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Mansour K, Fredj NB, Ammar H, Romdhane HB, Mhalla A, Chaabane A, Chadli Z, Aouam K. Exploring clozapine pharmacokinetics in Tunisian schizophrenic patients: A population-based modelling approach investigating the impact of genetic and non-genetic variables. Basic Clin Pharmacol Toxicol 2024; 134:805-817. [PMID: 38599832 DOI: 10.1111/bcpt.14009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/29/2024] [Accepted: 03/22/2024] [Indexed: 04/12/2024]
Abstract
Clozapine is characterized by a large within- and between-patient variability in its pharmacokinetics, attributed to non-genetic and genetic factors. A cross-sectional analysis of clozapine trough concentration (Clz C0) issued from Tunisian schizophrenic patients was collected and analysed using a nonparametric modelling approach. We assessed the impact of demographic covariates (age, weight and sex), patient's habits (smoking status, alcohol and caffeine intake) and the genetic factors (CYP1A2*1C, CYP1A2*1F and CYP2C19*2 polymorphisms) on each pharmacokinetic parameter. An external validation of this pharmacokinetic model using an independent data set was performed. Fit goodness between observed- and individual-predicted data was evaluated using the mean prediction error (% MPE), the mean absolute prediction error (% MAPE) as a measure of bias, and the root mean squared error (% RMSE) as a measure of precision. Sixty-three CLz C0 values issued from 51 schizophrenic patients were assessed in this study and divided into building and validation groups. CYP1A2*1F polymorphism and smoking status were the only covariates significantly associated with clozapine clearance. Precision parameters were as follows: 1.02%, 0.95% and 22.4%, respectively, for % MPE, % MAPE and % RMSE. We developed and validated an accurate pharmacokinetic model able to predict Clz C0 in Tunisian schizophrenic patients using the two parameters CYP1A2*1F polymorphism and smoking.
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Affiliation(s)
- Khadija Mansour
- Department of Clinical Pharmacology, Fattouma Bourguiba Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Nadia Ben Fredj
- Department of Clinical Pharmacology, Fattouma Bourguiba Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Helmi Ammar
- Department of Clinical Pharmacology, Fattouma Bourguiba Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Haifa Ben Romdhane
- Department of Clinical Pharmacology, Fattouma Bourguiba Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Ahmed Mhalla
- Department of Psychiatry, Fattouma Bourguiba Hospital, Monastir, Tunisia
| | - Amel Chaabane
- Department of Clinical Pharmacology, Fattouma Bourguiba Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Zohra Chadli
- Department of Clinical Pharmacology, Fattouma Bourguiba Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Karim Aouam
- Department of Clinical Pharmacology, Fattouma Bourguiba Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
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Kang N, Yoon HS, Kim SH, Jeong JH, Kim M, Kwon JS. Comparative Study of the Efficacy and Side Effects of Brand-Name and Generic Clozapine for Long-Term Maintenance Treatment Among Korean Patients With Schizophrenia: A Retrospective Naturalistic Mirror-Image Study. Psychiatry Investig 2024; 21:311-320. [PMID: 38569589 PMCID: PMC10990625 DOI: 10.30773/pi.2023.0413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/01/2024] [Accepted: 01/17/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE Clozapine is considered the most reliable drug for treatment-resistant schizophrenia. In 2014, a generic formulation of clozapine (Clzapine) was introduced in Korea. This study was performed to provide clinical information regarding the use of clozapine and to compare efficacy and tolerability when converting from the brand-name formulation (Clozaril) to the generic formulation during longterm maintenance treatment among Korean patients with schizophrenia. METHODS This mirror-image study retrospectively investigated the electronic medical records of patients who had switched from Clozaril to Clzapine with a ≥1-year duration for each formulation. Clinical data were collected, including information regarding clozapine use, psychiatric hospitalization, co-medications, and blood test findings. Data before and after the switch were compared using paired t-tests. RESULTS Among 332 patients, the mean 1-year dosages were 233.32±149.35 mg/day for Clozaril and 217.36±136.66 mg/day for Clzapine. The mean clozapine concentration-to-dose ratios were similar before and after the switch (Clozaril, 1.33±0.68; Clzapine, 1.26±0.80). Switching from Clozaril to Clzapine resulted in no significant differences in the hospitalization rate, hospitalization duration, or laboratory findings (liver function parameters, serum cholesterol level, and serum glucose level). Equivalent doses of co-prescribed antidepressants were decreased, but concomitant medications otherwise showed no significant differences. CONCLUSION Clinical efficacy and tolerability appear comparable when switching to Clzapine during clozapine maintenance treatment. This study offers descriptive real-world clinical insights into clozapine maintenance treatment in Korea, thereby providing patients with more treatment options and contributing to the development of maintenance guidelines tailored to the Korean population.
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Affiliation(s)
- Nuree Kang
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Soo Yoon
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Se Hyun Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Hoon Jeong
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Minah Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jun Soo Kwon
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea
- Institute of Human Behavioral Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
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Smessaert S, Detraux J, Desplenter F, De Hert M. Evaluating Monitoring Guidelines of Clozapine-Induced Adverse Effects: a Systematic Review. CNS Drugs 2024; 38:105-123. [PMID: 38236524 DOI: 10.1007/s40263-023-01054-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND OBJECTIVES Despite the evidence that no other antipsychotic is effective as clozapine for the treatment of resistant schizophrenia, it is associated with various metabolic, neuroendocrine, cardiovascular, and gastrointestinal adverse effects. Guidelines aiming to address the monitoring of clozapine's (serious) adverse effects can be helpful to prevent and treat these effects. However, many of these guidelines seem to lack one or more important monitoring recommendations. We aimed to systematically review the content and quality of existing monitoring guidelines/recommendations for clozapine-induced adverse effects. METHODS A comprehensive and systematic literature search, using the MEDLINE, Embase, Web of Science, and Cochrane databases, was conducted for guidelines/recommendations on the monitoring of clozapine-induced adverse events, published between January 2004 and April 2023 (last search 16 April 2023). Only peer-reviewed published guidelines reporting on the comprehensive monitoring of all major clozapine-induced adverse effects and including evidence-based recommendations, developed after the year 2004, were included. Studies reporting on the monitoring of adverse effects of clozapine without being a formal guideline, guidelines reporting on the monitoring of one or a limited number of adverse effects of clozapine, guidelines that were not peer reviewed or published, expert opinion papers without formal consensus guideline development, or guidelines developed before the year 2004, were excluded. The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool was used to evaluate the guidelines/recommendations' quality. RESULTS Only one guideline met the inclusion criteria. This consensus statement made recommendations for hematological monitoring, and the monitoring of metabolic, cardiac, and three other adverse effects. Highest scores for the qualitative assessment were found for the domains "scope and purpose" (66.7%), "clarity of presentation" (44.4%), and "editorial independence" (66.7%). Lowest scores were found for "rigor of development" (14.6%) and "applicability" (0%). CONCLUSIONS Future guidelines should develop more comprehensive recommendations about specific clozapine-induced adverse effects, including constipation, myocarditis, tachycardia, and seizures, as well as include a rechallenge policy. There is an urgent need for well-developed, methodologically stringent, guidelines. REGISTRATION PROSPERO registration number, CRD42023402480.
