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Leung JG, Allen ND, Markota M. A case series of clozapine titrations affected by inflammatory processes. Schizophr Res 2024; 268:94-97. [PMID: 37633777 DOI: 10.1016/j.schres.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 08/10/2023] [Accepted: 08/12/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Jonathan G Leung
- Department of Pharmacy, Mayo Clinic Rochester, MN, United States of America.
| | - Nicholas D Allen
- Department of Psychiatry and Psychology, Mayo Clinic Rochester, MN, United States of America
| | - Matej Markota
- Department of Psychiatry and Psychology, Mayo Clinic Rochester, MN, United States of America
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2
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Kang N, Kim SH, Kim J, Kim S, Jang J, Yoon H, Lee J, Kim M, Kim YS, Kwon JS. Association between initial pattern of clozapine titration, concentration-to-dose ratio, and incidence of fever in patients with schizophrenia spectrum disorders in a Korean tertiary hospital. Schizophr Res 2024; 268:131-137. [PMID: 37633775 DOI: 10.1016/j.schres.2023.08.001] [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] [Received: 05/31/2023] [Revised: 08/01/2023] [Accepted: 08/04/2023] [Indexed: 08/28/2023]
Abstract
Safe and effective administration of clozapine requires careful monitoring for inflammatory reactions during the initial titration. The concentration-to-dose (C/D) ratio must be taken into account, which may vary among ethnicities. In this retrospective study, 1408 Korean schizophrenia inpatients were examined for during the first 8 weeks of clozapine titration. The average doses of clozapine administered during weeks 1, 2, 4, and 8 were 77.37, 137.73, 193.20, and 212.83 mg/day, with significantly lower doses for females than males. The average C/D ratio was significantly higher in females (1.75 ± 1.04 and 1.11 ± 0.67 ng/mL per mg/day). Patients with higher C/D ratios were more likely to experience fever and were prescribed lower doses of clozapine starting from week 4. In total, 22.1 % of patients developed a fever at an average of 15.74 days after initiating clozapine. Patients who developed a fever were younger, used more antipsychotics at baseline, had a higher C/D ratio, and had a higher incidence of an elevated C-reactive protein level. A higher C/D ratio, use of a greater number of antipsychotics at baseline, and concomitant olanzapine use were risk factors for the development of inflammatory reactions. The incidence of pneumonia, agranulocytosis, and myocarditis within 8 weeks were 3.7 %, 0.3 %, and 0.1 %. In summary, the target dose of clozapine titration is lower for Korean schizophrenia patients, with a higher C/D ratio and more frequent fever compared to Western patients; however, myocarditis occurs rarely. Our findings may contribute to the titration methods for clozapine for the East Asian population.
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Affiliation(s)
- Nuree Kang
- 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.
| | - Jayoun Kim
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Sungkyu Kim
- Biomedical research institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jinhyeok Jang
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Heesoo Yoon
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Junhee Lee
- Department of Psychiatry, Uijeongbu Eulji Medical Center, Uijeongbu, 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
| | - Yong Sik Kim
- Department of Psychiatry, Nowon Eulji Medical Center, Eulji University, 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, SNU-MRC, Seoul, Republic of Korea
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Kikuchi Y, Komatsu H, Otsuka Y, Ito F, Kanahara N, Tanifuji H, Tomita H. Slower clozapine titration than the official Japanese protocol led to fewer inflammatory adverse effects: A retrospective chart review of seven hospitals. Schizophr Res 2024; 268:98-106. [PMID: 37331881 DOI: 10.1016/j.schres.2023.06.003] [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] [Received: 05/17/2023] [Revised: 06/06/2023] [Accepted: 06/08/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Higher frequencies of inflammatory adverse effects of clozapine have been reported in Japan. As the international titration protocol for Asians has set slower dose titration than the Japanese package insert, we hypothesized that a dose titration speed slower than the recommendation of the guideline would be associated with fewer inflammatory-related adverse events. METHODS The medical records of all 272 patients who were first started on clozapine at seven hospitals between 2009 and 2023 were studied retrospectively. Of those, 241 were included in the analysis. The patients were divided into two groups regarding whether the titration speed was faster or slower than the guideline for Asians. The incidence of inflammatory adverse events with clozapine was compared between the groups. RESULTS The frequency of inflammatory adverse events was 34 % (37/110) in the faster titration group and 13 % (17/131) in the slower titration group, and a significant difference was observed by Fisher exact test (odds ratio 3.38; 95 % confidence interval 1.71-6.91; p < 0.001). Serious adverse effects, fever for more than five days, and clozapine discontinuation were significantly more frequent in the faster titration group. Logistic regression analysis indicated significantly more inflammatory adverse events in the faster titration group (adjusted odds ratio 4.01; 95 % confidence interval 2.02-7.87; p < 0.001) considering age, sex, body mass index, concomitant valproic acid, and smoking as confounding factors. CONCLUSION Clozapine-induced inflammatory adverse events were less frequent in Japanese individuals when a titration rate was more gradual than the protocol recommended in the Japanese package insert.
