The use of clozapine in borderline-intellectual-functioning and mentally retarded schizophrenic patients

Effect of Intravenous Lipid Emulsion on Clozapine Acute Toxicity in Rats

Objectives

Many studies have been reported the efficacy of intravenous lipid emulsion (ILE) as an antidote on acute lipophilic drug toxicity. Clozapine, highly lipophilic dibenzodiazepine neuroleptics, is an important medication in the schizophrenia therapy regimen. Acute intoxication with antipsychotics is one of the main reasons for the referral of poisoned patients to the hospital. We expected that ILE could be used for the therapy of acute clozapine intoxicated patients.

Methods

We used two groups of consisting of six male rats. Both groups received a toxic dose of clozapine (40 mg/kg) intravenously, via the tail vein. After 15 minutes, they were treated with intravenous infusion of 18.6 mg/kg normal saline (NS group), or 18.6 mg/kg ILE 20% (ILE group). We evaluated blood pressure (BP) and heart rate by power lab apparatus through the tail artery, ataxia by a rat rotary circle, seizure scores and death in multiple times after starting clozapine administration. For biochemical and pathological evaluations the samples of tissue and blood were taken.

Results

Our results demonstrated that ILE 20% could return hypotension-induced clozapine better than normal saline. Furthermore, ataxia and seizure have rectified more rapidly and deaths reduced. Clozapine administration causes pancreatitis and lung injury but fat emulsion did not show an optimal effect on tissue damages caused by clozapine toxicity.

Conclusion

In conclusion, ILE can remove toxic signs of clozapine same as other lipophilic medicines, however, clinical uses of ILE for this intention requires more appraisement to determine the precise implication and safety.

Clozapine for psychotic disorders in adults with intellectual disabilities

BACKGROUND

Psychosis is three times more common in people with an intellectual disability than in those without an intellectual disability. A low intelligence quotient (IQ) is a defining characteristic for intellectual disability and a risk factor for poor outcome in psychosis. Clozapine is recommended for treatment-resistant psychosis. The effect of psychotropic medication can be different in people with intellectual disability; for example, they may be more prone to side effects. People with an intellectual disability and psychosis form a special subgroup and we wanted to examine if there is randomised controlled trial (RCT) data in this population to support the use of clozapine.

OBJECTIVES

To determine the effects of clozapine for treating adults with a dual diagnosis of intellectual disability and psychosis.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, Embase and eight other databases up to December 2014. We also searched two trials registers, the Cochrane Schizophrenia Group's Register of Trials, and contacted the manufacturers of clozapine.

SELECTION CRITERIA

RCTs that assessed the effects of clozapine, at any dose, for treating adults (aged 18 years and over) with a dual diagnosis of intellectual disability and psychotic disorder, compared with placebo or another antipsychotic medication.

DATA COLLECTION AND ANALYSIS

Three review authors independently screened all titles, abstracts and any relevant full-text reports against the inclusion criteria.

MAIN RESULTS

Of the 1224 titles and abstracts screened, we shortlisted 38 full-text articles, which we subsequently excluded as they did not meet the inclusion criteria. These studies were not RCTs. Consequently, no studies are included in this Cochrane review.

AUTHORS' CONCLUSIONS

There are currently no RCTs that assess the efficacy and side effects of clozapine in people with intellectual disabilities and psychoses. Given the use of clozapine in this vulnerable population, there is an urgent need for a RCT of clozapine in people with a dual diagnosis of intellectual disability and psychosis to fill the evidence gap.

Use of clozapine in a mental handicap hospital — report of the first 17 patients

Objectives: To examine the process and outcome of use of clozapine in patients with mental handicap, with particular reference to selection of patients, response to treatment, adverse effects and withdrawal from treatment.

Methods: The case notes and medication charts of all patients commenced on clozapine between January 1991 and December 1994 were examined.

Results: Seventeen patients had been commenced on clozapine, the majority in the mild and moderate range of handicap. Fifteen had ICD-9 diagnosis of schizophrenia and all were refractory to conventional neuroleptics. Improvement was marked in 47% and substantial in 76%, with a mean daily dose of 453.8(sd = 238.5)mg and a range of 200mg-900mg. Reduction of aggressive behaviour was an important indicator of improvement. Five patients were withdrawn but only one related to side effects. Four patients had a past history of epilepsy and six others either developed seizures or EEG changes on treatment.