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Affiliation(s)
- Sarah Smessaert
- University Psychiatric Center Katholieke Universiteit Leuven, Leuvensesteenweg 517, 3070, Kortenberg, Belgium.
| | - Johan Detraux
- Department of Biomedical Sciences, Research Group Psychiatry, University Psychiatric Center KU Leuven, Leuvensesteenweg 517, 3070, Kortenberg, Belgium
| | - Franciska Desplenter
- University Psychiatric Center Katholieke Universiteit Leuven, Leuvensesteenweg 517, 3070, Kortenberg, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Marc De Hert
- University Psychiatric Center Katholieke Universiteit Leuven, Leuvensesteenweg 517, 3070, Kortenberg, Belgium
- Department of Neurosciences, Centre for Clinical Psychiatry, Katholieke Universiteit Leuven, Leuven, Belgium
- Leuven Brain Institute, Katholieke Universiteit Leuven, Leuven, Belgium
- Antwerp Health Law and Ethics Chair, University of Antwerp, Antwerp, Belgium
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Hönig G, Daray FM, Rodante D, Drucaroff L, Gutiérrez ML, Lenze M, García Bournissen F, Wikinski S. Body mass index, waist circumference, insulin, and leptin plasma levels differentiate between clozapine-responsive and clozapine-resistant schizophrenia. J Psychopharmacol 2023; 37:1023-1029. [PMID: 37377097 DOI: 10.1177/02698811231181565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
BACKGROUND Between 25% and 50% of patients suffering from treatment-resistant schizophrenia fail to achieve a clinical response with clozapine. The rapid identification and treatment of this subgroup of patients represents a challenge for healthcare practice. AIMS To evaluate the relationship between metabolic alterations and the clinical response to clozapine. METHODS A multicenter, observational, case-control study was performed. Patients diagnosed with schizophrenia treated with clozapine were eligible (minimum dose 400 mg/d for at least 8 weeks and/or clozapine plasma levels ⩾ 350 µg/mL). According to the Positive and Negative Syndrome Scale (PANSS) total score, patients were classified as clozapine-responsive (CR) (<80 points) or clozapine non-responsive (CNR) (⩾80 points). Groups were compared based on demographic and treatment-related characteristics, together with body mass index (BMI), waist circumference, insulin, leptin, and C-reactive protein plasma levels. Plasma levels of clozapine and its main metabolite, nor-clozapine, were measured in all the participants. In addition, the potential relationship between PANSS scores and leptin or insulin plasma levels was assessed. RESULTS A total of 46 patients were included: 25 CR and 21 CNR. BMI and waist circumference, fasting insulin and leptin plasma levels were lower in the CNR group, while C-reactive protein was not different. Moreover, significant negative correlations were observed between PANSS positive and general psychopathology subscores, on one hand, and insulin and leptin plasma levels, on the other hand, as well as between PANSS negative subscores and leptin plasma levels. CONCLUSIONS Our results suggest that the lack of metabolic effect induced by clozapine is associated with the lack of clinical response.
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Affiliation(s)
- Guillermo Hönig
- Hospital Interdisciplinario Psicoasistencial José Tiburcio Borda, Ciudad de Buenos Aires, Argentina
| | - Federico M Daray
- Facultad de Medicina, Instituto de Farmacología, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Demián Rodante
- Hospital Neuropsiquiátrico Braulio A. Moyano, Ciudad de Buenos Aires, Argentina
| | - Lucas Drucaroff
- Instituto de Neurociencias, FLENI-CONICET, Buenos Aires, Argentina
| | - María Laura Gutiérrez
- Facultad de Medicina, Instituto de Farmacología, Universidad de Buenos Aires, Buenos Aires, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Argentina
| | - Mariela Lenze
- Facultad de Medicina, Instituto de Farmacología, Universidad de Buenos Aires, Buenos Aires, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Argentina
| | - Facundo García Bournissen
- Division of Pediatric Clinical Pharmacology, Department of Pediatrics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Silvia Wikinski
- Facultad de Medicina, Instituto de Farmacología, Universidad de Buenos Aires, Buenos Aires, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Argentina
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Longman K, Frampas C, Lewis H, Costa C, Nilforooshan R, Chambers M, Bailey M. Noninvasive drug adherence monitoring of antipsychotic patients via finger sweat testing. Front Chem 2023; 11:1245089. [PMID: 37720721 PMCID: PMC10500062 DOI: 10.3389/fchem.2023.1245089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/02/2023] [Indexed: 09/19/2023] Open
Abstract
Collection of finger sweat is explored here as a rapid and convenient way of monitoring patient adherence to antipsychotic drugs. Finger sweat samples (n = 426) collected from patients receiving treatment with clozapine, quetiapine and olanzapine were analysed by liquid chromatography mass spectrometry, including a subgroup of patients with paired plasma samples. Finger sweat samples were also analysed from a negative control group and patients who had handled antipsychotic medication only. The finger sweat test (based on the detection of parent drug in one donated sample) was 100% effective in monitoring adherence within commonly prescribed dosing ranges. In comparison to participants who handled the medication only, the test could distinguish between contact and administration through monitoring of the drug metabolite, or the level of parent drug. Additionally, in a subgroup of patients prescribed clozapine, a statistically significant correlation was observed between the mass of parent drug in finger sweat and plasma concentration. The finger sweat technology shows promise as a dignified, noninvasive method to monitor treatment adherence in patients taking antipsychotics.
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Affiliation(s)
- K. Longman
- School of Chemistry and Chemical Engineering, University of Surrey, Guildford, United Kingdom
| | - C. Frampas
- School of Chemistry and Chemical Engineering, University of Surrey, Guildford, United Kingdom
| | - H. Lewis
- School of Chemistry and Chemical Engineering, University of Surrey, Guildford, United Kingdom
| | - C. Costa
- Surrey Ion Beam Centre, University of Surrey, Guildford, United Kingdom
| | - R. Nilforooshan
- Abraham Cowley Unit, St Peter’s Hospital, Surrey and Borders Partnership NHS Foundation Trust, Chertsey, United Kingdom
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - M. Chambers
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - M. Bailey
- School of Chemistry and Chemical Engineering, University of Surrey, Guildford, United Kingdom
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Pharmacometric modeling of drug adverse effects: an application of mixture models in schizophrenia spectrum disorder patients treated with clozapine. J Pharmacokinet Pharmacodyn 2023; 50:21-31. [PMID: 36380133 DOI: 10.1007/s10928-022-09833-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022]
Abstract
Clozapine has superior efficacy to other antipsychotics yet is underutilized due to its adverse effects, such as neutropenia, weight gain, and tachycardia. The current investigation aimed to introduce a pharmacometric approach to simultaneously model drug adverse effects, with examples from schizophrenia spectrum patients receiving clozapine. The adverse drug effects were represented as a function of time by incorporating a mixture model to describe individual susceptibility to the adverse effects. Applications of the proposed method were presented by analyzing retrospective data from patients' medical records in Psychiatric Clinic, Penang General Hospital. Tachycardia, weight gain, and absolute neutrophils count (ANC) decrease were best described by an offset, a piecewise linear, and a transient surge function, respectively. 42.9% of the patients had all the adverse effects, including weight gain (0.01 kg/m2 increase every week over a baseline of 24.7 kg/m2 until stabilizing at 279 weeks), ANC decrease (20% decrease from 4540 cells/µL week 12-20.8), and tachycardia (14% constant increase over a baseline of 87.9 bpm for a clozapine maintenance dose of 450 mg daily). 32.5% of the patients had only tachycardia, while the remaining 24.6% had none of the adverse effects. A new pharmacometric approach was proposed to describe adverse drug effects with examples of clozapine-induced weight gain, ANC drop, and tachycardia. The current approach described the longitudinal time changes of continuous data while assessing patient susceptibility. Furthermore, the model revealed the possible co-existence of ANC drop and weight gain; thus, neutrophil monitoring might predict future changes in body weight.
