1
|
Yang CC, Wang XY, Chou PH, Lin CH. Valproate-related neutropenia and lithium-related leukocytosis in patients treated with clozapine: a retrospective cohort study. BMC Psychiatry 2023; 23:170. [PMID: 36922799 PMCID: PMC10018892 DOI: 10.1186/s12888-023-04659-2] [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: 12/30/2022] [Accepted: 03/06/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Neutropenia is a noteworthy side effect of clozapine, which might warrant this drugs' discontinuance for safety. Studies have revealed that the risk of neutropenia increases with concurrent administration of valproate, but the evidence was limited. Conversely, lithium may have an ameliorating effect on clozapine-induced neutropenia. This study explored the effects of valproate and lithium on white blood cell counts in patients treated with clozapine. METHODS We retrospectively investigated the electronic medical records from one tertiary psychiatric hospital in Taiwan and enrolled patients discharged between January 1, 2006, and December 31, 2017, with clozapine prescriptions. We scrutinized their demographic data, medications, and hematological results at discharge and during follow-up outpatient clinic visits over the subsequent 3 years. Patients were classified into four groups: clozapine only (CLO), clozapine and valproate (CLO + VAL), clozapine and lithium (CLO + Li), and clozapine, valproate, and lithium (CLO + VAL + Li). We also identified hematological events (neutropenia or leukocytosis) of these patients during outpatient follow-ups. RESULTS Of the included 1084 patients, 55(5.1%) developed neutropenia. Concurrent valproate use (odds ratio [OR] = 3.49) and older age (p = .007) were identified as risk factors. Moreover, 453 (41.79%) patients developed leukocytosis. Younger age; male sex; and concurrent use of lithium (OR = 3.39, p < .001), clozapine daily dosage, and benzodiazepines were the risk factors for leukocytosis. CONCLUSION Concurrent valproate use and older age are associated with the development of neutropenia in patients treated with clozapine. Concurrent lithium usage, younger age, male sex, and concurrent benzodiazepine use might be related to leukocytosis.
Collapse
Affiliation(s)
- Chia-Chun Yang
- Department of General Psychiatry, Taoyuan Psychiatric Center, No. 71, Longshou St., Taoyuan Dist, 33058 Taoyuan City, Taiwan
| | - Xi-Yu Wang
- Department of General Psychiatry, Taoyuan Psychiatric Center, No. 71, Longshou St., Taoyuan Dist, 33058 Taoyuan City, Taiwan
| | - Po-Han Chou
- Department of Psychiatry, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Ching-Hua Lin
- grid.414813.b0000 0004 0582 5722Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
- grid.412019.f0000 0000 9476 5696Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| |
Collapse
|
2
|
Güneş H, Tanıdır C, Doktur H, Karaçetin G, Kılıçoğlu AG, Yalçın Ö, Bahalı MK, Mutlu C, Üneri ÖŞ, Erdoğan A. Long-Term Effects of Lithium Use on Children and Adolescents: A Retrospective Study from Turkey. J Child Adolesc Psychopharmacol 2022; 32:162-170. [PMID: 35384703 DOI: 10.1089/cap.2021.0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: The aim of this study was to evaluate the long-term effects of lithium treatment on white blood cell (WBC) count, serum creatinine, and thyroid-stimulating hormone (TSH) levels in children and adolescents with bipolar disorder (BD) and non-BD in a Turkish children and adolescent sample. Methods: The study is based on retrospective chart review. Children and adolescent patients with BD and non-BD prescribed lithium in a mental health and neurological disorders hospital between 2012 and 2017 were included in the study. Data were collected from the electronic medical files. Laboratory values for WBC count, serum creatinine, and TSH levels at baseline within the week before the onset of lithium, and at 1st, 3rd, 6th, and 12th month of treatment were recorded. Results: A total of 143 patients (82 females, 61 males; 100 BD, 43 non-BD) aged 9-18 were included. Non-BD diagnoses were psychotic and schizoaffective disorders, unipolar depression, attention-deficit/hyperactivity disorder, conduct disorder, severe mood dysregulation syndrome, borderline personality disorder, and autism. Mean age of the participants were 15.90 ± 1.16 years for the bipolar group and 14.88 ± 1.79 years for the nonbipolar group. Patients with BD reported more adverse effects. There was a statistically significant increase in WBC counts and TSH levels at any time point. A statistically significant elevation in serum creatinine was found at 3rd and 12th month of treatment. During the course of lithium treatment, WBC counts exceeded 13,000 in 14 (9.8%) patients, and TSH levels exceeded 5.5 mU/L in 41 patients (28.6%). Twenty-one (14.68%) patients were started on thyroxin replacement. Basal TSH levels and duration of the lithium treatment were higher in the participants with TSH levels exceeding 5.5 mU/L. Lithium maximum dose, lithium blood level, basal TSH level, and duration of treatment were higher in the participants receiving thyroxin replacement. No patients had serum creatinine levels exceeding the normal reference values. Conclusion: Our study suggests that lithium is a generally safe and tolerable agent for children and adolescents with BD and non-BD; however, close monitoring of thyroid functions particularly in patients with a higher basal TSH level and longer duration of lithium use is important.