Conclusion: Clozapine use has been associated with considerable benefit in patients with mild and moderate handicap wh o have schizophrenia. In this population aggression responded well but a high prevalence of drug-induced epilepsy was evident.

The use of clozapine in an individual with moderate intellectual disability, aggressive behaviour and resistant psychosis

The case of a 32 year old man with moderate intellectual disability, severe behavioural problems and psychotic symptoms is described. Having tried various traditional antipsychotics he was commenced on clozapine with a marked improvement in symptoms. Clozapine is a useful drug for the treatment of schizophrenia in the intellectually disabled who are refractory to the conventional antipsychotics. It improves aggressive and self-injurious behaviour which may be in addition to its antipsychotic effect.

The use of clozapine among individuals with intellectual disability: a review

Clozapine has been approved in the United States since 1990 for refractory or treatment resistant schizophrenia in the general population. However, as with many other antipsychotic medications, it is being prescribed for reasons other than those indicated. Among individuals with intellectual disabilities, clozapine is increasingly being prescribed to treat behavioral problems, although the empirical evidence for such a practice is lacking. This review was undertaken as an attempt to summarize the available studies regarding the use of clozapine for behavioral purposes among individuals with intellectual disabilities. Findings of our review suggest that the effectiveness of clozapine in targeting challenging behaviors among individuals with intellectual disabilities is relatively inconclusive at present. We discuss reasons why these limitations exist and offer some solutions to help alleviate these limitations.

Guidelines for the use of clozapine in individuals with developmental disabilities

Clozapine is the most effective antipsychotic medication currently in use, but there has been a paucity of well-controlled research on its efficacy with people with developmental disabilities. We present a set of guidelines to ensure proper utilization of clozapine in individuals with developmental disabilities, because it can offer them therapeutic advantages similar to those observed in people with schizophrenia. We provide recommendations regarding the use of clozapine that are based on three main sources: literature and published professional practice guidelines regarding the use of clozapine in individuals who do not have developmental disabilities, the limited literature on the use of clozapine in individuals who have developmental disabilities, and our own clinical experience. The first part of the guidelines contains an overview of necessary practical knowledge regarding side effects, dose and blood level considerations, and interactions with other medications, diet and tobacco smoking. In the second part, we offer procedures for selecting individuals for clozapine therapy based on proper indications and contraindications for treatment. We also include requirements regarding informed consent, dosage and special laboratory and clinical monitoring.

Reviewing the use of antipsychotic drugs in people with intellectual disability

INTRODUCTION

Antipsychotics are the most widely prescribed drugs in people with intellectual disability even if schizophrenia and other psychotic disorders do not affect more than 3% of such population. Many authors outline the lack of studies on the efficacy of antipsychotics on schizophrenia or other psychotic disorders in people with intellectual disability.

MATERIALS AND METHODS

The aim of the present study is to review all evidences resulting from international trials selected by Medline, and compare efficacy and side effects of different antipsychotics in people with both intellectual disability and psychotic disorders and/or behavioural disorders.

RESULTS

195 studies were identified; 117 concern traditional antipychotics while 78 new generation ones. If we consider the type of studies, it results that only the 12.8% of all production is represented by meta-analyses, systematic reviews, and randomised and not controlled trials.

CONCLUSIONS

Randomised controlled trials and systematic reviews would be the golden standard for therapeutical studies; unfortunately they are really few in this field. It is anyway significative that all the studies reported focus on the use of antipsychotics in people with intellectual disability presenting behavioural problems. To increase the validity of these studies it is recommendable to proceed only with well-designed studies, possibly double-blind versus placebo or other medications. There is need to define precise inclusion criteria, precise symptomatological or behavioural targets and adaptative ability assessment, using valid and reliable diagnostic instruments.

Antipsychotic medication versus placebo for people with both schizophrenia and learning disability

BACKGROUND

Antipsychotic medication is the standard treatment for people with learning disability and schizophrenia.

OBJECTIVES

To determine the effects of any antipsychotic medication compared with placebo for treating people with a dual diagnosis of learning disability and schizophrenia.

