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García Gómez C, Navarro E, Alcázar V, López-Guzmán A, Arrieta F, Anda E, Biagetti B, Guerrero-Pérez F, Villabona C, de Assín Valverde AR, Lamas C, Lecumberri B, Rosado Sierra JA, Sastre J, Díez JJ, Iglesias P. Therapeutic Management and Long-Term Outcome of Hyperthyroidism in Patients with Antithyroid-Induced Agranulocytosis: A Retrospective, Multicenter Study. J Clin Med 2023; 12:6556. [PMID: 37892693 PMCID: PMC10607319 DOI: 10.3390/jcm12206556] [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: 09/13/2023] [Revised: 10/08/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Antithyroid drug-induced agranulocytosis (AIA) (neutrophils <500/µL) is a rare but serious complication in the treatment of hyperthyroidism. METHODOLOGY Adult patients with AIA who were followed up at 12 hospitals in Spain were retrospectively studied. A total of 29 patients were studied. The etiology of hyperthyroidism was distributed as follows: Graves' disease (n = 21), amiodarone-induced thyrotoxicosis (n = 7), and hyperfunctioning multinodular goiter (n = 1). Twenty-one patients were treated with methimazole, as well as six patients with carbimazole and two patients with propylthiouracil. RESULTS The median (IQR) time to development of agranulocytosis was 6.0 (4.0-11.5) weeks. The most common presenting sign was fever accompanied by odynophagia. All of the patients required admission, reverse isolation, and broad-spectrum antibiotics; moreover, G-CSF was administered to 26 patients (89.7%). Twenty-one patients received definitive treatment, thirteen patients received surgery, nine patients received radioiodine, and one of the patients required both treatments. Spontaneous normalization of thyroid hormone values occurred in six patients (four patients with amiodarone-induced thyrotoxicosis and two patients with Graves' disease), and two patients died of septic shock secondary to AIA. CONCLUSIONS AIA is a potentially lethal complication that usually appears around 6 weeks after the initiation of antithyroid therapy. Multiple drugs are required to control hyperthyroidism before definitive treatment; additionally, in a significant percentage of patients (mainly in those treated with amiodarone), hyperthyroidism resolved spontaneously.
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Affiliation(s)
- Carlos García Gómez
- Department of Endocrinology and Nutrition, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), 28222 Madrid, Spain; (J.J.D.); (P.I.)
- Department of Medicine, Universidad Autónoma de Madrid, 28046 Madrid, Spain
| | - Elena Navarro
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain;
| | - Victoria Alcázar
- Department of Endocrinology and Nutrition, Hospital Universitario Severo Ochoa, 28914 Madrid, Spain;
| | - Antonio López-Guzmán
- Department of Endocrinology and Nutrition, Complejo Asistencial de Ávila, 05004 Ávila, Spain;
| | - Francisco Arrieta
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain;
| | - Emma Anda
- Department of Endocrinology and Nutrition, Complejo Hospitalario de Navarra, 31008 Pamplona, Spain;
| | - Betina Biagetti
- Department of Endocrinology and Nutrition, Hospital Universitari Vall d’Hebrón, 08035 Barcelona, Spain;
| | - Fernando Guerrero-Pérez
- Department of Endocrinology and Nutrition, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (F.G.-P.); (C.V.)
| | - Carles Villabona
- Department of Endocrinology and Nutrition, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (F.G.-P.); (C.V.)
| | - Andrés Ruiz de Assín Valverde
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario de Albacete, 02008 Albacete, Spain (C.L.)
| | - Cristina Lamas
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario de Albacete, 02008 Albacete, Spain (C.L.)
| | - Beatriz Lecumberri
- Department of Endocrinology and Nutrition, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | | | - Julia Sastre
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario de Toledo, 45007 Toledo, Spain;
| | - Juan José Díez
- Department of Endocrinology and Nutrition, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), 28222 Madrid, Spain; (J.J.D.); (P.I.)
- Department of Medicine, Universidad Autónoma de Madrid, 28046 Madrid, Spain
| | - Pedro Iglesias
- Department of Endocrinology and Nutrition, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), 28222 Madrid, Spain; (J.J.D.); (P.I.)