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Affiliation(s)
- Yuki Kikuchi
- Department of Psychiatry, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; Department of Psychiatry, Kodama Hospital, Ishinomaki, Miyagi, Japan.
| | - Hiroshi Komatsu
- Department of Psychiatry, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yuji Otsuka
- Department of Psychiatry, Asahi General Hospital, Asahi, Japan.
| | - Fumiaki Ito
- National Hospital Organization Hanamaki Hospital, Hanamaki, Japan
| | - Nobuhisa Kanahara
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan; Division of Medical Treatment and Rehabilitation, Center for Forensic Mental Health, Chiba University, Chiba, Japan.
| | - Hiroaki Tanifuji
- Department of Pharmacy, Kodama Hospital, Ishinomaki, Miyagi, Japan.
| | - Hiroaki Tomita
- Department of Psychiatry, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; Department of Psychiatry, Tohoku University Hospital, Sendai, Miyagi, Japan.
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de Leon J. Can Slow Personalized Titration Using C-Reactive Protein Monitoring Decrease the High Rates and Mortality of Clozapine-Associated Myocarditis Seen in Some Countries? A Call for Research. J Clin Psychopharmacol 2024; 44:212-219. [PMID: 38595145 DOI: 10.1097/jcp.0000000000001843] [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] [Indexed: 04/11/2024]
Abstract
PURPOSE/BACKGROUND The hypothesis that slower personalized titration may prevent clozapine-associated myocarditis and decrease the disproportion incidence of 3% found in Australia was not described in a recent Australian article in this journal. METHODS Six countries in addition to Australia have published information suggesting a similar incidence of clozapine-associated myocarditis. On September 19, 2023, PubMed searches were updated for articles from the United States, Korea, Japan, Canada, New Zealand, and Turkey. FINDINGS/RESULTS An incidence of 3.5% (4/76) was found in a US hospital, but US experts were the first to propose that clozapine-associated myocarditis may be a hypersensitivity reaction associated with rapid titration and possibly preventable. Koreans and Japanese are of Asian ancestry and need lower minimum therapeutic doses for clozapine than patients of European ancestry. A 0.1% (2/1408) incidence of myocarditis during clozapine titration was found in a Korean hospital, but pneumonia incidence was 3.7% (52/1408). In 7 Japanese hospitals, 34% (37/110) of cases of clozapine-associated inflammation were found during faster titrations (based on the official Japanese titration) versus 13% (17/131) during slower titrations (based on the international titration guideline for average Asian patients). Recent limited studies from Canada, New Zealand, and Turkey suggest that slower personalized titration considering ancestry may help prevent clozapine-associated myocarditis. IMPLICATIONS/CONCLUSIONS Other countries have very limited published data on clozapine-associated myocarditis. Based on a recent Australian case series and these non-Australian studies, the author proposes that Australia (and other countries) should use slow personalized titration for clozapine based on ancestry and c-reactive protein monitoring.
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Kikuchi Y, Yada Y, Otsuka Y, Ito F, Tanifuji H, Komatsu H, Tomita H. Slower clozapine titration is associated with delayed onset of clozapine-induced fever among Japanese patients with schizophrenia. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2023; 9:82. [PMID: 37985654 PMCID: PMC10661360 DOI: 10.1038/s41537-023-00412-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/10/2023] [Indexed: 11/22/2023]
Abstract
Clozapine-induced fever marks the beginning of its inflammatory and potentially life-threatening adverse effects, such as myocarditis. We retrospectively analyzed the correlation between clozapine titration rate and fever onset date in 254 Japanese patients, including 55 with treatment-resistant schizophrenia who developed clozapine-induced fever. Pearson's product-moment correlation indicated a significant delay in the fever onset date with slower titration. Most fever onset cases occurred within 4 weeks, even with slow titration. Therefore, clinicians should remain vigilant in monitoring clozapine-induced fever within 4 weeks of clozapine initiation, regardless of the titration rate.