SEARCH STRATEGY

For this update we searched the Cochrane Schizophrenia Group's Register of trials (July 2004), relevant reference lists and sought unpublished data from pharmaceutical companies.

SELECTION CRITERIA

We included all randomised clinical trials of longer than one month's duration, involving people with both schizophrenia and learning disability (a measured IQ of 70 or less) that evaluated antipsychotic medication versus placebo.

DATA COLLECTION AND ANALYSIS

We reliably selected and assessed studies for methodological quality. Two reviewers, working independently, extracted data. We would have analysed dichotomous data on an intention-to-treat basis and presented continuous data with 65% completion rate. For dichotomous outcomes, our intention was to estimate a fixed effect relative risk (RR) with the 95% confidence interval (CI) together with the number needed to treat/harm (NNT/H).

MAIN RESULTS

We found only one relevant randomised trial using our search method and this had to be excluded. This study included four people with a dual diagnosis of schizophrenia and learning disability, but results were only available for two of the participants. It was unclear as to which groups the other two people were allocated. In order to display the data, we would have had to have made too many assumptions about these two people and any results would be uninformative and potentially misleading.

REVIEWERS' CONCLUSIONS

Using the methods described we found no randomised controlled trial evidence to guide the use of antipsychotic medication for people with both learning disability and schizophrenia. Until the urgent need for randomised controlled trials is met, clinical practice will continue to be guided by extrapolation of evidence from randomised controlled trials involving people with schizophrenia, but without learning disability, and non-randomised trials of those with learning disability and schizophrenia.

The use of clozapine in adults with intellectual disability

BACKGROUND

There are not many studies on the use of clozapine in patients with intellectual disability (ID). The authors describe a case series of patients treated with clozapine, drawn from a medium secure unit, a low secure assessment and treatment service and a community team in the London region.

METHOD

A retrospective file-review of patients treated in these three settings during the time period March-June 2002 was performed (n = 24). Information was collected using a semistructured proforma.

RESULTS

Of the 24 patients, 67% had schizophrenia, 17% had schizoaffective disorder and 8% had bipolar disorder. Patients had been unwell for a mean of 6 years and had been tried on a mean of four antipsychotics. The mean maximum dose of clozapine was 488 mg. The outcomes on the clinical global impression (CGI) scale showed 29% very much improved, 42% much improved, 21% minimally improved and 8% no change. 54% of the whole sample and 53% of those from the medium secure unit were discharged to homes in the community. The drug had to be stopped in four patients, of which three were because of neutropaenia.

CONCLUSION

Clozapine appears to be safe and efficacious in many people with ID. Careful monitoring of side-effects is needed during therapy.

Pharmacotherapy of disorders in mental retardation

This is a review of pharmacotherapy in children and adolescents with mental retardation from the perspective of DSM and ICD disorders. The existing research is reviewed in young people with mental retardation but, when data are lacking, we examined the literature from adults with mental retardation and from typically-developing children. The literature is discussed for each of the following disorders: ADHD, anxiety disorders, bipolar disorder, conduct disorder, depression, enuresis, schizophrenia, self injury, and tics and movement disorders. With the possible exception of ADHD, there is a woeful lack of empirical data on most of these disorders in young people with mental retardation. Clinicians will often be forced to extrapolate from data on adults having mental retardation and from typically-developing children. The best policy is probably to treat such patients cautiously, while gathering data on the effects of such therapy in the hopes of beginning a data base.

Brief report: effects of clozapine on self-injurious behavior of two risperidone nonresponders with mental retardation

Atypical antipsychotic medications for self-injurious behavior (SIB), aggression, and destruction among people with mental retardation and development disabilities are becoming increasingly accepted. Most studies are on risperidone and fewer have been conducted on clozapine. The present single-blind study reports marked reductions in SIB and aggression of two persons with profound mental retardation who were nonresponsive to all other behavioral and psychopharmacological interventions, including risperidone. The most effective dose was 200 mg/day. Side effects were mild and the drug was tolerated well.

Antipsychotic medication for those with both schizophrenia and learning disability

BACKGROUND

Antipsychotic medication is the standard treatment for people with learning disability and schizophrenia.

OBJECTIVES

To determine the efficacy of any antipsychotic medication for treating people with a dual diagnosis of learning disability and schizophrenia.