- Department of Medicine, Universidad Autónoma de Madrid, 28046 Madrid, Spain
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Abstract
AIMS Clozapine is licensed for treatment-resistant psychosis and remains underutilised. This may berelated to the stringent haematological monitoring requirements that are mandatory in most countries. We aimed to compare guidelines internationally and develop a novel Stringency Index. We hypothesised that the most stringent countries would have increased healthcare costs and reduced prescription rates. METHOD We conducted a literature review and survey of guidelines internationally. Guideline identification involved a literature review and consultation with clinical academics. We focused on the haematological monitoring parameters, frequency and thresholds for discontinuation and rechallenge after suspected clozapine-induced neutropenia. In addition, indicators reflecting monitoring guideline stringency were scored and visualised using a choropleth map. We developed a Stringency Index with an international panel of clozapine experts, through a modified-Delphi-survey. The Stringency Index was compared to health expenditure per-capita and clozapine prescription per 100 000 persons. RESULTS One hundred twocountries were included, from Europe (n = 35), Asia (n = 24), Africa (n = 20), South America (n = 11), North America (n = 7) and Oceania and Australia (n = 5). Guidelines differed in frequency of haematological monitoring and discontinuation thresholds. Overall, 5% of included countries had explicit guidelines for clozapine-rechallenge and 40% explicitly prohibited clozapine-rechallenge. Furthermore, 7% of included countries had modified discontinuation thresholds for benign ethnic neutropenia. None of the guidelines specified how long haematological monitoring should continue. The most stringent guidelines were in Europe, and the least stringent were in Africa and South America. There was a positive association (r = 0.43, p < 0.001) between a country's Stringency Index and healthcare expenditure per capita. CONCLUSIONS Recommendations on how haematological function should be monitored in patients treated with clozapine vary considerably between countries. It would be useful to standardise guidelines on haematological monitoring worldwide.
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Batool S, Voloshyna D, Usama M, Suleman M, Sandhu QI, Nepal L, Ghobriel NG, Mengar J, Mohammed Rasmy AS. The Co-Existence of Agranulocytosis and Stevens-Johnson Syndrome (SJS) in Carbamazepine Therapy: A Case Report. Cureus 2022; 14:e28917. [PMID: 36237740 PMCID: PMC9547122 DOI: 10.7759/cureus.28917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 11/30/2022] Open
Abstract
The therapeutic significance of carbamazepine in individuals with trigeminal neuralgia, epilepsy, and bipolar disorder is well recognized. Although it has high effectiveness, it raises the patient's risk for some adverse effects. The relationship between carbamazepine usage and agranulocytosis is well-established. Agranulocytosis is characterized by an unusually low number of neutrophils. This disorder poses a grave hazard to the patient since they are more likely to get potentially lethal bacterial or fungal infections. Moreover, carbamazepine is one of the most common causes of Stevens-Johnson syndrome (SJS), a severe skin condition with a high mortality rate. In cases where agranulocytosis and Stevens-Johnson syndrome coexist, the prognosis is relatively poor. We report a rare case of a patient who developed agranulocytosis and Stevens-Johnson syndrome after taking carbamazepine. Neutrophils accounted for 2.1% of the patient's differential leukocyte count. Furthermore, Naranjo's scale found a score of 8 for Stevens-Johnson syndrome, placing it in the "probable" category, while a score of 9 for agranulocytosis indicated that it was a confirmed adverse reaction to carbamazepine.
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Sing C, Tang CTL, Chui CSL, Fan M, Lai FTT, Li X, Wan EYF, Wong CKH, Chan EWY, Hung IFN, Leung AY, Cheung C, Wong ICK. COVID-19 vaccines and risks of hematological abnormalities: Nested case-control and self-controlled case series study. Am J Hematol 2022; 97:470-480. [PMID: 35080247 PMCID: PMC9011752 DOI: 10.1002/ajh.26478] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/13/2022] [Accepted: 01/21/2022] [Indexed: 01/08/2023]
Abstract
Several studies reported hematological abnormalities after vaccination against the coronavirus disease 2019 (COVID‐19). We evaluated the association between COVID‐19 vaccines (CoronaVac and BNT162b2) and hematological abnormalities. We conducted nested case–control and self‐controlled case series analyses using the data from the Hong Kong Hospital Authority and the Department of Health, HKSAR. Outcomes of interest were thrombocytopenia, leukopenia, and neutropenia. Adjusted odds ratios (aORs), incidence rate ratios (IRRs), and 95% confidence intervals (CIs) were estimated using conditional logistic regression. In total, 1 643 419 people received COVID‐19 vaccination (738 609 CoronaVac; 904 810 BNT162b2). We identified 457 and 422 cases after CoronaVac and BNT162b2 vaccination, respectively. For CoronaVac, the incidence of thrombocytopenia, leukopenia, and neutropenia was 2.51, 1.08, and 0.15 per 10 000 doses. For BNT162b2, the corresponding incidence was 1.39, 1.17, and 0.26 per 10 000 doses. The incidence per 10 000 COVID‐19 cases were 1254, 2341, and 884, respectively. We only observed an increased risk of leukopenia following the second dose of BNT162b2 (aOR 1.58, 95% CI 1.24–2.02; day 0–14, IRR 2.21; 95% CI 1.59–3.08). There was no increased risk of any hematological abnormalities after CoronaVac vaccination. We observed an increased risk of leukopenia shortly after the second dose of BNT162b2. However, the incidence was much lower than the incidence following severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infections. There was no association between CoronaVac and hematological abnormalities. The benefits of vaccination against COVID‐19 still outweigh the risk of hematological abnormalities.