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Kappel DB, Legge SE, Hubbard L, Willcocks IR, O'Connell KS, Smith RL, Molden E, Andreassen OA, King A, Jansen J, Helthuis M, Owen MJ, O'Donovan MC, Walters JTR, Pardiñas AF. Genomic Stratification of Clozapine Prescription Patterns Using Schizophrenia Polygenic Scores. Biol Psychiatry 2023; 93:149-156. [PMID: 36244804 PMCID: PMC10804961 DOI: 10.1016/j.biopsych.2022.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/14/2022] [Accepted: 07/19/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Treatment-resistant schizophrenia affects approximately 30% of individuals with the disorder. Clozapine is the medication of choice in treatment-resistant schizophrenia, but optimizing administration and dose titration is complex. The identification of factors influencing clozapine prescription and response, including genetics, is of interest in a precision psychiatry framework. METHODS We used linear regression models accounting for demographic, pharmacological, and clinical covariates to determine whether a polygenic risk score (PRS) for schizophrenia would be associated with the highest dose recorded during clozapine treatment. Analyses were performed across 2 independent multiancestry samples of individuals from a UK patient monitoring system, CLOZUK2 (n = 3133) and CLOZUK3 (n = 909), and a European sample from a Norwegian therapeutic drug monitoring service (n = 417). In a secondary analysis merging both UK cohorts, logistic regression models were used to estimate the relationship between schizophrenia PRSs and clozapine doses classified as low, standard, or high. RESULTS After controlling for relevant covariates, the schizophrenia PRS was correlated with the highest clozapine dose on record for each individual across all samples: CLOZUK2 (β = 12.22, SE = 3.78, p = .001), CLOZUK3 (β = 12.73, SE = 5.99, p = .034), and the Norwegian cohort (β = 46.45, SE = 18.83, p = .014). In a secondary analysis, the schizophrenia PRS was associated with taking clozapine doses >600 mg/day (odds ratio = 1.279, p = .006). CONCLUSIONS The schizophrenia PRS was associated with the highest clozapine dose prescribed for an individual in records from 3 independent samples, suggesting that the genetic liability for schizophrenia might index factors associated with therapeutic decisions in cohorts of patients with treatment-resistant schizophrenia.
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Affiliation(s)
- Djenifer B Kappel
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Sophie E Legge
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Leon Hubbard
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Isabella R Willcocks
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Kevin S O'Connell
- Norwegian Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Robert L Smith
- Norwegian Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo and Oslo University Hospital, Oslo, Norway; Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Espen Molden
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway; Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Ole A Andreassen
- Norwegian Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Adrian King
- Magna Laboratories Ltd., Ross-on-Wye, United Kingdom
| | | | | | - Michael J Owen
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Michael C O'Donovan
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - James T R Walters
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Antonio F Pardiñas
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom.
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Amano Y, Mazda J, Amano K, Ohi K, Shioiri T. Efficacy of sofpironium bromide gel on clozapine-induced hypersalivation in patients with treatment-resistant schizophrenia: double-blind, controlled crossover study. BJPsych Open 2023; 9:e14. [PMID: 36636808 PMCID: PMC9885354 DOI: 10.1192/bjo.2022.630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Hypersalivation is a major side-effect of clozapine in patients with treatment-resistant schizophrenia. AIMS We investigated the efficacy of topical anticholinergic formulation sofpironium bromide gel for improving hypersalivation in patients with treatment-resistant schizophrenia receiving clozapine. METHOD A double-blind, controlled crossover study was conducted with sofpironium bromide gel and a placebo gel to treat clozapine-induced hypersalivation in 16 patients with treatment-resistant schizophrenia. Patients were randomly divided between groups A and B (each n = 8). Group A was treated with sofpironium bromide gel for 6 weeks, followed by a 2-week washout period and 6 weeks of placebo gel, after which they were observed for another 2 weeks. In contrast, group B was treated with placebo gel for 6 weeks, followed by a 2-week washout period, 6 weeks of sofpironium bromide gel and a 2-week observation period. One-minute saliva volume, objective salivation ratings (Drooling Severity and Frequency Scale and Nocturnal Hypersalivation Rating Scale) and subjective salivation ratings (Visual Analogue Scale) were assessed every 2 weeks. RESULTS All patients completed the trials. Three patients reported mild, spontaneously resolved skin itching. Compared with baseline values, the 1-min saliva volumes of both groups were significantly decreased by approximately 30% at the second week of sofpironium bromide gel treatment (P < 0.001), and significantly decreased by >40% at the fourth and sixth weeks of treatment (P < 0.001). The effects were maintained for over 2 weeks even after the treatment was discontinued. CONCLUSIONS We suggest that sofpironium bromide gel is effective in treating clozapine-induced hypersalivation in patients with treatment-resistant schizophrenia.
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Affiliation(s)
- Yuhei Amano
- Anzunokai Kakamigahara Hospital, Kakamigahara, Japan; and Department of Psychiatry, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Jun Mazda
- Anzunokai Kakamigahara Hospital, Kakamigahara, Japan
| | - Koichi Amano
- Anzunokai Kakamigahara Hospital, Kakamigahara, Japan
| | - Kazutaka Ohi
- Department of Psychiatry, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Toshiki Shioiri
- Department of Psychiatry, Gifu University Graduate School of Medicine, Gifu, Japan
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Marasca C, Mandrioli R, Sardella R, Vovk T, Armirotti A, Cavalli A, Serretti A, Protti M, Mercolini L. Dried Volumetric Microsampling Approaches for the Therapeutic Drug Monitoring of Psychiatric Patients Undergoing Clozapine Treatment. Front Psychiatry 2022; 13:794609. [PMID: 35722565 PMCID: PMC9198272 DOI: 10.3389/fpsyt.2022.794609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 04/20/2022] [Indexed: 01/18/2023] Open
Abstract
Clozapine is one of the most widely used second-generation antipsychotic drugs (SGAs) for the treatment of schizophrenia. Despite advantages over first-generation drugs, clozapine still shows significant side effects and interindividual variations in efficacy. In order to ensure frequent therapeutic drug monitoring (TDM) and improve the compliance of psychiatric patients undergoing clozapine treatment, two novel dried microsampling approaches based on whole blood and plasma volumetric absorptive microsampling (b-VAMS and p-VAMS) and microfluidic generated-dried blood spot technology (mfDBS) were developed and coupled to HPLC with electrochemical detection (ED). The proposed miniaturized strategies by means of VAMS and microfluidic channel-based devices provide several advantages in terms of collection, storage, and handling compared to classical blood and plasma processing. Satisfactory validation results were obtained for all microsampling platforms, with mean extraction yields >85.1%, precision as relative standard deviation (RSD) < 5.1%, and stability < 4.5% analyte loss after 30 days for p-VAMS; mean extraction yields > 83.4%, precision RSD < 5.4%, and stability < 4.6% analyte loss after 30 days for b-VAMS, and mean extraction yields > 74.0%, precision RSD < 5.6%, and stability < 4.9% analyte loss after 30 days for mfDBS. The original microsampling methodologies have been successfully applied to the blood and plasma collected from five psychiatric patients for the monitoring of the levels of clozapine and its main metabolites, providing robust and reliable quali-quantitative results. Comparisons between results of the two dried microsampling technologies with those obtained by classic fluid plasma analysis were in good agreement and have demonstrated that the proposed miniaturized approaches could be suitable for TDM purposes.
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Affiliation(s)
- Camilla Marasca
- Research Group of Pharmaco-Toxicological Analysis (PTA Lab), Department of Pharmacy and Biotechnology (FaBiT), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Computational and Chemical Biology, Fondazione Istituto Italiano di Tecnologia (IIT), Genoa, Italy
| | - Roberto Mandrioli
- Department for Life Quality Studies (QuVi), Alma Mater Studiorum - University of Bologna, Rimini, Italy
| | - Roccaldo Sardella
- Department of Pharmaceutical Sciences, University of Perugia, Perugia, Italy
| | - Tomaž Vovk
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Andrea Armirotti
- Analytical Chemistry Lab, Fondazione Istituto Italiano di Tecnologia (IIT), Genoa, Italy
| | - Andrea Cavalli
- Computational and Chemical Biology, Fondazione Istituto Italiano di Tecnologia (IIT), Genoa, Italy.,Department of Pharmacy and Biotechnology (FaBiT), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Alessandro Serretti
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Michele Protti
- Research Group of Pharmaco-Toxicological Analysis (PTA Lab), Department of Pharmacy and Biotechnology (FaBiT), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Laura Mercolini
- Research Group of Pharmaco-Toxicological Analysis (PTA Lab), Department of Pharmacy and Biotechnology (FaBiT), Alma Mater Studiorum - University of Bologna, Bologna, Italy
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Lucca JM, Al-Turaifi FM, Safyah AM, Hamad Al-Awad FA. A Comprehensive Monitoring of Clozapine and Related Components in Clinical Practices. Saudi Arabian Scenario. PSYCHOPHARMACOLOGY BULLETIN 2021; 51:40-50. [PMID: 34887598 PMCID: PMC8601762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Clozapine is considered as effective medication for treatment resistant schizophrenia. Due to its potential severe adverse effects' clozapine is underused in the clinical settings. Information's on clinical use and monitoring of clozapine is lacking in middle east. This research analysis clozapine prescription and monitoring patterns a in a university teaching hospital in Saudi Arabia. EXPERIMENTAL DESIGN A retrospective observational study was conducted in the psychiatric department of a university hospital in Saudi Arabia. Patients on treatment with clozapine for minimum one year were reviewed and assessed for clozapine mandatory and non-mandatory requirements and its correlated factors. OBSERVATION Majority of patients were male [(n = 36) 63%] and the average age of was 36.8 ± 12.3. TRS schizophrenia[(n = 49),85%] was the common indications. Prior to initiation of clozapine all recommended guidelines was followed for all patients (100%). In addition to the blood monitoring and vitals LFT (80.75%) and weight (87.77%) were frequently measured. Hematological work up performed routinely throughout initial 18 weeks (71.9 %) and every month (59.6%). Weight gain (29.8%) was the most documented adverse effects. CONCLUSION The current study explored experiences with clozapine prescribing practices in a university hospital KSA and suggest that clozapine prescription is completely adhered with already existing guidelines in terms of dosing and monitoring. There exist a careful balance of benefit and risk in term of adverse reaction of clozapine in the local population.