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Affiliation(s)
- Yuki Kikuchi
- Department of Psychiatry, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan.
- Department of Psychiatry, Kodama Hospital, Ishinomaki, Miyagi, Japan.
| | - Yuji Yada
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Yuji Otsuka
- Department of Psychiatry, Asahi General Hospital, Asahi, Japan
| | - Fumiaki Ito
- National Hospital Organization Hanamaki Hospital, Hanamaki, Japan
| | - Hiroaki Tanifuji
- Department of Pharmacy, Kodama Hospital, Ishinomaki, Miyagi, Japan
| | - Hiroshi Komatsu
- Department of Psychiatry, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hiroaki Tomita
- Department of Psychiatry, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan
- Department of Psychiatry, Tohoku University Hospital, Sendai, Miyagi, Japan
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Yasui‐Furukori N, Otsuka Y, de Leon J. Japanese patients need slower, personalized clozapine titrations: A comment on the case described by Kikuchi et al. PCN REPORTS : PSYCHIATRY AND CLINICAL NEUROSCIENCES 2023; 2:e70. [PMID: 38868406 PMCID: PMC11114375 DOI: 10.1002/pcn5.70] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 12/08/2022] [Accepted: 12/22/2022] [Indexed: 06/14/2024]
Affiliation(s)
- Norio Yasui‐Furukori
- Department of Psychiatry, School of MedicineDokkyo Medical UniversityTochigiJapan
| | - Yuji Otsuka
- Department of PsychiatryAsahi General HospitalChibaJapan
| | - Jose de Leon
- Mental Health Research CenterEastern State HospitalLexingtonKentuckyUSA
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol HospitalUniversity of the Basque CountryVitoriaSpain
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De Las Cuevas C, Sanz EJ, Ruan CJ, de Leon J. Clozapine-associated myocarditis in the World Health Organization's pharmacovigilance database: Focus on reports from various countries. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2022; 15:238-250. [PMID: 36513400 DOI: 10.1016/j.rpsmen.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/10/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The incidence of clozapine-associated myocarditis varies by country. These variations were explored in VigiBase, the World Health Organization's global database which has >25 million spontaneously reported adverse drug reaction (ADR) reports from 145 national drug agencies. METHODS On January 15, 2021, a search of VigiBase since inception focused on myocarditis in clozapine patients. The 3572 individual reports were studied using the standard VigiBase logarithmic measure of disproportionality called information component (IC). The IC measures the disproportionality between the expected and the reported rates. After duplicates were eliminated there were 3274 different patients with myocarditis studied in logistic regression models. RESULTS The first case was published in 1980 but since 1993 the VigiBase clozapine-myocarditis IC has been significant; moreover, currently it is very strong (IC=6.0, IC005-IC995=5.9-6.1) and statistically significantly different from other antipsychotics. Of the 3274 different patients with myocarditis, 43.4% were non-serious cases, 51.8% were serious but non-fatal, and 4.8% were fatal. More than half (1621/3274) of the reports came from Australia, of which 69.2% were non-serious, 27.7% serious but non-fatal, and 3.1% fatal. Asian countries contributed only 41 cases. CONCLUSIONS In pharmacovigilance studies, confounding factors may explain statistical associations, but the strength and robustness of these results are compatible with the hypothesis that myocarditis is definitively associated with early clozapine treatment (84% [1309/1560] and 5% [82/1560] in the first and second months). Myocarditis reports from Australia are over-represented to a major degree. Asian countries may be underreporting myocarditis to their drug agencies.
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Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, Instituto Universitario de Neurociencias (IUNE), University of La Laguna, Canary Islands, Spain
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain; Hospital Universitario de Canarias, Tenerife, Spain
| | - 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; Department of Psychiatry, The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders & Beijing Institute for Brain Disorders Center of Schizophrenia, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA; Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain.