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Affiliation(s)
- Chor‐Wing Sing
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
- Laboratory of Data Discovery for Health (D24H) Hong Kong Science Park Hong Kong Special Administrative Region China
| | - Casey Tze Lam Tang
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
| | - Celine Sze Ling Chui
- Laboratory of Data Discovery for Health (D24H) Hong Kong Science Park Hong Kong Special Administrative Region China
- School of Nursing, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
- School of Public Health, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
| | - Min Fan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
| | - Francisco Tsz Tsun Lai
- Laboratory of Data Discovery for Health (D24H) Hong Kong Science Park Hong Kong Special Administrative Region China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
| | - Xue Li
- Laboratory of Data Discovery for Health (D24H) Hong Kong Science Park Hong Kong Special Administrative Region China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
- Department of Medicine, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
| | - Eric Yuk Fai Wan
- Laboratory of Data Discovery for Health (D24H) Hong Kong Science Park Hong Kong Special Administrative Region China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
- Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
| | - Carlos King Ho Wong
- Laboratory of Data Discovery for Health (D24H) Hong Kong Science Park Hong Kong Special Administrative Region China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
- Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
| | - Esther Wai Yin Chan
- Laboratory of Data Discovery for Health (D24H) Hong Kong Science Park Hong Kong Special Administrative Region China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
| | - Ivan Fan Ngai Hung
- Department of Medicine, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
- Expert Committee on Clinical Events Assessment Following COVID‐19 Immunization, Department of Health The Government of the Hong Kong Special Administrative Region Hong Kong Special Administrative Region China
| | - Anskar Yu‐Hung Leung
- Division of Haematology, Department of Medicine, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
| | - Ching‐Lung Cheung
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
- Laboratory of Data Discovery for Health (D24H) Hong Kong Science Park Hong Kong Special Administrative Region China
| | - Ian Chi Kei Wong
- Laboratory of Data Discovery for Health (D24H) Hong Kong Science Park Hong Kong Special Administrative Region China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong Special Administrative Region China
- Expert Committee on Clinical Events Assessment Following COVID‐19 Immunization, Department of Health The Government of the Hong Kong Special Administrative Region Hong Kong Special Administrative Region China
- Research Department of Practice and Policy, School of Pharmacy University College London London UK
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Abstract
OBJECTIVE Agranulocytosis is a rare but serious adverse drug reaction (ADR) of thionamide antithyroid drugs (ATDs). We explored the characteristics of ADRs in patients with hyperthyroidism. METHODS This retrospective study included 3558 inpatients with Graves disease treated in a Class A Grade 3 hospital between 2015 and 2019. The clinical presentation and laboratory workup of patients with antithyroid drug (ATD)-induced agranulocytosis was analyzed. RESULTS Agranulocytosis was thought to be caused by ATDs in 36 patients. The hospital length of stay was 12 (10-16) days, and hospitalization costs were approximately $2810.89 ($2156.50-$4164.67). The median duration of ATD therapy prior to agranulocytosis development was 30 (20-40) days. Fever (83.33%) and sore throat (75%) were the most common symptoms as early signs of agranulocytosis. The lowest neutrophil counts were 0.01 (0.00-0.03) × 109/L and 0.14 (0.02-0.29) × 109/L in the methimazole and propylthiouracil groups, respectively (P = .037). The recovery times of agranulocytosis were 9.32 ± 2.89 days and 5.60 ± 4.10 days in the methimazole and propylthiouracil groups, respectively (P = .016). Patients with severe agranulocytosis required a longer time to recover (P < .001) and had closer to normal serum thyroxine and triiodothyronine levels. The interval between the first symptom of agranulocytosis and ATD withdrawal was 1 (0-3) day. CONCLUSIONS Patients with agranulocytosis needed a long hospital length of stay and incurred high costs. Methimazole was prone to causing a more serious agranulocytosis than propylthiouracil. High thyroid hormone was unlikely to play a role in adverse drug reactions. Patient education is important.