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Affiliation(s)
- Jisha M Lucca
- Dr. Lucca, Assistant professor Department of Pharmacy Practice, College of Clinical Pharmacy Imam Abdulrahman Bin Faisal University, Dammam, KSA. Al-Turaifi, Safyah Al-Mubayedh, Pharm D Interns, Department of Pharmacy Practice, College of Clinical Pharmacy Imam Abdulrahman Bin Faisal University, Dammam, KSA. Hamad Al-Awad, Consultant Psychiatrist Department Psychiatry, College of Medicine Imam Abdulrahman Bin Faisal University Hospital Dammam, KSA
| | - Fatima M Al-Turaifi
- Dr. Lucca, Assistant professor Department of Pharmacy Practice, College of Clinical Pharmacy Imam Abdulrahman Bin Faisal University, Dammam, KSA. Al-Turaifi, Safyah Al-Mubayedh, Pharm D Interns, Department of Pharmacy Practice, College of Clinical Pharmacy Imam Abdulrahman Bin Faisal University, Dammam, KSA. Hamad Al-Awad, Consultant Psychiatrist Department Psychiatry, College of Medicine Imam Abdulrahman Bin Faisal University Hospital Dammam, KSA
| | - Al-Mubayedh Safyah
- Dr. Lucca, Assistant professor Department of Pharmacy Practice, College of Clinical Pharmacy Imam Abdulrahman Bin Faisal University, Dammam, KSA. Al-Turaifi, Safyah Al-Mubayedh, Pharm D Interns, Department of Pharmacy Practice, College of Clinical Pharmacy Imam Abdulrahman Bin Faisal University, Dammam, KSA. Hamad Al-Awad, Consultant Psychiatrist Department Psychiatry, College of Medicine Imam Abdulrahman Bin Faisal University Hospital Dammam, KSA
| | - Feras A Hamad Al-Awad
- Dr. Lucca, Assistant professor Department of Pharmacy Practice, College of Clinical Pharmacy Imam Abdulrahman Bin Faisal University, Dammam, KSA. Al-Turaifi, Safyah Al-Mubayedh, Pharm D Interns, Department of Pharmacy Practice, College of Clinical Pharmacy Imam Abdulrahman Bin Faisal University, Dammam, KSA. Hamad Al-Awad, Consultant Psychiatrist Department Psychiatry, College of Medicine Imam Abdulrahman Bin Faisal University Hospital Dammam, KSA
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11
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Wagner E, Siafis S, Fernando P, Falkai P, Honer WG, Röh A, Siskind D, Leucht S, Hasan A. Efficacy and safety of clozapine in psychotic disorders-a systematic quantitative meta-review. Transl Psychiatry 2021; 11:487. [PMID: 34552059 PMCID: PMC8458455 DOI: 10.1038/s41398-021-01613-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/19/2021] [Accepted: 09/07/2021] [Indexed: 02/08/2023] Open
Abstract
A recent increase in the literature regarding the evidence base for clozapine has made it increasingly difficult for clinicians to judge "best evidence" for clozapine use. As such, we aimed at elucidating the state-of-the-art for clozapine with regard to efficacy, effectiveness, tolerability, and management of clozapine and clozapine-related adverse events in neuropsychiatric disorders. We conducted a systematic PRISMA-conforming quantitative meta-review of available meta-analytic evidence regarding clozapine use. Primary outcome effect sizes were extracted and transformed into relative risk ratios (RR) and standardized mean differences (SMD). The methodological quality of meta-analyses was assessed using the AMSTAR-2 checklist. Of the 112 meta-analyses included in our review, 61 (54.5%) had an overall high methodological quality according to AMSTAR-2. Clozapine appears to have superior effects on positive, negative, and overall symptoms and relapse rates in schizophrenia (treatment-resistant and non-treatment-resistant subpopulations) compared to first-generation antipsychotics (FGAs) and to pooled FGAs/second-generation antipsychotics (SGAs) in treatment-resistant schizophrenia (TRS). Despite an unfavorable metabolic and hematological adverse-event profile compared to other antipsychotics, hospitalization, mortality and all-cause discontinuation (ACD) rates of clozapine surprisingly show a pattern of superiority. Our meta-review outlines the superior overall efficacy of clozapine compared to FGAs and most other SGAs in schizophrenia and suggests beneficial efficacy outcomes in bipolar disorder and Parkinson's disease psychosis (PDP). More clinical studies and subsequent meta-analyses are needed beyond the application of clozapine in schizophrenia-spectrum disorders and future studies should be directed into multidimensional clozapine side-effect management to foster evidence and to inform future guidelines.
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Affiliation(s)
- Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.
| | - Spyridon Siafis
- grid.15474.330000 0004 0477 2438Department of Psychiatry and Psychotherapy, School of Medicine, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Piyumi Fernando
- grid.7307.30000 0001 2108 9006Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Peter Falkai
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - William G. Honer
- grid.17091.3e0000 0001 2288 9830Department of Psychiatry, The University of British Columbia, Vancouver, Canada
| | - Astrid Röh
- grid.7307.30000 0001 2108 9006Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Dan Siskind
- grid.1003.20000 0000 9320 7537School of Medicine, University of Queensland, Brisbane, Australia ,Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Stefan Leucht
- grid.15474.330000 0004 0477 2438Department of Psychiatry and Psychotherapy, School of Medicine, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Alkomiet Hasan
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany ,grid.7307.30000 0001 2108 9006Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, Medical Faculty, University of Augsburg, Augsburg, Germany
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12
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Pallares Vela E, Dave P, Cancarevic I. Clozapine-Related Thromboembolic Events. Cureus 2021; 13:e16883. [PMID: 34513458 PMCID: PMC8412001 DOI: 10.7759/cureus.16883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/04/2021] [Indexed: 11/05/2022] Open
Abstract
Clozapine is an atypical antipsychotic used for treatment-resistant schizophrenia. Venous thromboembolism (VTE) is a rare side effect of clozapine which can be fatal. This article summarizes current evidence regarding the risk of VTE associated with the use of clozapine. We performed a PubMed (MeSH) and Google Scholar search for the last two decades. Studies or case reports performed in humans were included in the review, of which 42 case reports of patients taking clozapine at VTE onset were included in the analysis of this review. According to the articles reviewed, the mean age was 42.9 years, with more males (71.43%) than females (28.57%). The average clozapine dose was 285.62 mg/day. VTE onset occurred within the first six months in 71.8% of the cases. Overall, 70.37% of the patients had comorbidities, and 87.5% had risk factors for VTE. In total, 68.57% were prescribed other medications at VTE onset, and 60% were being treated with another antipsychotic concomitantly. Finally, 32.5% of the patients died, while 67.5% survived. In 60% of the cases, clozapine was discontinued after VTE. In our literature review, we observed that among clozapine users, VTE occurred at a wide dose range, and most of the events occurred within the first six months. As many patients who are prescribed clozapine have risk factors for VTE, the risk should be considered at the time of prescribing. Further research should be conducted to elucidate the risk of VTE in clozapine users and the benefits of thromboprophylaxis.