Collapse
Affiliation(s)
- Hatice Güneş
- Department of Psychology, Istanbul Gelisim University, Istanbul, Turkey
| | - Canan Tanıdır
- Department of Psychology, Istanbul Gelisim University, Istanbul, Turkey
| | - Hilal Doktur
- Department of Child and Adolescent Psychiatry, Bakirkoy Training and Research Hospital for Mental Health and Neurological Disorders, Istanbul, Turkey
| | - Gül Karaçetin
- Department of Child and Adolescent Psychiatry, Bakirkoy Training and Research Hospital for Mental Health and Neurological Disorders, Istanbul, Turkey
| | - Ali Güven Kılıçoğlu
- Department of Child and Adolescent Psychiatry, Bezm-i Alem Vakıf University, Istanbul, Turkey
| | - Özhan Yalçın
- Department of Child and Adolescent Psychiatry, Ankara University Faculty of Medicine, Ankara, Turkey
| | | | - Caner Mutlu
- Department of Child and Adolescent Psychiatry, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | | | - Ayten Erdoğan
- Department of Psychology, Istanbul Gelisim University, Istanbul, Turkey
| |
Collapse
|
3
|
Fourrier C, Sampson E, Hori H, Schubert KO, Clark S, Mills NT, Baune BT. Exploratory study of association between blood immune markers and cognitive symptom severity in major depressive disorder: Stratification by body mass index status. Brain Behav Immun 2020; 88:242-251. [PMID: 32526448 DOI: 10.1016/j.bbi.2020.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND A subset of patients with Major Depressive Disorder (MDD) have shown differences relative to healthy controls in blood inflammatory and immune markers. Meanwhile, MDD and comorbid obesity appear to present with distinct biological and symptom characteristics, categorised as "atypical" or "immunometabolic" depression, although the relevant underlying biological mechanisms are still uncertain. Therefore, this exploratory study aimed to better characterise the relationship between peripheral blood immune markers and symptoms of MDD, as well as the extent to which body mass index (BMI) may alter this relationship. METHODS Linear regression analyses were performed between selected baseline characteristics including clinical scales and blood inflammatory markers in participants with MDD (n = 119) enrolled in the PREDDICT randomised controlled trial (RCT), using age, sex and BMI as covariates, and then stratified by BMI status. Specifically, the Montgomery-Åsberg Depression Rating Scale (MADRS) for symptom severity, Clinical Global Impression scale (CGI) for functional impairment, Oxford Depression Questionnaire (ODQ) for emotional blunting, and THINC integrated tool (THINC-it) for cognitive function were considered as clinical measures. RESULTS There was a significant association between basophil count and THINC-it Codebreaker mean response time (associated with complex attention, perceptual motor, executive function, and learning and memory abilities) in overweight individuals and with THINC-it Trails total response time (associated with executive function ability) in moderately obese individuals, when controlling for age, sex, and years of education. No correlation was found between any tested blood markers and MADRS, CGI or ODQ clinical measures, regardless of BMI. DISCUSSION Although the present study is exploratory, the results suggest that targeting of the immune system and of metabolic parameters might confer benefits, specifically in patients with high BMI and experiencing cognitive impairment associated with MDD. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12617000527369p. Registered on 11 April 2017.
Collapse
Affiliation(s)
- Célia Fourrier
- Discipline of Psychiatry, Adelaide Medical School, University of Adelaide, Adelaide, Australia; Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Emma Sampson
- Discipline of Psychiatry, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Hikaru Hori
- Department of Psychiatry, School of Medicine, University of Occupational and Environmental Health, Kitakyushu City, Japan
| | - K Oliver Schubert
- Discipline of Psychiatry, Adelaide Medical School, University of Adelaide, Adelaide, Australia; Northern Adelaide Mental Health Service, Salisbury, Australia
| | - Scott Clark
- Discipline of Psychiatry, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Natalie T Mills
- Discipline of Psychiatry, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Bernhard T Baune
- Department of Psychiatry and Psychotherapy, University Hospital Münster, University of Münster, Münster, Germany; Department of Psychiatry, Melbourne Medical School, The University of Melbourne, Melbourne, Australia; The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, Australia.