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Ribé Buitrón JM, González Rodríguez M, Barceló Colomer ME. [Clozapine and agranulocytosis: Rethinking the usefulness of its monitoring]. Aten Primaria 2021; 53:102114. [PMID: 34116408 PMCID: PMC8193365 DOI: 10.1016/j.aprim.2021.102114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- José Miguel Ribé Buitrón
- Centre de Salut Mental d'Adults Sant Andreu, Fundació Vidal i Barraquer, Barcelona, España; Institut Universitari Salut Mental Vidal i Barraquer, Universitat Ramon Llull, Barcelona, España.
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Borrelli EP, Lee EY, Caffrey AR. Clozapine and hematologic adverse reactions: Impact of the Risk Evaluation and Mitigation Strategy program. Ment Health Clin 2020; 10:70-75. [PMID: 32420002 PMCID: PMC7213944 DOI: 10.9740/mhc.2020.05.070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction In October 2015, the Food and Drug Administration (FDA) instituted an update to the mandatory Risk Evaluation and Mitigation Strategy (REMS) program for clozapine to improve safety monitoring of hematologic events. However, the impact of the clozapine REMS program on reporting of hematologic adverse events has not been quantified. Methods We assessed adverse event reports for agranulocytosis, granulocytopenia, leukopenia, and neutropenia from the FDA Adverse Event Reporting System (FAERS) for a 1-year time period before (October 2014 to September 2015, pre-REMS) and after (October 2015 to September 2016, post-REMS) the implementation of the clozapine REMS program. The AERSMine platform was used to capture historical effect estimates (October 2004 to September 2014). Reporting odds ratios (ROR), proportional reporting ratios (PRR), and corresponding Taylor series 95% confidence intervals (CIs) were calculated for hematologic events with clozapine compared with all other medications using OpenEpi. Results Reporting rates for agranulocytosis, granulocytopenia, leukopenia, and neutropenia with clozapine all increased from the pre-REMS to post-REMS time frames, ranging from a 2-fold increase with leukopenia to a 40-fold increase with neutropenia; the composite measure of all hematologic reports had a 12-fold increase. During the post-REMS time frame, the ROR increased by 1691% (111.4, 95% CI 100.6-123.4) compared with the pre-REMS time frame (7.1, 95% CI 5.2-9.6), and the PRR increased by 1280% (83.1, 95% CI 76.8-90.0 vs 6.9, 95% CI 5.1-9.4) for the composite outcome. Discussion We observed significant increases in reports of hematologic adverse events with clozapine after the introduction of the clozapine REMS program. Future research should explore the impact of the less stringent exclusionary and discontinuation criteria on utilization (eg, expanded access) and clinical outcomes (eg, treatment effectiveness and adverse events).
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Boegeholz J, Brueggen CS, Pauli C, Dimitriou F, Haralambieva E, Dummer R, Manz MG, Widmer CC. Challenges in diagnosis and management of neutropenia upon exposure to immune-checkpoint inhibitors: meta-analysis of a rare immune-related adverse side effect. BMC Cancer 2020; 20:300. [PMID: 32290812 PMCID: PMC7155336 DOI: 10.1186/s12885-020-06763-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 03/17/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Cancer immunotherapy via immune-checkpoint inhibition (ICI) by antibodies against cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and cell death protein 1 (PD-1) have significantly improved the outcome of metastasized melanoma and of a rapidly increasing number of other cancer types. The anti-tumor effect is often accompanied by immune-related adverse events (irAE). Hematological irAE, specifically neutropenia, are rarely observed. However, neutropenia is associated with high morbidity and mortality due to infection complications. Thus, early detection and treatment is crucial. METHODS We present the clinical course of two patients with severe neutropenia after ICI therapy and demonstrate the difficulty of the diagnosis when a comedication of metamizole, a well-known analgesic drug used to treat cancer pain, is present. Further, we provide a comprehensive descriptive and statistical analysis of published data on diagnostics, treatment and infection complication in patients with at least grade 4 neutropenia by a systematic database search. RESULTS Finally, 34 patients were analyzed, including the two case reports from our cohort. The median onset of neutropenia was 10.5 weeks after first ICI administration (interquartile range: 6 weeks). In 76% (N = 26), a normalization of the neutrophil count was achieved after a median duration of neutropenia of 13 days. In a subsample of 22 patients with detailed data, the infection rate was 13%, proven by positive blood culture in 3 cases, but 68% (N = 15) presented with fever > 38 °C. Treatment regime differed relevantly, but mainly included G-CSF and intravenous corticosteroids. Death was reported in 14 patients (41%), 3 of whom (9%) were associated with hematological irAE but only two directly associated with neutropenia. CONCLUSION With an increasing number of cancer patients eligible to ICI therapy, the incidence of severe hematological toxicities may rise substantially over the next years. Clinicians working in the field of cancer immune therapies should be aware of neutropenia as irAE to provide immediate treatment.
