Clozapine use in geriatric patients- Challenges

Risk of agranulocytosis and neutropenia in patients with Parkinson's disease psychosis receiving clozapine treatment: A systematic review and meta-analysis

OBJECTIVE

To assess the cumulative incidence of severe neutropenia and agranulocytosis (SNA) and mild and moderate neutropenia (MMN) in patients with Parkinson's disease psychosis (PDP) who receive clozapine treatment.

METHODS

We searched multiple databases to identify clozapine studies in PDP patients. Incidence rates were assessed during short-term (within 1 month), medium-term (within 6 months), and long-term (> 6 months) monitoring periods. A proportional meta-analysis was performed using random-effects and generalized linear mixed models (GLMMs).

RESULTS

We included 691 PDP patients from 19 studies. During the short-term monitoring period, none of the 573 participants in 16 studies developed SNA. The pooled incidence of SNA was 0.001 (95 % confidence interval [CI]: 0.000-0.253, 525 participants, 15 studies) during the medium-term period and 0.002 (95 % CI: 0.000-0.015, 475 participants, 12 studies) during the long-term period. The pooled incidence of MMN was 0.004 (95 % CI: 0.000-0.281, 164 participants, 7 studies) for short- and medium-term periods and 0.013 (95 % CI: 0.002-0.094, 193 participants, 7 studies) in the long-term period. Funnel plot asymmetry indicated potential bias in the medium-term dataset of SNA (p = 0.035).

CONCLUSION

Clozapine treatment in PDP patients may carry a very low risk of SNA and a low risk of MMN.

Drug-Induced Cognitive Impairment

Drug-induced cognitive impairment (DICI) is a well-established, yet under-recognised, complication of many types of pharmacological treatment. While there is a large body of scientific literature on DICI, most papers are about drug-induced dementia in the elderly and one specific drug class. However, DICI also comprises subclinical symptoms, domain-specific forms of cognitive impairment as well as mild cognitive impairment (MCI), and delirium. Even mild forms of DICI, if not recognised as such, can have deleterious and life-long consequences. In addition, DICI also occurs in younger adults and in children, and has been reported with many different drug classes. The aim of this review is to raise awareness of DICI by providing an overview on the type(s) and symptoms of observed DICI and the suspected underlying mechanism(s) for various drug classes: antiseizure medications, antidepressants, antiparkinsonian drugs, antipsychotics, lithium, benzodiazepines/Z-drugs, opioids, first-generation antihistamines, drugs for urinary incontinence, proton pump inhibitors, glucocorticoids, NSAIDs, statins, antihypertensives, and chemotherapeutic agents.

An experience of using Clozapine in elderly patients with mental disorders

BACKGROUND

There is little information on using clozapine in elderly patients with mental disorders from India.

AIM

To evaluate the sociodemographic and clinical profile of elderly (age ≥ 60 years) patients started on clozapine.

METHODOLOGY

The clozapine registry in the department was screened to identify elderly patients who were started on clozapine. Treatment records of these patients were reviewed to extract sociodemographic and clinical details.

RESULTS

Out of the available information of 1058 patients in the registry, 42 (3.96 %) were elderly (≥ 60 years) patients. About two-thirds of the patients had treatment resistance, i.e., their psychotic illness had not responded to two adequate trials of antipsychotics, and the second most common indication for starting clozapine was tardive dystonia or tardive dyskinesia (23.8 %). The mean dose of clozapine was 135.89 (SD: 109.6; Range: 37.5-500; median: 87.5) mg/day. The mean duration of clozapine use at the time of data extraction for the study sample was 3.55 (SD: 2.15; Range 0.3-9; median: 3) years. At the last follow-up, about three-fourths of patients were experiencing at least one side effect, with constipation being the most common side effect, followed by sedation, weight gain, and hypersalivation. In only four patients, clozapine was stopped during the follow-up. In terms of effectiveness, majority of the patients were rated as much improved or very much improved on Clinical Global Impression-Improvement subscale.

CONCLUSION

Clozapine can be safely used in elderly patients with mental disorders. Hence, clozapine should not be withheld in elderly patients with mental disorders whenever indicated.