| |
Collapse
|
4
|
Pinna M, Manchia M, Visioli C, Tondo L. Clinical response and metabolic effects of lithium in 323 mood disorder patients. J Affect Disord 2020; 270:9-14. [PMID: 32275226 DOI: 10.1016/j.jad.2020.03.066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/13/2020] [Accepted: 03/22/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Lithium is the mainstay for the maintenance treatment of mood disorders (MD), but its efficacy needs to be weighed against its side effects profile. Here, we assessed retrospectively the clinical response to long-term lithium treatment, as well as the rate of associated metabolic side effects. METHODS Clinical data were collected from patients treated with lithium for at least 12 months at the Lucio Bini Center for Mood Disorders in Cagliari, Italy. Clinical response was determined as the difference in number of mood episodes and percent of illness time before and during lithium treatment. Symptomatic values of metabolic parameters (plasma levels of glucose, cholesterol, urea nitrogen [BUN], creatinine, TSH, white blood cells [WBC]), and Body Mass Index (BMI) were determined. RESULTS We studied 323 MD patients (60.2% women). The percent of illness time was significantly reduced for both depressive (F = 4.94, p<0.0001), and manic (F = 3.95, p < 0.0001) episodes, whereas the rates of episodes/year were significantly reduced for mania (F = 2.01, p = 0.02), but not for depression (F = 1.54, p = 0.06). Rates of MD patients with symptomatic values of metabolic parameters were 14.3% for WBC ≥10,000/µl, 26.9% for glucose levels ≥100 mg/dl, 54.2% for cholesterol levels ≥200 mg/dl, 7.5% for BUN ≥50 mg/dl, 21.9% for creatinine levels ≥1.2 mg/dl, and 20.9% for TSH levels ≥3.50 mU/l. CONCLUSIONS Long-term lithium treatment was clinically effective, but the rates of metabolic effects were substantial although some of them were also associated with older age. Lithium-treated patients should receive accurate clinical monitoring to decrease the impact of long-term side effects.
Collapse
Affiliation(s)
- Marco Pinna
- Mood Disorder Lucio Bini Center, Cagliari, Italy; Unit of Psychiatry, Department of Mental Health, Santissima Trinità Hospital, Cagliari, Italy
| | - Mirko Manchia
- Unit of Psychiatry, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; Department of Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada.
| | | | - Leonardo Tondo
- Mood Disorder Lucio Bini Center, Cagliari, Italy; McLean Hospital-Harvard University, Boston, United States
| |
Collapse
|
5
|
Abstract
Lithium is an effective agent approved for the treatment of bipolar disorder. It has narrow therapeutic window and significant variability in its pharmacokinetic. The aim of this study is to determine the population pharmacokinetics of lithium in patients with bipolar disorder in Saudi Arabia and to identify the factors that explain variability. A retrospective chart review was performed on patients with bipolar disorder who received oral lithium. The population pharmacokinetic models were developed using Monolix 4.4. After the appropriate base model was established, five covariates were tested, namely age, sex, weight, serum creatinine, and creatinine clearance. The analysis included a total of 170 lithium plasma concentrations from 31 patients. The data were adequately described by a two-compartment open model with linear absorption and elimination. The average parameter estimates for lithium CL/F, V1/F, V2/F, and Q/F were estimated. The inter-individual variability (coefficients of variation) in CL was 42%. The most significant covariate on lithium CL was found to be creatinine clearance. The population pharmacokinetic model of lithium in patients with bipolar disorder in Saudi Arabia was established. Our findings showed that creatinine clearance is the most significant covariate on lithium clearance. Further studies are required to understand the factors that may influence the pharmacokinetics of lithium and assist in drug dosage decisions.
Collapse
|
6
|
Núñez C, Stephan-Otto C, Usall J, Bioque M, Lobo A, González-Pinto A, Pina-Camacho L, Vieta E, Castro-Fornieles J, Rodriguez-Jimenez R, Butjosa A, Janssen J, Cabrera B, Parellada M, Bernardo M. Neutrophil Count Is Associated With Reduced Gray Matter and Enlarged Ventricles in First-Episode Psychosis. Schizophr Bull 2019; 45:846-858. [PMID: 30107610 PMCID: PMC6581126 DOI: 10.1093/schbul/sby113] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Although there is recent evidence that cells from the peripheral immune system can gain access to the central nervous system in certain conditions such as multiple sclerosis, their role has not been assessed in psychosis. Here, we aimed to explore whether blood cell count was associated with brain volume and/or clinical symptomatology. A total of 218 participants (137 first-episode psychosis patients [FEP] and 81 healthy controls [HC]) were included in the study. For each participant, a T1 structural image was acquired, from which brain tissue volumes were calculated. We found that, in FEP, neutrophil count was associated with reduced gray matter (GM) volume (β = -0.117, P < .001) and increased cerebrospinal fluid volume (β = 0.191, P = .007). No associations were observed in HC. GM reduction was generalized but more prominent in certain regions, notably the thalamus, the anterior insula, and the left Heschl's gyrus, among many others. Neutrophil count was also associated with the total PANSS score (β = 0.173, P = .038), including those items assessing hallucinations (β = 0.182, P = .028) and avolition (β = 0.197, P = .018). Several confounders, such as antipsychotic medication, body mass index, and smoking, were controlled for. Overall, the present study may represent the first indirect evidence of brain tissue loss associated with neutrophils in psychosis, and lends support to the hypothesis of a dysregulated immune system. Higher neutrophil count was also associated with more severe clinical symptomatology, which renders it a promising indicator of schizophrenia severity and could even give rise to new therapies.