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de Leon J, Ruan CJ, Schoretsanitis G, Rohde C, Yağcıoğlu EA, Baptista T, Kirilochev OO, De Las Cuevas C, Correll CU. An international guideline with six personalised titration schedules for preventing myocarditis and pneumonia associated with clozapine. Gen Psychiatr 2022; 35:e100773. [PMID: 35866000 PMCID: PMC9244675 DOI: 10.1136/gpsych-2022-100773] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/14/2022] [Indexed: 12/12/2022] Open
Abstract
White blood cell (WBC) monitoring has reduced clozapine-treated patient deaths associated with agranulocytosis to a rarity. However, clozapine protocols and package inserts worldwide provide no instructions for preventing myocarditis or pneumonia during clozapine titrations. Prescribers worldwide are largely unaware of that. Meanwhile, as they worry about agranulocytosis, their clozapine-treated patients are at risk of dying from pneumonia or myocarditis. Consequently, an international guideline with 104 authors from 50 countries/regions was recently published to provide personalised clozapine titration schedules for adult inpatients. This forum article reviews pneumonia and myocarditis occurring during clozapine titration, as well as the three most innovative aspects of this new guideline: (1) personalised titration, (2) C reactive protein (CRP) measures, and (3) dose predictions based on blood levels. Clozapine metabolism is influenced by 3 levels of complexity: (1) ancestry groups, (2) sex-smoking subgroups, and (3) presence/absence of poor metabolizer status. These 3 groups of variables should determine the maintenance dose and speed of clozapine titration; they are summarised in a table in the full-text. The international clozapine titration guideline recommends measuring CRP levels simultaneously with WBC, at baseline and weekly at least for the first 4 weeks of titration, the highest risk period for clozapine-induced myocarditis.
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Affiliation(s)
- Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, Kentucky, USA.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Hospital Santiago Apóstol, Vitoria-Gasteiz, Spain
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology, Beijing An Ding Hospital, Beijing, China.,The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing An Ding Hospital, Beijing, China
| | - Georgios Schoretsanitis
- Psychiatry, University of Zürich, Zurich, Switzerland.,Psychiatry Research, Zucker Hillside Hospital, Glen Oaks, New York, USA
| | - Christopher Rohde
- Affective Disorders, Aarhus University Hospital, Aarhus, Denmark.,Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
| | | | - Trino Baptista
- Physiology, Los Andes University Medical School, Merida, Bolivarian Republic of Venezuela
| | - Oleg O Kirilochev
- Clinical Pharmacology, Astrakhan State Medical University, Astrakhan, Astrahanskaâ, Russian Federation
| | - Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry and Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, La Laguna, Spain
| | - Christoph U Correll
- Psychiatry Research, Zucker Hillside Hospital, Glen Oaks, New York, USA.,Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
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de Filippis R, Kane JM, Kuzo N, Spina E, De Sarro G, de Leon J, De Fazio P, Schoretsanitis G. Screening the European pharmacovigilance database for reports of clozapine-related DRESS syndrome: 47 novel cases. Eur Neuropsychopharmacol 2022; 60:25-37. [PMID: 35635994 DOI: 10.1016/j.euroneuro.2022.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/12/2022] [Accepted: 04/16/2022] [Indexed: 12/13/2022]
Abstract
Clozapine-related drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare adverse reaction. We aimed to screen a large pharmacovigilance database to identify clozapine-related DRESS cases, even if otherwise reported and provide a clinical overview. We screened spontaneous reports of clozapine-related DRESS syndrome in EudraVigilance database applying the European Registry on Severe Cutaneous Adverse Drug Reactions (RegiSCAR) criteria and scores to identify probable/definite DRESS syndrome cases. Clinical and demographic characteristics of included cases were provided and associations between RegiSCAR scores, and time to develop/recover DRESS were assessed. In a total of 262,146 adverse drug reactions reports for 75,190 clozapine-treated patients, 596 cases fulfilled RegiSCAR criteria; ultimately, 51 cases were rated as probable/definite DRESS according to RegiSCAR scores, of which 4 were previously published as case reports. The mean age of patients was 41.06 years (43.1% females), with 13 patients (25.5%) receiving reported co-medication with other DRESS culprit drugs. Median time between clozapine initiation and DRESS symptoms was 25 days. Clozapine dose was associated with days to develop symptoms (Spearman's ρ 0.40, p = 0.03). Organ involvement was reported in all cases followed by fever (n = 49; 96.1%) and eosinophilia (n = 47; 92.2%). Treatment involved clozapine discontinuation for 37 patients (72.5%), while 3.9% (n = 2) of cases ended fatally. Clozapine rechallenge was undertaken in 25 patients (49.0%). The screening of the EudraVigilance database revealed 47 novel clozapine-related DRESS cases, and only one was originally reported as DRESS. Clozapine-related DRESS may occur with clozapine monotherapy not only during dose titration, but also during maintenance treatment.
