italy
| | - Alberto Brugnoli
- Department of Medical Sciences, Section of Pharmacology, Neuroscience Center and National Institute of Neuroscience, University of Ferrara, Ferrara, Italy
| | - Francesco Longo
- Department of Medical Sciences, Section of Pharmacology, Neuroscience Center and National Institute of Neuroscience, University of Ferrara, Ferrara, Italy
| | - Chiara Gardin
- Department of Biomedical Sciences, University of Padua, Padua, Italy
| | - Letizia Ferroni
- Department of Biomedical Sciences, University of Padua, Padua, Italy
| | - Michele Morari
- Department of Medical Sciences, Section of Pharmacology, Neuroscience Center and National Institute of Neuroscience, University of Ferrara, Ferrara, Italy
| | - Vincenzo Vindigni
- Unit of Plastic Surgery, Department of Neurosciences NPSRR, University of Padua, Padua, Italy
| | - Barbara Zavan
- Department of Biomedical Sciences, University of Padua, Padua, Italy
| | - Paolo Pinton
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Ferrara, Italy,Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Via Fossato di Mortara 70 (c/o CUBO), Ferrara 44121, Italy, Tel: +0039 0532455802, Fax: +0039 0532455351, E-mail:
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Alfirevic A, Pirmohamed M. Genomics of Adverse Drug Reactions. Trends Pharmacol Sci 2017; 38:100-109. [DOI: 10.1016/j.tips.2016.11.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 11/06/2016] [Accepted: 11/07/2016] [Indexed: 11/16/2022]
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