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Affiliation(s)
- J Boegeholz
- Department of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland
| | - C S Brueggen
- Department of Dermatology, University and University Hospital Zurich, Zurich, Switzerland
| | - C Pauli
- Department of Dermatology, University and University Hospital Zurich, Zurich, Switzerland
| | - F Dimitriou
- Department of Dermatology, University and University Hospital Zurich, Zurich, Switzerland
| | - E Haralambieva
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - R Dummer
- Department of Dermatology, University and University Hospital Zurich, Zurich, Switzerland
| | - M G Manz
- Department of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland
| | - C C Widmer
- Department of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland.
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Li XH, Zhong XM, Lu L, Zheng W, Wang SB, Rao WW, Wang S, Ng CH, Ungvari GS, Wang G, Xiang YT. The prevalence of agranulocytosis and related death in clozapine-treated patients: a comprehensive meta-analysis of observational studies. Psychol Med 2020; 50:583-594. [PMID: 30857568 DOI: 10.1017/s0033291719000369] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Clozapine treatment increases the risk of agranulocytosis, but findings on the epidemiology of agranulocytosis have been inconsistent. This meta-analysis examined the prevalence of agranulocytosis and related death in clozapine-treated patients. METHODS A literature search in the international (PubMed, PsycINFO, and EMBASE) and Chinese (WanFang, Chinese National Knowledge Infrastructure, and Sinomed) databases was conducted. Prevalence estimates of agranulocytosis and related death in clozapine-treated patients were synthesized with the Comprehensive Meta-Analysis program using the random-effects model. RESULTS Thirty-six studies with 260 948 clozapine-treated patients published between 1984 and 2018 were included in the meta-analysis. The overall prevalence of agranulocytosis and death caused by agranulocytosis were 0.4% (95% CI 0.3-0.6%) and 0.05% (95% CI 0.03-0.09%), respectively. The prevalence of agranulocytosis was moderated by sample size, study quality, year of publication, and that of data collection. CONCLUSIONS The prevalence of clozapine-associated agranulocytosis is low. Agranulocytosis-related death appears rare.
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Affiliation(s)
- Xiao-Hong Li
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders & the Advanced Innovation Center for Human Brain Protection, Beijing Anding Hospital, School of Mental Health, Capital Medical University, Beijing, China
| | - Xiao-Mei Zhong
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Li Lu
- Unit of Psychiatry, Centre of Translational Medicine, Faculty of Health Sciences, University of Macau, Macao SAR, China
| | - Wei Zheng
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Shi-Bin Wang
- Guangdong Mental Health Center, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Wen-Wang Rao
- Unit of Psychiatry, Centre of Translational Medicine, Faculty of Health Sciences, University of Macau, Macao SAR, China
| | - Shuai Wang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders & the Advanced Innovation Center for Human Brain Protection, Beijing Anding Hospital, School of Mental Health, Capital Medical University, Beijing, China
| | - Chee H Ng
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
| | - Gabor S Ungvari
- University of Notre Dame Australia, Fremantle, Australia
- Division of Psychiatry, Medical School, University of Western Australia, Perth, Australia
| | - Gang Wang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders & the Advanced Innovation Center for Human Brain Protection, Beijing Anding Hospital, School of Mental Health, Capital Medical University, Beijing, China
| | - Yu-Tao Xiang
- Unit of Psychiatry, Centre of Translational Medicine, Faculty of Health Sciences, University of Macau, Macao SAR, China
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Qin X, Tsoi MF, Zhao X, Zhang L, Qi Z, Cheung BMY. Vancomycin-associated acute kidney injury in Hong Kong in 2012-2016. BMC Nephrol 2020; 21:41. [PMID: 32013870 PMCID: PMC6998253 DOI: 10.1186/s12882-020-1704-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 01/24/2020] [Indexed: 11/12/2022] Open
Abstract