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Affiliation(s)
- Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, 88100, Italy; Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland.
| | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, 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
| | - Nazar Kuzo
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, 98125, Messina, Italy
| | | | - Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain
| | - Pasquale De Fazio
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, 88100, Italy
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland; The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
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de Leon J. The history of clozapine in clinical practice: From its introduction to a guideline proposing personalized titrations. J Psychopharmacol 2022; 36:657-660. [PMID: 35634693 DOI: 10.1177/02698811221101059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria-Gasteiz, Spain
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11
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De Las Cuevas C, Sanz EJ, Ruan CJ, de Leon J. Clozapine-associated myocarditis in the World Health Organization's pharmacovigilance database: Focus on reports from various countries. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2021; 15:S1888-9891(21)00070-7. [PMID: 34298164 DOI: 10.1016/j.rpsm.2021.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The incidence of clozapine-associated myocarditis varies by country. These variations were explored in VigiBase, the World Health Organization's global database which has >25 million spontaneously reported adverse drug reaction (ADR) reports from 145 national drug agencies. METHODS On January 15, 2021, a search of VigiBase since inception focused on myocarditis in clozapine patients. The 3572 individual reports were studied using the standard VigiBase logarithmic measure of disproportionality called information component (IC). The IC measures the disproportionality between the expected and the reported rates. After duplicates were eliminated there were 3274 different patients with myocarditis studied in logistic regression models. RESULTS The first case was published in 1980 but since 1993 the VigiBase clozapine-myocarditis IC has been significant; moreover, currently it is very strong (IC=6.0, IC005-IC995=5.9-6.1) and statistically significantly different from other antipsychotics. Of the 3274 different patients with myocarditis, 43.4% were non-serious cases, 51.8% were serious but non-fatal, and 4.8% were fatal. More than half (1621/3274) of the reports came from Australia, of which 69.2% were non-serious, 27.7% serious but non-fatal, and 3.1% fatal. Asian countries contributed only 41 cases. CONCLUSIONS In pharmacovigilance studies, confounding factors may explain statistical associations, but the strength and robustness of these results are compatible with the hypothesis that myocarditis is definitively associated with early clozapine treatment (84% [1309/1560] and 5% [82/1560] in the first and second months). Myocarditis reports from Australia are over-represented to a major degree. Asian countries may be underreporting myocarditis to their drug agencies.
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Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, Instituto Universitario de Neurociencias (IUNE), University of La Laguna, Canary Islands, Spain
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain; Hospital Universitario de Canarias, Tenerife, Spain
| | - 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; Department of Psychiatry, The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders & Beijing Institute for Brain Disorders Center of Schizophrenia, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA; Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain.
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Silva E, Higgins M, Hammer B, Stephenson P. Clozapine re-challenge and initiation following neutropenia: a review and case series of 14 patients in a high-secure forensic hospital. Ther Adv Psychopharmacol 2021; 11:20451253211015070. [PMID: 34221348 PMCID: PMC8221694 DOI: 10.1177/20451253211015070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 04/16/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Clozapine remains the most effective intervention for treatment resistant schizophrenia; however, its use is prohibited following neutropenias. We review neutrophil biology as applied to clozapine and describe the strategies to initiate clozapine following neutropenia used in a case series of 14 consecutive patients rechallenged in a United Kingdom (UK) high-secure psychiatric hospital. We examine outcomes including the use of seclusion and transfer. METHODS A case series of 14 male patients with treatment resistant schizophrenia treated with clozapine despite previous episodes of neutropenia between 2006 and 2015 is presented. Data were collected during 2015 and 2019. Using this routinely collected clinical data, we describe the patient characteristics, causes of neutropenia, the strategies used for rechallenging with clozapine and clinical outcomes. RESULTS Previous neutropenias were the result of benign ethnic neutropenia, clozapine, other medications and autoimmune-related. Our risk mitigation strategies included: granulocyte-colony stimulating factor (G-CSF), lithium and watch-and-wait. There were no serious adverse events; at follow up half of the patient's had improved sufficiently to transfer them to conditions of lesser security. There were dramatic reductions in the use of seclusion. CONCLUSION Even in this extreme group, clozapine can be safely and effectively re/initiated following neutropenias, resulting in marked benefits for patients. This requires careful planning based on an understanding of neutrophil biology and the aetiology of the specific episode of neutropenia.
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Affiliation(s)
- Edward Silva
- Rathbone Low Secure Unit, Mersey Care NHS Foundation Trust, Rathbone Hospital, Mill Lane, Liverpool, L13 4AW, UK
| | - Melanie Higgins
- Ashworth Hospital, Mersey Care NHS Foundation Trust, Liverpool, UK
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