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Affiliation(s)
- Elisa Pallares Vela
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Prashil Dave
- General Practice, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ivan Cancarevic
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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13
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Chakrabarti S. Clozapine resistant schizophrenia: Newer avenues of management. World J Psychiatry 2021; 11:429-448. [PMID: 34513606 PMCID: PMC8394694 DOI: 10.5498/wjp.v11.i8.429] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/12/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
About 40%-70% of the patients with treatment-resistant schizophrenia have a poor response to adequate treatment with clozapine. The impact of clozapine-resistant schizophrenia (CRS) is even greater than that of treatment resistance in terms of severe and persistent symptoms, relapses and hospitalizations, poorer quality of life, and healthcare costs. Such serious consequences often compel clinicians to try different augmentation strategies to enhance the inadequate clozapine response in CRS. Unfortunately, a large body of evidence has shown that antipsychotics, antidepressants, mood stabilizers, electroconvulsive therapy, and cognitive-behavioural therapy are mostly ineffective in augmenting clozapine response. When beneficial effects of augmentation have been found, they are usually small and of doubtful clinical significance or based on low-quality evidence. Therefore, newer treatment approaches that go beyond the evidence are needed. The options proposed include developing a clinical consensus about the augmentation strategies that are most likely to be effective and using them sequentially in patients with CRS. Secondly, newer approaches such as augmentation with long-acting antipsychotic injections or multi-component psychosocial interventions could be considered. Lastly, perhaps the most effective way to deal with CRS would be to optimize clozapine treatment, which might prevent clozapine resistance from developing. Personalized dosing, adequate treatment durations, management of side effects and non-adherence, collaboration with patients and caregivers, and addressing clinician barriers to clozapine use are the principal ways of ensuring optimal clozapine treatment. At present, these three options could the best way to manage CRS until research provides more firm directions about the effective options for augmenting clozapine response.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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14
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A Repeated Time-to-Positive Symptoms Improvement among Malaysian Patients with Schizophrenia Spectrum Disorders Treated with Clozapine. Pharmaceutics 2021; 13:pharmaceutics13081121. [PMID: 34452082 PMCID: PMC8401956 DOI: 10.3390/pharmaceutics13081121] [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] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/17/2021] [Accepted: 07/19/2021] [Indexed: 01/09/2023] Open
Abstract
Clozapine remains the drug of choice for resistant schizophrenia. However, its dose-response relationship is still controversial. The current investigation aimed to develop a repeated time-to-positive symptoms improvement following the onset of clozapine treatment in Malaysian schizophrenia spectrum disorder patients. Data from patients’ medical records in the Psychiatric Clinic, Penang General Hospital, were retrospectively analyzed. Several parametric survival models were evaluated using nonlinear mixed-effect modeling software (NONMEM 7.3.0). Kaplan–Meier-visual predictive check (KM-VPC) and sampling-importance resampling (SIR) methods were used to validate the final model. A total of 116 patients were included in the study, with a mean follow-up of 306 weeks. Weibull hazard function best fitted the data. The hazard of positive symptoms improvement decreased 4% for every one-year increase in age over the median of 41 years (adjusted hazard ratio (aHR), 0.96; 95% confidence intervals (95% CI), (0.93–0.98)). However, patients receiving a second atypical antipsychotic agent had four-folds higher hazard (aHR, 4.01; 95% CI, (1.97–7.17)). The hazard increased 2% (aHR, 1.02; 95% CI, (1.01–1.03)) for every 1 g increase in the clozapine six months cumulative dose over the median of 34 g. The developed model provides essential information on the hazard of positive symptoms improvement after the first clozapine dose administration, including modifiable predictors of high clinical importance.
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15
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Le DS, Su H, Liao ZL, Yu EY. Low-dose clozapine-related seizure: A case report and literature review. World J Clin Cases 2021; 9:5611-5620. [PMID: 34307616 PMCID: PMC8281419 DOI: 10.12998/wjcc.v9.i20.5611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/07/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Treatment-resistant schizophrenia is a severe form of schizophrenia characterized by poor response to at least two antipsychotic drugs and is typically treated with clozapine. However, clozapine lowers the epileptic threshold, leading to seizures, which are severe side effects of antipsychotics that result in multiple complications. Clozapine-related seizures are generally considered to be dose-dependent and especially rare in the low-dose (150-300 mg/d) clozapine treated population. Due to clinical rarity, little is known about its clinical characteristics and treatment.
CASE SUMMARY A 62-year-old Chinese man with a 40-year history of treatment-resistant schizophrenia presented to the Emergency Department with symptoms of myoclonus, consciousness disturbance and vomiting after taking 125 mg clozapine. Upon admission, the patient had a suddenly generalized tonic-clonic seizure lasting for about half a minute with persistent disturbance of consciousness, fever, cough and bloody sputum, which was considered to be low-dose clozapine-related seizure. After antiepileptic and multiple anti-infection treatments, the patient was discharged without epileptic or psychotic symptoms.
CONCLUSION Our aim is to highlight the early prevention and optimal treatment of clozapine-related seizure through case analysis and literature review.
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Affiliation(s)
- Dan-Sheng Le
- The Second Clinical Medical College, Zhejiang Chinese Medicine University, Hangzhou 310051, Zhejiang Province, China
| | - Heng Su
- Department of Psychiatry, Zhejiang Provincial People’s Hospital, Hangzhou 310000, Zhejiang Province, China
| | - Zheng-Luan Liao
- Department of Psychiatry, Zhejiang Provincial People’s Hospital, Hangzhou 310000, Zhejiang Province, China
| | - En-Yan Yu
- Department of Psychiatry, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer, Chinese Academy of Sciences, Hangzhou 310022, Zhejiang Province, China
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16
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de Filippis R, Gaetano R, Schoretsanitis G, Verde G, Oliveti CA, Kane JM, Segura-Garcia C, De Fazio P. Clozapine Management in Schizophrenia Inpatients: A 5-Year Prospective Observational Study of Its Safety and Tolerability Profile. Neuropsychiatr Dis Treat 2021; 17:2141-2150. [PMID: 34234440 PMCID: PMC8257059 DOI: 10.2147/ndt.s312095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/15/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Clozapine is well known for its efficacy and clinical superiority compared to other antipsychotics in treatment-resistant schizophrenia (TRS). However, it is frequently underutilized worldwide because of its acute adverse events, as well as for its long-term cardiometabolic and hematological consequences. OBJECTIVE The aim of the study was to evaluate 5-year safety in chronic TRS inpatients with continuous clozapine use. METHODS Patients with TRS and clozapine treatment were evaluated for 5 years. All participants were assessed using the Brief Psychiatric Rating Scale (BPRS), Glasgow Antipsychotic Side-effect Scale for Clozapine (GASS-C), Social Performance Scale (PSP) and Short Portable Mental Status Questionnaire (SPMSQ). Clinical, cardiometabolic and hematological data were collected periodically. General linear models (GLM) repeated measures controlling for CLZ dose were utilized to determine differences in variables across the time. RESULTS Overall, 189 inpatients were screened for study participation. The final sample included twenty-one TRS patients (16 males, 76%) with an average age of 57.6 years, all with 5-year continuous use of clozapine (mean dose 266 mg/day). There was not a significant effect of time on BPRS (p=0.774), PSP (p=0.855) and SPMSQ (p=0.066); differences remained not significant after controlling for CLZ dose (p=0.585, p=0.467 and p=0.105, respectively). No changes were found in blood and clinical parameters except for red blood cell count, which decreased over time (p=0.024; η2= 0.952). Patients reported a significant BMI decrease (-8.98 kg, p=0.008) between baseline and 5 years last observation. CONCLUSION The findings show how the application of a structured dietary, clinical and therapeutic monitoring program in psychiatric care facilities could allow the safe and effective long-term cardiometabolic and hematological management of clozapine. The unique role that clozapine plays in the current treatment of patients with TRS requires greater clinical awareness. Although its acute and chronic side effects are notorious, its safety management is feasible and broadens its potential practical application.