Background To study the incidence of vancomycin-associated acute kidney injury (VA-AKI) in Hong Kong and identify risk factors for VA-AKI. Method Patients with vancomycin prescription and blood level measurement in 2012–2016 were identified using the Hong Kong Hospital Authority Clinical Data Analysis and Reporting System. Acute kidney injury was defined using KDIGO criteria. Patients without creatinine measurements, steady-state trough vancomycin level or who had vancomycin treatment < 3 days were excluded. Results were analyzed using SPSS version 22.0. Logistic regression was used to identify the predictors for VA-AKI. Odds ratio and 95% confidence interval were estimated. Results One thousand four hundred fifty patients were identified as VA-AKI from 12,758 records in Hong Kong in 2012–2016. The incidence was respectively 10.6, 10.9, 11.3, 12.2, 11.2% from 2012 to 2016. The incidence of VA-AKI was 16.3, 12.2, 11.3 and 6.2% in patients aged 1–12, 12–60, elderly aged > 60 and newborn and infants, respectively. Baseline creatinine, serum trough vancomycin level, systematic disease history including respiratory failure, hypertension, congestive heart failure, chronic renal failure, anemia and type II diabetes, and concomitant diuretics, piperacillin-tazobactam (PTZ) and meropenem prescription were significantly higher in VA-AKI patients older than 12 years. Logistic regression showed that older age group, higher baseline creatinine, serum trough vancomycin level, respiratory failure, chronic renal failure and congestive heart failure, concomitant diuretics, PTZ and meropenem prescription, and longer hospital stay were all associated with increased risk of VA-AKI. Conclusion The incidence of VA-AKI in Hong Kong is low but shows no decline. Patients with higher baseline creatinine, multi-organ diseases and multiple drugs administration should have their vancomycin level monitored to decrease the risk of VA-AKI.
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Affiliation(s)
- Xuzhen Qin
- Department of Laboratory Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Man-Fung Tsoi
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Xinyu Zhao
- Department of epidemiology and health statistics, Institute of basic medicine, Peking Union Medical College, Beijing, China
| | - Lin Zhang
- Department of Laboratory Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Zhihong Qi
- Department of Laboratory Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Bernard M Y Cheung
- Department of Medicine, The University of Hong Kong, Hong Kong, China. .,State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong, China.
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Tunsirimas N, Pariwatcharakul P, Choovanichvong S, Ratta-Apha W. Clozapine-induced agranulocytosis and leukopenia: Incidence, associated factors, and rate of hematologic adverse-effects monitoring in psychiatric out-patient services in Thailand. Asian J Psychiatr 2019; 41:13-16. [PMID: 30856469 DOI: 10.1016/j.ajp.2019.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 02/27/2019] [Accepted: 03/04/2019] [Indexed: 01/21/2023]
Abstract
The present study aimed to investigate the incidence of agranulocytosis and leukopenia and its associated factors in Thai schizophrenia patients treated with clozapine and the rate of hematologic adverse events monitored in clinical practice. Data were collected from the medical records of 641 outpatients at two hospitals. The results showed no cases of agranulocytosis and 20 cases of leukopenia (3.1%), 85% of which were observed after 1 year of prescription. The associated factors were female (p = 0.019) and duration of clozapine prescription (p = 0.026). According to the guideline for safety monitoring, 23.6% of cases had neutrophils count monitoring.
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Affiliation(s)
- Noppawan Tunsirimas
- Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Nakorn Ratchasima Rajanagarindra Psychiatric Hospital, Nakorn Ratchasima, Thailand
| | - Pornjira Pariwatcharakul
- Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Woraphat Ratta-Apha
- Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Abstract
Recent studies have revealed that the intestinal bacterial microbiome plays an important role in the regulation of hematopoiesis. A correlation between adverse hematologic effects and imbalance of the intestinal microbiome, or dysbiosis, is evident in several human conditions, such as inflammatory bowel disease, obesity, and, critically, in the setting of antibiotic exposure. Here we review the effects of gut dysbiosis on the hematological compartment and our current understanding of the mechanisms through which changes in the bacterial microbiome affect hematopoiesis.
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