Collapse
Affiliation(s)
- Christian Núñez
- Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain,Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - Christian Stephan-Otto
- Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain,Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain,Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain,To whom correspondence should be addressed; Unit of Research and Development, PSSJD, c\ Doctor Antoni Pujadas 42, 08830 Sant Boi de Llobregat, Barcelona, Spain; tel: 93-640-63-50, fax: 93 630 53 19, e-mail:
| | - Judith Usall
- Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain,Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain,Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain
| | - Miquel Bioque
- Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain,Barcelona Clínic Schizophrenia Unit, Neuroscience Institute, Hospital Clínic de Barcelona, Barcelona, Spain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Antonio Lobo
- Department of Medicine and Psychiatry, Instituto de Investigación Sanitaria Aragón, Universidad de Zaragoza, Zaragoza, Spain
| | - Ana González-Pinto
- International Mood Disorders Research Centre, Hospital Santiago Apóstol, University of the Basque Country, Vitoria, Spain
| | - Laura Pina-Camacho
- Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain,Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón, IiSGM, Madrid, Spain
| | - Eduard Vieta
- Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain,Psychiatry Department, Hospital Clínic de Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Josefina Castro-Fornieles
- Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain,Child and Adolescent Psychiatry and Psychology Department, Clinic Institute of Neurosciences, Hospital Clínic de Barcelona, Barcelona, Spain,Department of Medicine, University of Barcelona, Barcelona, Spain
| | | | - Anna Butjosa
- Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain,Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - Joost Janssen
- Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain,Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón, IiSGM, Madrid, Spain,Brain Center Rudolf Magnus, Department of Psychiatry, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bibiana Cabrera
- Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain,Barcelona Clínic Schizophrenia Unit, Neuroscience Institute, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Mara Parellada
- Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain,Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón, IiSGM, Madrid, Spain
| | - Miquel Bernardo
- Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain,Barcelona Clínic Schizophrenia Unit, Neuroscience Institute, Hospital Clínic de Barcelona, Barcelona, Spain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain,Department of Psychiatry and Clinical Psychobiology, University of Barcelona, Barcelona, Spain
| | | |
Collapse
|
7
|
Bhardwaj P, Jain K, Dhawan DK. Lithium Treatment Aggregates the Adverse Effects on Erythrocytes Subjected to Arsenic Exposure. Biol Trace Elem Res 2018; 184:206-213. [PMID: 28988373 DOI: 10.1007/s12011-017-1168-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 09/25/2017] [Indexed: 10/18/2022]
Abstract
The present study was designed to investigate the effects of lithium treatment on red blood cells which were given arsenic exposure. Long-term lithium therapy is being extensively used for the treatment of bipolar disorders. Arsenic is a group I carcinogen and a major toxic pollutant in drinking water that affects millions of people worldwide. Male SD rats were segregated into four groups, viz. normal control, lithium treated, arsenic treated, and lithium + arsenic treated. Lithium was supplemented as lithium carbonate at a dose level of 1.1 g/kg diet for a period of 8 weeks. Arsenic was given in the form of sodium arsenite at a dose level of 100 ppm in drinking water, ad libitum, for the same period. Lysates of red blood cells were used to investigate the effects of lithium and arsenic treatments on anti-oxidant enzymes, reduced glutathione (GSH), and lipid peroxidation (LPO) levels. Various hematological parameters, activities of Na+ K+ ATPase and delta-aminolevulinic acid dehydratase (δ-ALAD) were also assessed. A significant reduction was observed in the activities of antioxidant enzymes, GSH levels, total erythrocyte counts, Na+ K+ ATPase, and ALAD enzyme activities in lysates of red blood cells when exposed either to lithium or arsenic. In addition, a significant increase in the levels of malondialdehyde (MDA), lymphocytes, neutrophils, and total leukocytes was also observed following lithium as well as arsenic treatments. However, when arsenic-treated rats were subjected to lithium treatment, a pronounced alteration was noticed in all the above parameters. Therefore, we conclude that lithium supplementation to the arsenic-treated rats enhances the adverse effects on red blood cells and therefore use of lithium may not be medicated to patients who are vulnerable to arsenic exposure through drinking water. It can also be inferred that adverse effects of lithium therapy may get aggravated in patients thriving in the arsenic-contaminated area.
Collapse
Affiliation(s)
- Priti Bhardwaj
- Department of Biophysics, Panjab University Chandigarh, Chandigarh, 160014, India
| | - Kinnri Jain
- Centre of Nuclear Medicine, Panjab University Chandigarh, Chandigarh, India
| | | |
Collapse
|
8
|
Munkholm K, Jacoby AS, Lenskjold T, Bruunsgaard H, Vinberg M, Kessing LV. Leukocytes in peripheral blood in patients with bipolar disorder - Trait and state alterations and association with levels of cytokines and C-reactive protein. Psychiatry Res 2018; 261:383-390. [PMID: 29353768 DOI: 10.1016/j.psychres.2018.01.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 12/20/2017] [Accepted: 01/09/2018] [Indexed: 12/13/2022]
Abstract
Low-grade inflammation has been found in patients with bipolar disorder (BD), but rarely assessed using leukocyte counts and findings are limited by lack of control for confounding factors. As a result, it is unclear whether BD per se is associated with peripheral inflammation. We pooled populations from two studies using similar longitudinal designs, including 300 blood samples from a total of 97 patients with BD and 133 blood samples from a total of 72 healthy control individuals (HC). Total leukocyte and neutrophil counts were measured together with interleukin (IL) - 6, IL-8, IL-18, tumor necrosis factor (TNF) - α and high sensitivity C-reactive protein (hsCRP). Adjusted for confounders, leukocyte counts were 23% higher and neutrophil counts were 30% higher in patients with BD compared with HC. There were no state-related differences in leukocyte or neutrophil counts. Lithium use, cigarette smoking as well as levels of IL-6, TNF-α and hsCRP were positively associated with leukocyte and neutrophil counts. Due to confounding issues it cannot be concluded that differences were related to bipolar disorder per se. Future studies are recommended to include leukocytes as markers of low-grade inflammation and to include relevant confounders in statistical analyses.