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Affiliation(s)
- Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Raffaele Gaetano
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | | | - Giuseppe Verde
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | | | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Cristina Segura-Garcia
- Psychiatry Unit, Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Pasquale De Fazio
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
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Clozapine intoxication with severe adverse effects induced by an inflammatory and infectious process: a case report. J Med Case Rep 2021; 15:47. [PMID: 33550992 PMCID: PMC7869193 DOI: 10.1186/s13256-020-02660-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 12/29/2020] [Indexed: 12/30/2022] Open
Abstract
Background Clozapine intoxication can be life-threatening. Outside of the common drug–drug interactions, tobacco smoking, and caffeine consumption, infectious and inflammatory processes are important contributors to clozapine intoxication. Although this relationship has been reported previously, the literature is scant of proper research articles describing the presentation and management of this unpredictable interaction. Therefore, clinicians need to rely heavily on case reports describing clozapine intoxication caused by inflammation and/or infection. Case presentation A 64-year-old Caucasian woman known for schizophrenia was brought to the emergency department (ED) with severe signs and symptoms of clozapine intoxication (general deterioration, drowsiness, neutropenia, and ileus). She was on clozapine 700 mg daily amongst other medications. The clozapine dose was stable for over 3 years, and there were no recent changes in her medications. The initial culprit was determined to be an infectious/inflammatory process of gastrointestinal origin with contribution from dehydration and constipation. Clozapine and norclozapine serum concentrations confirmed the intoxication: 1315 ng/mL and 653 ng/mL, respectively. She drastically improved with clozapine dose reduction and antibiotic therapy. She remained stable for years with clozapine 600 mg daily with stable clozapine serum levels. Conclusion This case report illustrates the possibility of severe toxicity associated with an acute infectious and/or inflammatory process in patients on clozapine therapy. Clinicians must maintain a high level of suspicion in patients taking clozapine who develop and an infectious and/or inflammatory process. Constipation secondary to clozapine intoxication can exacerbate the initial intoxication process.
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Mayén-Lobo YG, Martínez-Magaña JJ, Pérez-Aldana BE, Ortega-Vázquez A, Genis-Mendoza AD, Dávila-Ortiz de Montellano DJ, Soto-Reyes E, Nicolini H, López-López M, Monroy-Jaramillo N. Integrative Genomic-Epigenomic Analysis of Clozapine-Treated Patients with Refractory Psychosis. Pharmaceuticals (Basel) 2021; 14:118. [PMID: 33557049 PMCID: PMC7913835 DOI: 10.3390/ph14020118] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/19/2021] [Accepted: 01/26/2021] [Indexed: 02/07/2023] Open
Abstract
Clozapine (CLZ) is the only antipsychotic drug that has been proven to be effective in patients with refractory psychosis, but it has also been proposed as an effective mood stabilizer; however, the complex mechanisms of action of CLZ are not yet fully known. To find predictors of CLZ-associated phenotypes (i.e., the metabolic ratio, dosage, and response), we explore the genomic and epigenomic characteristics of 44 patients with refractory psychosis who receive CLZ treatment based on the integration of polygenic risk score (PRS) analyses in simultaneous methylome profiles. Surprisingly, the PRS for bipolar disorder (BD-PRS) was associated with the CLZ metabolic ratio (pseudo-R2 = 0.2080, adjusted p-value = 0.0189). To better explain our findings in a biological context, we assess the protein-protein interactions between gene products with high impact variants in the top enriched pathways and those exhibiting differentially methylated sites. The GABAergic synapse pathway was found to be enriched in BD-PRS and was associated with the CLZ metabolic ratio. Such interplay supports the use of CLZ as a mood stabilizer and not just as an antipsychotic. Future studies with larger sample sizes should be pursued to confirm the findings of this study.
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Affiliation(s)
- Yerye Gibrán Mayén-Lobo
- Department of Biological Systems, Metropolitan Autonomous University-Xochimilco, Mexico City 04960, Mexico; (Y.G.M.-L.); (B.E.P.-A.); (A.O.-V.); (M.L.-L.)
- Department of Genetics, National Institute of Neurology and Neurosurgery, “Manuel Velasco Suárez”, Mexico City 14269, Mexico;
| | - José Jaime Martínez-Magaña
- Genomics of Psychiatric and Neurodegenerative Diseases Laboratory, Instituto Nacional de Medicina Genómica, SSA, Mexico City 14610, Mexico; (J.J.M.-M.); (A.D.G.-M.); (H.N.)
| | - Blanca Estela Pérez-Aldana
- Department of Biological Systems, Metropolitan Autonomous University-Xochimilco, Mexico City 04960, Mexico; (Y.G.M.-L.); (B.E.P.-A.); (A.O.-V.); (M.L.-L.)
| | - Alberto Ortega-Vázquez
- Department of Biological Systems, Metropolitan Autonomous University-Xochimilco, Mexico City 04960, Mexico; (Y.G.M.-L.); (B.E.P.-A.); (A.O.-V.); (M.L.-L.)
| | - Alma Delia Genis-Mendoza
- Genomics of Psychiatric and Neurodegenerative Diseases Laboratory, Instituto Nacional de Medicina Genómica, SSA, Mexico City 14610, Mexico; (J.J.M.-M.); (A.D.G.-M.); (H.N.)
| | | | - Ernesto Soto-Reyes
- Natural Sciences Department, Universidad Autónoma Metropolitana-Cuajimalpa, Mexico City 05348, Mexico;
| | - Humberto Nicolini
- Genomics of Psychiatric and Neurodegenerative Diseases Laboratory, Instituto Nacional de Medicina Genómica, SSA, Mexico City 14610, Mexico; (J.J.M.-M.); (A.D.G.-M.); (H.N.)
- Grupo de Estudios Médicos y Familiares Carracci, Mexico City 03740, Mexico
| | - Marisol López-López
- Department of Biological Systems, Metropolitan Autonomous University-Xochimilco, Mexico City 04960, Mexico; (Y.G.M.-L.); (B.E.P.-A.); (A.O.-V.); (M.L.-L.)
| | - Nancy Monroy-Jaramillo
- Department of Genetics, National Institute of Neurology and Neurosurgery, “Manuel Velasco Suárez”, Mexico City 14269, Mexico;
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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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Su J, Li Z, Yamashita A, Kusumoto-Yoshida I, Isomichi T, Hao L, Kuwaki T. Involvement of the Nucleus Accumbens in Chocolate-induced Cataplexy. Sci Rep 2020; 10:4958. [PMID: 32188934 PMCID: PMC7080740 DOI: 10.1038/s41598-020-61823-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 03/04/2020] [Indexed: 11/09/2022] Open
Abstract
Happiness is key for both mental and physical well-being. To further understand the brain mechanisms involved, we utilized the cataplexy that occurs in narcoleptic animal models as a quantitative behavioral measure because it is triggered by actions associated with happiness, such as laughter in humans and palatable foods in mice. Here we report that the rostral part of the nucleus accumbens (NAc) shell is strongly activated during the beginning of chocolate-induced cataplexy in orexin neuron-ablated mice. We made a local lesion in the NAc using ibotenic acid and observed the animals' behavior. The number of cataplexy bouts was negatively correlated to the lesion size. We also examined the hedonic response to palatable food by measuring the number of tongue protrusions in response to presentation of honey, which was also found to be negatively correlated to the lesion size. Next, we used clozapine N-oxide to either activate or inactivate the NAc through viral DREADD expression. As expected, the number of cataplexy bouts increased with activation and decreased with inactivation, and saline control injections showed no changes. Hedonic response in the DREADD experiment varied and showed both increases and decreases across mice. These results demonstrated that the rostral part of the NAc plays a crucial role in triggering cataplexy and hedonic orofacial movements. Since the NAc is also implicated in motivated behavior, we propose that the NAc is one of the key brain structures involved in happiness and is a driving force for positive emotion-related behaviors.