Second to none: rationale, timing, and clinical management of clozapine use in schizophrenia

Despite its enduring relevance as the single most effective and important evidence-based treatment for schizophrenia, underutilization of clozapine remains considerable. To a substantial degree, this is attributable to a reluctance of psychiatrists to offer clozapine due to its relatively large side-effect burden and the complexity of its use. This underscores the necessity for continued education regarding both the vital nature and the intricacies of clozapine treatment. This narrative review summarizes all clinically relevant areas of evidence, which support clozapine's wide-ranging superior efficacy - for treatment-resistant schizophrenia (TRS) and beyond - and make its safe use eminently feasible. Converging evidence indicates that TRS constitutes a distinct albeit heterogeneous subgroup of schizophrenias primarily responsive to clozapine. Most importantly, the predominantly early onset of treatment resistance and the considerable decline in response rates associated with its delayed initiation make clozapine an essential treatment option throughout the course of illness, beginning with the first psychotic episode. To maximize patients' benefits, systematic early recognition efforts based on stringent use of TRS criteria, a timely offer of clozapine, thorough side-effect screening and management as well as consistent use of therapeutic drug monitoring and established augmentation strategies for suboptimal responders are crucial. To minimize permanent all-cause discontinuation, re-challenges after neutropenia or myocarditis should be considered. Owing to clozapine's unique efficacy, comorbid conditions including substance use and most somatic disorders should not dissuade but rather encourage clinicians to consider clozapine. Moreover, treatment decisions need to be informed by the late onset of clozapine's full effects, which for reduced suicidality and mortality rates may not even be readily apparent. Overall, the singular extent of its efficacy combined with the high level of patient satisfaction continues to distinguish clozapine from all other available antipsychotics.

Clozapine research from India: A systematic review

BACKGROUND

Although clozapine is much researched in western literature, a review on Indian research on clozapine published in 2010 reported limited data and need for further research in this area.

AIM

We aimed to conduct a systematic review of research on clozapine from India from 2010 to mid-2022 and also compare the same with research output before 2010.

METHODOLOGY

A systematic various search engines, i.e., PUBMED, Medknow, Hinari and Google Scholar was done using the key words clozapine and India. Published articles with clozapine in the title and having an author from India, published during 2010 to July 2022 were included.

RESULTS

Initial Internet and hand searches yielded 280 articles, out of which 126 articles were excluded due to various reasons and 154 articles, were included for the review. This included 84 case reports, 49 original articles, 11 review articles and 10 letters to the editor as comments. We found an increase in the number of publications during the period of 2010-2022 compared to 1997-2009 in all types of publications. Over the years a significant proportion of the articles focused on various side effects of clozapine, factors associated with response and non-response to clozapine and evaluation of outcomes other than efficacy/effectiveness. However, all the studies were limited to a single centre with no multicentric studies on clozapine.

CONCLUSION

Over the last 12 years or so, there is increase in the number of publications on clozapine. However, there is lack of multicentric studies.

Comparison of psychotropic drug preferences and side effects in old and young patients with schizophrenia and schizoaffective disorder

Purpose: The current study investigates the preferred psychotropic drug treatments and their tolerability in elderly patients (EP) with a diagnosis of schizophrenia or schizoaffective disorder compared to younger patients (YP). Materials and Methods: The study included 154 EP and 195 YP with schizophrenia/schizoaffective disorder admitted to the outpatient unit at a university hospital in the last decade. The medical records of the patients were reviewed. The types and doses of antipsychotic drugs used by each patient, use of other psychotropic drugs, ongoing complaints, drug-related side effects and compliance with treatment were also examined. Results: Second generation antipsychotic use was higher in YP (88% in YP, 80% in EP). Antipsychotic equivalent doses were found 266.63 mg in EP, 522.21 mg in YP, that also higher in the YP group. The use of clozapine (7% in EP, 37% in YP) and mood stabilizers (4.5% in EP, 18% in YP) were higher in YP. There was a higher rate of dose reduction of antipsychotic drugs in EP (21.5% in YP, 52% in EP). When the groups were compared in terms of the reasons of antipsychotic dose reduction, it was more frequent in EP due to side effects (21.4% in YP, 40% in EP), while the dose reduction due to remission was more common in YP (78.6% in YP, 60% in EP) . Conclusion: Lower doses of antipsychotics in EP suggests milder symptoms or lower tolerability. The higher clozapine and mood stabilizer use in YP can be explained by avoiding side effects like extrapyramidal, cardiovascular and metabolic side effects that are more frequent in EP.