Collapse
Affiliation(s)
- Klaus Munkholm
- Psychiatric Center Copenhagen, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Anne Sophie Jacoby
- Psychiatric Center Copenhagen, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Helle Bruunsgaard
- Department of Clinical Immunology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Maj Vinberg
- Psychiatric Center Copenhagen, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars Vedel Kessing
- Psychiatric Center Copenhagen, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
9
|
Paton C, Esop R. Managing clozapine-induced neutropenia with lithium. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.29.5.186] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Aims and MethodTo review the efficacy and safety of lithium augmentation for the management of clozapine-induced neutropenia. Medline search January 1966 to March 2004.ResultsThe ability of lithium to increase the white cell count (WBC) is well documented. A small number of published case reports of the successful treatment of clozapine-induced neutropenia with lithium were identified. Lithium does not protect against agranulocytosis.Clinical ImplicationsLithium may be useful in raising the WBC in patients whose baseline count is too low to allow treatment with clozapine to start and to protect against clozapine-induced neutropenia, thus allowing more patients to benefit from treatment with clozapine. It does not protect against agranulocytosis. There is no way of identifying patients whose neutropenia will progress to agranulocytosis. Careful monitoring is essential. Lithium is not licensed to increase WBC. Psychiatrists should be aware of the medicolegal implications of prescribing off-label.
Collapse
|
10
|
Atagün Mİ, Korkmaz ŞA, Soykan Ç, Büyüköz D, Can SS, Çayköylü A. Serum lithium levels are associated with white blood cell counts in bipolar disorder. Turk J Med Sci 2016; 46:1271-2. [PMID: 27513435 DOI: 10.3906/sag-1505-129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 09/13/2015] [Indexed: 11/03/2022] Open
Affiliation(s)
- Murat İlhan Atagün
- Department of Psychiatry, Faculty of Medicine, Yıldırım Beyazıt University, Ankara, Turkey
| | - Şükrü Alperen Korkmaz
- Department of Psychiatry, Faculty of Medicine, Yıldırım Beyazıt University, Ankara, Turkey
| | - Çağlar Soykan
- Department of Psychiatry, Faculty of Medicine, Yıldırım Beyazıt University, Ankara, Turkey
| | - Derya Büyüköz
- Department of Psychiatry, Ankara Atatürk Training and Education Hospital, Ankara, Turkey
| | - Serdar Süleyman Can
- Department of Psychiatry, Faculty of Medicine, Yıldırım Beyazıt University, Ankara, Turkey
| | - Ali Çayköylü
- Department of Psychiatry, Faculty of Medicine, Yıldırım Beyazıt University, Ankara, Turkey
| |
Collapse
|
11
|
Ferensztajn-Rochowiak E, Rybakowski JK. The effect of lithium on hematopoietic, mesenchymal and neural stem cells. Pharmacol Rep 2016; 68:224-30. [DOI: 10.1016/j.pharep.2015.09.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 09/14/2015] [Accepted: 09/14/2015] [Indexed: 12/01/2022]
|
12
|
Amitai M, Zivony A, Kronenberg S, Nagar L, Saar S, Sever J, Apter A, Shoval G, Golubchik P, Hermesh H, Weizman A, Zalsman G. Short-term effects of lithium on white blood cell counts and on levels of serum thyroid-stimulating hormone and creatinine in adolescent inpatients: a retrospective naturalistic study. J Child Adolesc Psychopharmacol 2014; 24:494-500. [PMID: 24828326 DOI: 10.1089/cap.2013.0046] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The purpose of this study was to determine if the known side effects of lithium in adults may be generalized to younger patients with psychiatric disorders. METHODS A retrospective naturalistic study design was used. Data were collected from the database of a tertiary pediatric medical center covering the years 1994-2010. Included were patients hospitalized for bipolar and non-bipolar disorders and treated with lithium, alone or in combination with other medications. The electronic medical files were reviewed for changes in thyroid and kidney function and for hematological parameters during the course of treatment. RESULTS Sixty-one patients 12.5-20.4 years of age (mean 16.94±1.66) met the study criteria: 33 with bipolar disorder and 28 with a non-bipolar disorder. Mean duration of lithium treatment (mean lithium blood level, 0.73±0.24 mEq/L) was 193.68±254.35 days. Mean levels of thyroid-stimulating hormones (TSH) rose significantly from baseline to last measurement (3.16±2.68 vs. 1.52±0.92 mU/L; paired t=-5.19, df=50, p<0.001); in 25% of patients, TSH levels at the last measurement were above normal (≥4 mU/L). Only one patient developed TSH values >10 mU/L (the threshold considered clinically significant). Positive correlation was found between pre- and posttreatment TSH levels (Pearson's r=0.60; n=51, p<0.05). White blood cell count (WBC) also increased significantly following lithium treatment (7195±2151 vs. 7944±2096 cells/mm(3); t=2.83, df=60, p=0.006). No significant changes were noted in serum creatinine levels. There was no difference in these parameters between patients treated with lithium alone or in combination with other medications. CONCLUSIONS Lithium treatment in adolescents with bipolar or non-bipolar disorders is associated with a significant increase in blood TSH levels and WBC count. Lithium-treated adolescent inpatients with a high basal TSH level may be at risk of developing pituitary-thyroid axis dysregulation. Therefore, baseline measurement of thyroid functions and serial monitoring throughout treatment are recommended.