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Affiliation(s)
- Jingyang Su
- Department of Physiology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
- Department of Pharmaceutical Toxicology, School of Pharmacy, China Medical University, Shenyang, China
| | - Zhi Li
- Department of Physiology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
- Department of Pharmaceutical Toxicology, School of Pharmacy, China Medical University, Shenyang, China
| | - Akira Yamashita
- Department of Physiology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Ikue Kusumoto-Yoshida
- Department of Physiology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Takuto Isomichi
- Department of Physiology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Liying Hao
- Department of Pharmaceutical Toxicology, School of Pharmacy, China Medical University, Shenyang, China
| | - Tomoyuki Kuwaki
- Department of Physiology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
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21
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Mizuno Y, McCutcheon RA, Brugger SP, Howes OD. Heterogeneity and efficacy of antipsychotic treatment for schizophrenia with or without treatment resistance: a meta-analysis. Neuropsychopharmacology 2020; 45:622-631. [PMID: 31766049 PMCID: PMC7021799 DOI: 10.1038/s41386-019-0577-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/30/2019] [Accepted: 11/08/2019] [Indexed: 01/08/2023]
Abstract
Two important clinical questions are whether there is a subtype of schizophrenia which responds differently to clozapine relative to other antipsychotics, and whether greater efficacy of clozapine is dependent on the degree of treatment-resistance. The authors address this by examining both variability and magnitude of response in patients treated with clozapine and other antipsychotics for both treatment-resistant schizophrenia (TRS) and non-resistant schizophrenia. Double-blind randomised controlled trials comparing clozapine with other antipsychotics in patients with schizophrenia were identified using five databases. Standard deviations and means of change in total, positive, and negative symptoms were extracted. Variability ratio (VR) and coefficient of variation ratio (CVR) were used to quantify relative variability in symptom change. Hedges' g was used to quantify mean differences. Ten TRS studies (n = 822) and 29 non-TRS studies (n = 2566) were meta-analysed. Relative variability in change of total symptoms did not differ significantly between clozapine and other antipsychotics in TRS studies (VR = 1.84; 95%CI, 0.85-4.02). These findings were similar with CVR, and for positive and negative symptoms. Clozapine was superior to other antipsychotics in improving total symptoms in both TRS (g = 0.34; 95%CI, 0.13-0.56) and non-TRS (g = 0.20; 95%CI, 0.08-0.32) studies. Furthermore, clozapine was superior in improving positive symptoms in both study groups, but not for negative symptoms. Pooled effect sizes showed no significant difference between TRS and non-TRS studies. These findings do not support a subtype of schizophrenia which responds specifically to clozapine. Clozapine is more effective than other antipsychotics irrespective of treatment-resistance, arguing for its use more generally in schizophrenia. PROSPERO CRD42018086507.
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Affiliation(s)
- Yuya Mizuno
- 0000 0001 2322 6764grid.13097.3cDepartment of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, SE5 8AF UK ,0000 0004 1936 9959grid.26091.3cDepartment of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Robert A. McCutcheon
- 0000 0001 2322 6764grid.13097.3cDepartment of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, SE5 8AF UK ,0000 0001 0705 4923grid.413629.bPsychiatric Imaging Group, MRC London Institute of Medical Sciences, Hammersmith Hospital, London, UK ,0000 0001 2113 8111grid.7445.2Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, UK
| | - Stefan P. Brugger
- 0000 0001 0705 4923grid.413629.bPsychiatric Imaging Group, MRC London Institute of Medical Sciences, Hammersmith Hospital, London, UK ,0000 0001 2113 8111grid.7445.2Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, UK ,0000 0004 1936 7603grid.5337.2Centre for Academic Mental Health, University of Bristol, Bristol, UK ,0000000121901201grid.83440.3bDivision of Psychiatry, University College London, London, UK ,0000 0001 0807 5670grid.5600.3Cardiff University Brain Research Imaging Centre, School of Psychology, Cardiff University, Cardiff, UK
| | - Oliver D. Howes
- 0000 0001 2322 6764grid.13097.3cDepartment of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, SE5 8AF UK ,0000 0001 0705 4923grid.413629.bPsychiatric Imaging Group, MRC London Institute of Medical Sciences, Hammersmith Hospital, London, UK ,0000 0001 2113 8111grid.7445.2Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, UK
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22
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Hellman K, Ohlsson J, Malo M, Olsson R, Ek F. Discovery of Procognitive Antipsychotics by Combining Muscarinic M 1 Receptor Structure-Activity Relationship with Systems Response Profiles in Zebrafish Larvae. ACS Chem Neurosci 2020; 11:173-183. [PMID: 31850734 DOI: 10.1021/acschemneuro.9b00524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Current antipsychotic drugs are notably ineffective at addressing the cognitive deficits associated with schizophrenia. N-Desmethylclozapine (NDMC), the major metabolite of clozapine, displays muscarinic M1 receptor (M1) agonism, an activity associated with improvement in cognitive functioning. Preclinical and clinical data support that M1 agonism may be a desired activity in antipsychotic drugs. However, NDMC failed clinical phase II studies in acute psychotic patients. NDMC analogues were synthesized to establish a structure-activity relationship (SAR) at the M1 receptor as an indication of potential procognitive properties. In vitro evaluation revealed a narrow SAR in which M1 agonist activity was established by functionalization in the 4- and 8-positions in the tricyclic core. In vivo behavioral response profiles were used to evaluate antipsychotic efficacy and exposure in zebrafish larvae and peripheral side effect related M1 activity in adult zebrafish. The NDMC analogue 13f demonstrated antipsychotic activity similar to clozapine including M1 agonist activity. Cotreatment with trospium chloride, an M1 peripheral acting antagonist, counteracted peripheral side effects. Thus, the NDMC analogue 13f, in combination with a peripherally acting anticholinergic compound, could be suitable for further development as an antipsychotic compound with potential procognitive activity.
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Affiliation(s)
- Karin Hellman
- Chemical Biology and Therapeutics, Department of Experimental Medical Science, Lund University, SE-221 84 Lund, Sweden
| | - Jörgen Ohlsson
- Chemical Biology and Therapeutics, Department of Experimental Medical Science, Lund University, SE-221 84 Lund, Sweden
| | - Marcus Malo
- Department of Chemistry and Molecular Biology, University of Gothenburg, SE-405 30 Gothenburg, Sweden
| | - Roger Olsson
- Chemical Biology and Therapeutics, Department of Experimental Medical Science, Lund University, SE-221 84 Lund, Sweden
- Department of Chemistry and Molecular Biology, University of Gothenburg, SE-405 30 Gothenburg, Sweden
| | - Fredrik Ek
- Chemical Biology and Therapeutics, Department of Experimental Medical Science, Lund University, SE-221 84 Lund, Sweden
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23
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de Leon J, Rajkumar AP, Kaithi AR, Schoretsanitis G, Kane JM, Wang CY, Tang YL, Lin SK, Hong KS, Farooq S, Ng CH, Ruan CJ, Andrade C. Do Asian Patients Require Only Half of the Clozapine Dose Prescribed for Caucasians? A Critical Overview. Indian J Psychol Med 2020; 42:4-10. [PMID: 31997860 PMCID: PMC6970303 DOI: 10.4103/ijpsym.ijpsym_379_19] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 09/24/2019] [Accepted: 10/07/2019] [Indexed: 12/12/2022] Open
Abstract
Since 1997, studies have found that Asians need lower clozapine doses than Caucasians. Caucasians with average clozapine metabolism may need from 300 to 600 mg/day to reach the therapeutic range (350 ng/ml). Thus, serum clozapine concentration-to-dose (C/D) ratios typically range between 0.60 (male smokers) and 1.20 (female non-smokers). A 2019 systematic review of clozapine levels demonstrated weighted mean C/D ratios of 1.57 in 876 East Asians and 1.07 in 1147 Caucasians (P < .001). In Asian countries, average clozapine doses are lower than 300 mg/day. After sex and smoking stratification in 5 Asian samples with clozapine concentrations, the clozapine dose required to reach 350 ng/ml in female non-smokers ranged from 145 to 189 mg/day and in male smokers, from 259 to 294 mg/day. Thus, in Asian patients with average metabolism (with no inducers other than smoking, with no inhibitors, and in the absence of extreme obesity), the dose needed for clinical response may range between 150 mg/day for female non-smokers to 300 mg/day for male smokers. Clozapine levels may help personalize dosing in clozapine poor metabolizers (PMs) and ultrarapid metabolizers (UMs). Asian PMs may need very low doses (50-150 mg/day) to obtain therapeutic concentrations. About 10% (range 2-13%) of Asians are genetic PM cases. Other PMs are patients taking CYP1A2 inhibitors such as fluvoxamine, oral contraceptives, and valproate. Temporary clozapine PM status may occur during severe systemic infections/inflammations with fever and C-reactive protein (CRP) elevations. Asian UMs include patients taking potent inducers such as phenytoin, and rarely, valproate.