SEARCH STRATEGY

Electronic searching of Biological Abstracts, the Cochrane Schizophrenia Group's Register of trials, the Cochrane Library, EMBASE, PsycLIT and MEDLINE. Unpublished data were sought from pharmaceutical companies. Both authors independently selected the relevant studies from the reports identified in this way.

SELECTION CRITERIA

1. All randomised controlled trials of antipsychotic medication, regardless of dosage, versus a placebo control, of longer than one month's duration. 2. Anyone over 18 years of age with both learning disability and schizophrenia. Learning disability was defined as a measured IQ of 70 or less. Any mode of diagnosis of schizophrenia was acceptable.

DATA COLLECTION AND ANALYSIS

The two reviewers independently attempted to select and then extract data but it was not possible to do this with the single study that met the inclusion criteria.

MAIN RESULTS

Only one relevant randomised trial was found by the searches. This study included four people with a dual diagnosis of schizophrenia and learning disability, but results were available for only two. The groups to which the other two people were allocated were unclear. In order to display the data, too many assumptions would have to have been made about these other two people and any results would be uninformative and potentially misleading.

REVIEWER'S CONCLUSIONS

Using the methods described the reviewers found no randomised controlled trial evidence to guide the use of antipsychotic medication for those with both learning disability and schizophrenia. Until the urgent need for randomised controlled trials is met clinical practice will continue to be guided by extrapolation of evidence from randomised controlled trials involving people with schizophrenia but without learning disability and non-randomised trials of those with learning disability and schizophrenia.

Psychopharmacotherapy in children and adults with intellectual disability

The prevalence of psychiatric disorders is increased in children and adults with intellectual disability. Brain damage or dysfunction interact with social and family factors to increase susceptibility to mental illness. Psychiatric disorders in the context of genetic syndromes are commonly overlooked, and there is substantial underdiagnosis of mental disorders because of the atypical and non-specific clinical presentations, and the frequent assumption that psychiatric symptoms are an inherent part of the underlying intellectual disability. There is a strong need for evidence-based practice in the prescribing and monitoring of drugs in this population, especially since many of the drugs are unlicensed for use in children. There is an urgent need to understand and establish the pharmacokinetics, pharmacodynamics, and side-effect profiles of psychotropic medication in this population. Positive trends in pharmacotherapy include the use of atypical antipsychotics instead of the classic antipsychotics, serotonin-specific reuptake inhibitors (SSRIs) rather than tricyclic antidepressants, and newer antiepileptic drugs. Another welcome trend is the use of SSRIs instead of antipsychotics in the long-term management of challenging behaviour in this population.

Effectiveness of antipsychotic medication in people with intellectual disability and schizophrenia: a systematic review

The aim of the present study was to determine the efficacy of any antipsychotic medication for treating people with a dual diagnosis of intellectual disability and schizophrenia. The authors performed an electronic search of Biological Abstracts, the Cochrane Schizophrenia Group's Register of trials, the Cochrane Library, EMBASE, PsycLIT and MEDLINE. Unpublished data were sought from pharmaceutical companies. Both authors independently selected the relevant studies from the reports identified in this way. Only one relevant randomized trial was found by the searches (Foote 1958). This study included four people with a dual diagnosis of schizophrenia and intellectual disability, but results were only available for two subjects. The groups to which the other two people were allocated were unclear. Using the methods described, the reviewers found no trial evidence to guide the use of antipsychotic medication for those with both intellectual disability and schizophrenia. Until the urgent need for randomized controlled trials is met, clinical practice will continue to be guided by evidence from trials involving people with schizophrenia but without intellectual disability.

Clozapine therapy in patients with neurologic illness

OBJECTIVE

This review will analyze the use of clozapine in patients with neurologic illness.

METHODS

A review of the literature was performed. Attention is focused particularly on patients with seizure disorder, head injury, mental retardation, Parkinson's disease, Huntington's disease, tardive dyskinesia, and selected other neurological disorders.

RESULTS

This review discusses clinical difficulties/issues associated with clozapine therapy in patients with a variety of neurological disorders.

CONCLUSION

Although clozapine therapy should be reserved for those patients who are refractory to conventional psychotropic medications, when used appropriately it may offer a safe and effective way of improving quality of life for patients with behavioral symptoms and neurologic illness.