Collapse
Affiliation(s)
- Maya Amitai
- 1 Geha Mental Health Center , Petach Tikva, Israel
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Rueda-Lara M, Lopez-Patton MR. Psychiatric and psychosocial challenges in patients undergoing haematopoietic stem cell transplants. Int Rev Psychiatry 2014; 26:74-86. [PMID: 24716502 DOI: 10.3109/09540261.2013.866075] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Haematological malignancies are often treated with haematopoietic stem cell transplants (HSCT). The disease and its treatment are challenging and life threatening, as they not only affect the recipients, but also their families. This review highlights the available data on the psychological, psychiatric and social impact of these illnesses and their treatment on recipients and families. There are robust data that correlate HSCT with emotional distress, as emotional and physical functioning significantly affect quality of life. Psychiatric co-morbidity including anxiety, depression, adjustment and post-traumatic stress disorder, delirium and cognitive deficits have been reported at different stages in the transplant process. This review will highlight the psychosocial and clinical research findings relevant to HSCT patients and will summarize recommendations for future psychosocial research in this population.
Collapse
Affiliation(s)
- Maria Rueda-Lara
- University of Miami/Leonard Miller School of Medicine, Department of Psychiatry and Behavioral Sciences, Sylvester Comprehensive Cancer Center , Miami, Florida , USA
| | | |
Collapse
|
14
|
Qureshi SU, Rubin E. Risperidone- and aripiprazole-induced leukopenia: a case report. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2012; 10:482-3. [PMID: 19287562 DOI: 10.4088/pcc.v10n0612c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
15
|
The combination of valproic acid and lithium delays hematopoietic stem/progenitor cell differentiation. Blood 2012; 119:3050-9. [PMID: 22327222 DOI: 10.1182/blood-2011-08-375386] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Despite increasing knowledge on the regulation of hematopoietic stem/progenitor cell (HSPC) self-renewal and differentiation, in vitro control of stem cell fate decisions has been difficult. The ability to inhibit HSPC commitment in culture may be of benefit to cell therapy protocols. Small molecules can serve as tools to manipulate cell fate decisions. Here, we tested 2 small molecules, valproic acid (VPA) and lithium (Li), to inhibit differentiation. HSPCs exposed to VPA and Li during differentiation-inducing culture preserved an immature cell phenotype, provided radioprotection to lethally irradiated recipients, and enhanced in vivo repopulating potential. Anti-differentiation effects of VPA and Li were observed also at the level of committed progenitors, where VPA re-activated replating activity of common myeloid progenitor and granulocyte macrophage progenitor cells. Furthermore, VPA and Li synergistically preserved expression of stem cell-related genes and repressed genes involved in differentiation. Target genes were collectively co-regulated during normal hematopoietic differentiation. In addition, transcription factor networks were identified as possible primary regulators. Our results show that the combination of VPA and Li potently delays differentiation at the biologic and molecular levels and provide evidence to suggest that combinatorial screening of chemical compounds may uncover possible additive/synergistic effects to modulate stem cell fate decisions.
Collapse
|
16
|
Neutropenia as a class effect of antipsychotic agents: a case report. J Clin Psychopharmacol 2010; 30:639-40. [PMID: 20841965 DOI: 10.1097/jcp.0b013e3181f100d4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
17
|
Mattai A, Fung L, Bakalar J, Overman G, Tossell J, Miller R, Rapoport J, Gogtay N. Adjunctive use of lithium carbonate for the management of neutropenia in clozapine-treated children. Hum Psychopharmacol 2009; 24:584-9. [PMID: 19743394 PMCID: PMC2772202 DOI: 10.1002/hup.1056] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clozapine, a dibenzodiazepine antipsychotic, is the most effective medication for treatment-resistant schizophrenia. However, its use has been limited by the high risk of neutropenia. In children, the rate of neutropenia is higher when compared to adults. We decided to explore the use of lithium to manage neutropenia in childhood-onset schizophrenia (COS) through a systematic audit of COS cases. METHODS Medical records were reviewed for patients with COS who had been treated with the combination of clozapine and lithium carbonate. RESULTS Seven patients were found to have been treated with both clozapine and lithium. After initiation of lithium, ANC increased significantly in six out of seven subjects by 29 to 106% with a mean of 66%. In addition, six out of seven subjects continued using both clozapine and lithium for over 2 years (range: 2.0-7.2 years) and do not have immediate plans for discontinuation of either medications. CONCLUSIONS Our study bolsters support for the use of lithium in the management of neutropenia in children treated with clozapine. Although the coadministration of lithium and clozapine appears effective in the management of neutropenia, it is not without its risks and clinicians must be diligent in their joint use of these medications.