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Affiliation(s)
- Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, Kentucky, USA.,Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain, and Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain
| | - Anto P Rajkumar
- Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India.,Institute of Mental Health, University of Nottingham, Nottingham, United Kingdom
| | | | - Georgios Schoretsanitis
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York, USA
| | - John M Kane
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York, USA.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Chuan-Yue Wang
- Department of Psychiatry, The National Clinical Research Centre for Mental Disorders and Beijing Key Lab of Mental Disorders and Beijing Institute for Brain Disorders Center of Schizophrenia, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Yi-Lang Tang
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, and Substance Abuse Treatment Program, Atlanta VA Medical Center, Decatur, Georgia, USA
| | - Shih-Ku Lin
- Department of General Psychiatry, Taipei City, Psychiatric Center, Taipei, Taiwan, and Department of Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kyung Sue Hong
- Department of Psychiatry, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Saeed Farooq
- School of Primary, Community and Social Care, Faulty of Medicine and Health Sciences, Keele University, Staffordshire, and Midlands Partnership NHS Foundation Trust, Staffordshire, United Kingdom
| | - Chee H Ng
- Department of Psychiatry, The Melbourne Clinic and St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology & The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Chittaranjan Andrade
- Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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24
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Inhibition of Epstein-Barr Virus Lytic Reactivation by the Atypical Antipsychotic Drug Clozapine. Viruses 2019; 11:v11050450. [PMID: 31108875 PMCID: PMC6563273 DOI: 10.3390/v11050450] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/09/2019] [Accepted: 05/15/2019] [Indexed: 12/15/2022] Open
Abstract
Epstein–Barr virus (EBV), a member of the Herpesviridae family, maintains a lifelong latent infection in human B cells. Switching from the latent to the lytic phase of its lifecycle allows the virus to replicate and spread. The viral lytic cycle is induced in infected cultured cells by drugs such as sodium butyrate and azacytidine. Lytic reactivation can be inhibited by natural products and pharmaceuticals. The anticonvulsant drugs valproic acid and valpromide inhibit EBV in Burkitt lymphoma cells. Therefore, other drugs that treat neurological and psychological disorders were investigated for effects on EBV lytic reactivation. Clozapine, an atypical antipsychotic drug used to treat schizophrenia and bipolar disorder, was found to inhibit the reactivation of the EBV lytic cycle. Levels of the viral lytic genes BZLF1, BRLF1, and BMLF1 were decreased by treatment with clozapine in induced Burkitt lymphoma cells. The effects on viral gene expression were dependent on the dose of clozapine, yet cells were viable at an inhibitory concentration of clozapine. One metabolite of clozapine—desmethylclozapine—also inhibited EBV lytic reactivation, while another metabolite—clozapine-N-oxide—had no effect. These drugs may be used to study cellular pathways that control the viral lytic switch in order to develop treatments for diseases caused by EBV.
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25
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Turkmani K, Marwa ME, Ahmad B, Ahmad T, Alrstom A, Essali A. Clozapine (generic versus branded) for people with schizophrenia. Hippokratia 2019. [DOI: 10.1002/14651858.cd013248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Khaled Turkmani
- Damascus University; Faculty of Medicine; Damascus Syrian Arab Republic
| | | | - Basel Ahmad
- Damascus University; Faculty of Medicine; Damascus Syrian Arab Republic
| | - Tareq Ahmad
- Damascus University; Faculty of Medicine; Damascus Syrian Arab Republic
| | - Ali Alrstom
- Damascus University, Almwasat hospital; Department of Medicine; Damascus Syrian Arab Republic
| | - Adib Essali
- Counties Manukau Health; Community Mental Health; Building 6, 17 Lambie Drive, Manukau Auckland New Zealand 2241
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26
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Asenjo-Lobos C, Cortés-Jofré M, Fonseca C, Leucht S, Madrid E, Bonfill Cosp X. Clozapine versus risperidone for people with schizophrenia. Hippokratia 2018. [DOI: 10.1002/14651858.cd013221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Claudia Asenjo-Lobos
- University of Concepción; Concepción Chile
- Universitat Autònoma de Barcelona; Methodology of Biomedical Research and Public Health; Barcelona Spain
| | - Marcela Cortés-Jofré
- Universitat Autònoma de Barcelona; Methodology of Biomedical Research and Public Health; Barcelona Spain
- Universidad Católica de la SS; Facultad de Medicina; Concepción Concepción Chile
| | - Carolina Fonseca
- Universidad de Santiago de Chile; Facultad de Medicina; Santiago de Chile Chile
| | - Stefan Leucht
- Technische Universität München Klinikum rechts der Isar; Klinik und Poliklinik für Psychiatrie und Psychotherapie; München Germany 81675
| | - Eva Madrid
- School of Medicine Universidad de Valparaiso. - Cochrane Centre; Interdisciplinary Centre for Health Studies CIESAL; Universidad de Valparaiso Chile
| | - Xavier Bonfill Cosp
- CIBER Epidemiología y Salud Pública (CIBERESP); Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau); Sant Antoni Maria Claret 167 Pavilion 18 Barcelona Catalunya Spain 08025
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27
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Asenjo-Lobos C, Fonseca C, Leucht S, Garcia-Ribera C, Cortés-Jofré M. Clozapine versus quetiapine for people with schizophrenia. Hippokratia 2018. [DOI: 10.1002/14651858.cd013220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Claudia Asenjo-Lobos
- University of Concepción; Concepción Chile
- Universitat Autònoma de Barcelona; Methodology of Biomedical Research and Public Health; Barcelona Spain
| | - Carolina Fonseca
- Universidad de Santiago de Chile; Facultad de Medicina; Santiago de Chile Chile
| | - Stefan Leucht
- Technische Universität München Klinikum rechts der Isar; Klinik und Poliklinik für Psychiatrie und Psychotherapie; München Germany 81675
| | - Carles Garcia-Ribera
- Hospital de la Santa Creu i Sant Pau; Psychiatry Department; Calle de Sant Quinti, 89 Barcelona Spain 08026
| | - Marcela Cortés-Jofré
- Universitat Autònoma de Barcelona; Methodology of Biomedical Research and Public Health; Barcelona Spain
- Universidad Católica de la SS; Facultad de Medicina; Concepción Concepción Chile
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28
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Asenjo-Lobos C, Fonseca C, Leucht S, Arancibia M, Cortés-Jofré M. Clozapine versus olanzapine for people with schizophrenia. Hippokratia 2018. [DOI: 10.1002/14651858.cd013219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Claudia Asenjo-Lobos
- University of Concepción; Concepción Chile
- Universitat Autònoma de Barcelona; Methodology of Biomedical Research and Public Health; Barcelona Spain
| | - Carolina Fonseca
- Universidad de Santiago de Chile; Facultad de Medicina; Santiago de Chile Chile
| | - Stefan Leucht
- Technische Universität München Klinikum rechts der Isar; Klinik und Poliklinik für Psychiatrie und Psychotherapie; München Germany 81675
| | - Marcelo Arancibia
- Universidad de Valparaíso; Interdisciplinary Centre for Health Studies CIESAL; Viña del Mar Chile
| | - Marcela Cortés-Jofré
- Universitat Autònoma de Barcelona; Methodology of Biomedical Research and Public Health; Barcelona Spain
- Universidad Católica de la SS; Facultad de Medicina; Concepción Concepción Chile
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