Collapse
Affiliation(s)
- Anand Mattai
- Child Psychiatry Branch, NIMH, NIH, MD 20892-1600, USA.
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Malhotra A, Dhawan DK. Zinc improves antioxidative enzymes in red blood cells and hematology in lithium-treated rats. Nutr Res 2009; 28:43-50. [PMID: 19083387 DOI: 10.1016/j.nutres.2007.11.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Revised: 10/05/2007] [Accepted: 11/09/2007] [Indexed: 10/22/2022]
Abstract
The present study was designed to evaluate the protective role of zinc in attenuating the adverse effects induced by lithium in blood of female Wistar rats. Female Wistar rats received lithium in the form of lithium carbonate in diet at a dose level of 1.1 g/kg diet, zinc alone in the form of zinc sulfate in drinking water at a dose level of 227 mg/L drinking water, or lithium plus zinc treatments in the combined group for a total duration of 2 months. Effects of the treatments were studied on antioxidant defense system, various hematologic parameters, and percentage of (65)Zn-specific activity. Lithium treatment resulted in a significant increase in lipid peroxidation levels but caused a significant decrease in reduced glutathione levels and the activities of catalase, glutathione S-transferase, and superoxide dismutase. Lithium treatment also caused a significant decrease in the activities of aminolevulinic acid dehydratase and Na(+) K(+) adenosine triphosphatase. However, it resulted in a significant increase in total leukocyte counts, neutrophils, and lymphocyte counts as well as zinc protoporphyrin levels, whereas a significant decrease in counts of monocytes, eosinophils, and percentage specific activity of (65)Zn in blood and its various fractions was noticed. Furthermore, lithium treatment caused a significant decrease in serum zinc levels. However, zinc supplementation to lithium-treated rats effectively raised the reduced glutathione levels and also normalized lipid peroxidation and the activities of antioxidative enzymes, which included catalase, glutathione S-transferase, and superoxide dismutase. Moreover, zinc supplementation could raise the activities of the enzymes aminolevulinic acid dehydratase and Na(+) K(+) adenosine triphosphatase as well as the percentage uptake values of (65)Zn in blood and its fractions. The study suggests that zinc, as a nutritional supplement, has the potential in attenuating most of the adverse effects induced by lithium in rat blood.
Collapse
Affiliation(s)
- Anshoo Malhotra
- Department of Biophysics, Panjab University, Chandigarh 160014, India
| | | |
Collapse
|
19
|
Abstract
Almost all classes of psychotropic agents have been reported to cause blood dyscrasias. Mechanisms include direct toxic effects upon the bone marrow, the formation of antibodies against haematopoietic precursors or involve peripheral destruction of cells. Agranulocytosis is probably the most important drug-related blood dyscrasia. The mortality from drug-induced agranulocytosis is 5-10% in Western countries. The manifestations of agranulocytosis are secondary to infection. Aggressive treatment with intravenous broad-spectrum antimicrobials and bone marrow stimulants may be required. Of drugs encountered in psychiatry, antipsychotics including clozapine (risk of agranulocytosis approximately 0.8%, predominantly in the first year of treatment) and phenothiazines (chlorpromazine agranulocytosis risk approximately 0.13%), and antiepileptics (notably carbamazepine, neutropenia risk approximately 0.5%) are the most common causes of drug-related neutropenia/agranulocytosis. Drugs known to cause neutropenia should not be used concomitantly with other drugs known to cause this problem. High temperature and other indicators of possible infection should be looked for routinely during treatment. Clozapine is well known as a drug that can cause blood dyscrasias, but olanzapine and other atypicals may also cause similar problems. In addition to genetic factors, there are likely to be dose-related and immunological components to these phenomena. Important lessons have been learnt from the haematological monitoring that is necessary with clozapine and the monitoring has been very successful in preventing deaths related to clozapine-induced agranulocytosis. Continuing research into the mechanisms of drug-induced neutropenia and agranulocytosis may serve to further enhance the safe use not only of clozapine, but also of other agents.
Collapse
Affiliation(s)
- Robert J Flanagan
- Toxicology Unit, Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.
| | | |
Collapse
|
20
|
Abstract
Clozapine remains the antipsychotic of choice for refractory schizophrenia despite its propensity for serious blood disorders. When neutropenia or agranulocytosis occur in people taking clozapine, cessation of treatment is mandated and relapse often results. Because such patients are usually unresponsive to other antipsychotics, many clinicians consider restarting clozapine, despite the risks involved. However, the risks of clozapine rechallenge vary according to the cause and nature of the blood dyscrasia. Neutropenia can arise because of factors unrelated or indirectly related to clozapine treatment. These include benign ethnic neutropenia, concomitant drug therapy, co-existing medical conditions and drug interactions. In such cases, clozapine may be restarted if non-clozapine causes of neutropenia are identified and eliminated, although concurrent treatment with lithium (to induce leukocytosis) is sometimes necessary. Close monitoring of the patient is essential because it is rarely possible to completely rule out the contribution of clozapine to the blood dyscrasia and because lithium does not protect against clozapine-related agranulocytosis. In cases of clozapine-induced neutropenia (as distinct from agranulocytosis, which may have a different pathology) rechallenge may also be considered and, again, lithium co-therapy may be required. Where clozapine is clearly the cause of agranulocytosis, rechallenge should not be considered or undertaken unless there are very exceptional circumstances (severe and prolonged relapse following clozapine discontinuation). In these cases, re-exposure to clozapine may rarely be attempted where there are facilities for very close and frequent monitoring. Granulocyte colony-stimulating factor is likely to be required as co-therapy, given the very high likelihood of recurrence. Uncertainty over the likely cause of blood dyscrasia in people taking clozapine, coupled with uncertainty over the mechanism by which clozapine causes both neutropenia and agranulocytosis, makes any attempt to restart clozapine a high-risk venture requiring the utmost caution.
Collapse
Affiliation(s)
- Eromona Whiskey
- Pharmacy Department, Maudsley Hospital, South London and Maudsley NHS Trust, London, UK
| | | |
Collapse
|
21
|
Esposito D, Rouillon F, Limosin F. Continuing clozapine treatment despite neutropenia. Eur J Clin Pharmacol 2004; 60:759-64. [PMID: 15660271 DOI: 10.1007/s00228-004-0835-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2004] [Accepted: 08/27/2004] [Indexed: 11/28/2022]
Abstract
RATIONALE Approximately 1-2% of patients treated with the atypical antipsychotic clozapine develop severe neutropenia and agranulocytosis. The usual recommendation is to discontinue treatment with the drug when the peripheral neutrophil count drops below 1,500/mm3. METHODS We have reviewed several reports describing procedures that allowed the patients to continue clozapine treatment despite the occurrence of these haematological side effects. RESULTS The therapeutic procedures described (symptomatic treatment of neutropenia by co-administration of lithium or granulopoiesis-stimulating factors, management of the adjunctive medication) seem to be efficient strategies that allow continuation of clozapine treatment despite the occurrence of neutropenia. However, these types of therapy have only been used in a limited number of cases, and the evidence supporting their use remains anecdotal. CONCLUSION Although the procedures adopted in the cases described in this review are uncommon, they potentially provide an alternative to the discontinuation of clozapine treatment in patients with complex symptomatologies for whom treatment with other antipsychotic medication is insufficient.
Collapse
Affiliation(s)
- David Esposito
- Department of Psychiatry, Albert Chenevier Hospital (AP-HP), 40, rue de Mesly, 94000, Créteil, France
| | | | | |
Collapse
|
22
|
Tramontina S, Schmitz M, Polanczyk G, Rohde LA. Juvenile bipolar disorder in Brazil: clinical and treatment findings. Biol Psychiatry 2003; 53:1043-9. [PMID: 12788249 DOI: 10.1016/s0006-3223(03)00008-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Because few studies were conducted to evaluate bipolar disorder in children and adolescents outside North America, this investigation aims to describe clinical features, pattern of comorbidities, and response to pharmacologic treatment in a sample of youths with bipolar disorder (BD) from a pediatric psychopharmacology outpatient clinic in Brazil. METHODS We performed a retrospective chart review of all patients under age 15 with BD diagnoses who were evaluated and treated in our clinic from 1998-2001. A comparison sample of subjects with attention-deficit/hyperactivity disorder (ADHD) without BD (n = 362) was also evaluated. RESULTS The prevalence of juvenile BD in our sample was 7.2% (36/500) (95% confidence interval = 5.2-9.9). Irritable mood was detected in 91.7% of the bipolar patients. The main comorbidity found was ADHD (58.3%). Children with BD had significantly higher rates of abnormally elevated CBCL scores in the externalizing dimension, anxiety and depression, delinquent behavior, and aggressive behavior scales than ADHD subjects (p <.05). Most BD patients (78%) needed combination drug therapy to achieve symptomatic control. CONCLUSIONS Our results replicate clinical and treatment findings from U.S. investigations in a different culture demonstrating that juvenile BD is not a rare disorder in clinical samples.
Collapse
Affiliation(s)
- Silzá Tramontina
- Federal University of Rio Grande do Sul, Rio Grande do Sul, Brazil
| | | | | | | |
Collapse
|
23
|
|
24
|
Abstract
Immune system parameters were investigated in euthymic bipolar patients and matched normal volunteers. A review of the existing literature suggested that bipolar patients might be more likely to demonstrate signs of immune activation. Serum-soluble interleukin-2 receptors, circulating phenotypic lymphocyte markers, levels were measured. Euthymic bipolar patients and normal volunteers did not differ or any of these measures. Furthermore, bipolar patients could not be differentiated by medication status or gender. In conclusion, there was no evidence of immune system activation in euthymic bipolar patients.
Collapse
Affiliation(s)
- M H Rapaport
- Department of Psychiatry, University of California at San Diego
| |
Collapse
|