Potentially inappropriate medications according to PRISCUS list and FORTA (Fit fOR The Aged) classification in geriatric psychiatry: a cross-sectional study

Adverse drug reactions (ADRs) constitute a frequent cause of hospitalization in older people. The risk of ADRs is increased by the prescription of potentially inappropriate medications for older people (PIMs). The PRISCUS list and the FORTA classification represent established tools to detect PIMs. The aim of the present study was to examine the prevalence and characteristics of PIM prescriptions on the gerontopsychiatric ward of a university hospital in Germany. To this aim, medication charts of 92 patients (mean age 75.9 ± 7.7 years; 66.3% female) were analyzed on a weekly basis until patient discharge by utilization of the PRISCUS list and the FORTA classification. Overall, 335 medication reviews comprising 2363 drug prescriptions were analyzed. 3.0% of the prescribed drugs were PIMs according to the PRISCUS list, with benzodiazepines and Z-drugs accounting for nearly half (49.3%) of all PIM prescriptions. 30.4% of the patients were prescribed at least one PRISCUS-PIM, while 43.5% of the study population took at least one FORTA class D drug. A considerable proportion of gerontopsychiatric patients were affected by PIMs; however, the overall number of PIM prescriptions in the study population was low. Further improvements in the quality of prescribing should target the use of sedating agents such as benzodiazepines and Z-drugs. Physicians should be aware of discrepancies between the PRISCUS list and the FORTA classification.

Pathogenesis and Personalized Interventions for Pharmacological Treatment-Resistant Neuropsychiatric Symptoms in Alzheimer’s Disease

Alzheimer’s disease (AD) is the most common form of dementia, with cognitive impairment as a core symptom. Neuropsychiatric symptoms (NPSs) also occur as non-cognitive symptoms during the disease course, worsening the prognosis. Recent treatment guidelines for NPSs have recommended non-pharmacological treatments as the first line of therapy, followed by pharmacological treatments. However, pharmacological treatment for urgent NPSs can be difficult because of a lack of efficacy or an intolerance, requiring multiple changes in psychotropic prescriptions. One biological factor that might be partly responsible for this difficulty is structural deterioration in elderly people with dementia, which may cause a functional vulnerability affecting the pharmacological response. Other causative factors might include awkward psychosocial interpersonal relations between patients and their caregiver, resulting in distressful vicious circles. Overlapping NPS sub-symptoms can also blur the prioritization of targeted symptoms. Furthermore, consistent neurocognitive reductions cause a primary apathy state and a secondary distorted ideation or perception of present objects, leading to reactions that cannot be treated pharmacologically. The present review defines treatment-resistant NPSs in AD; it may be necessary and helpful for clinicians to discuss the pathogenesis and comprehensive solutions based on three major hypothetical pathophysiological viewpoints: (1) biology, (2) psychosociology, and (3) neurocognition.

Risk factors for clozapine-induced myocarditis and cardiomyopathy: A systematic review and meta-analysis

OBJECTIVE

Clozapine is the most effective medication for treatment-refractory schizophrenia, but it is associated with severe cardiac adverse events including myocarditis and cardiomyopathy. To aid treatment decision-making for clinicians, patients and their carers, we conducted a systematic review and meta-analysis to identify potential risk factors for clozapine-induced myocarditis and cardiomyopathy.

METHODS

A systematic search was conducted of PubMed, Embase, CINAHL, Web of Science, Cochrane and PsycInfo for studies reporting myocarditis and cardiomyopathy among people on clozapine and potential risk factors. We calculated pooled effect sizes on risk factors using a random-effects meta-analytic model. Risk of publication bias was assessed using the Newcastle-Ottawa scale.

RESULTS

Seven studies met the inclusion criteria, of which six studies had quantitative data included in the meta-analysis. The odds of clozapine-induced myocarditis increased with concurrent sodium valproate use (k = 6, n = 903, pooled OR 3.58, 95% CI 1.81-7.06), but were not significantly greater with the use of quetiapine, lithium or selective serotonin reuptake inhibitors. Our qualitative review identified conflicting results reported for increasing age and higher clozapine dose as risk factors for myocarditis. No other factors, including genetic risk, sex, ethnicity, smoking, alcohol, substance abuse or cardiometabolic disease, were associated with greater odds of myocarditis. No risk factors for cardiomyopathy were identified in the literature.

CONCLUSION

Concurrent use of sodium valproate increases the odds of clozapine-induced myocarditis. Thus, clinicians should consider the temporary cessation of sodium valproate during the initial titration phase of clozapine.

SkipGNN: predicting molecular interactions with skip-graph networks

Molecular interaction networks are powerful resources for molecular discovery. They are increasingly used with machine learning methods to predict biologically meaningful interactions. While deep learning on graphs has dramatically advanced the prediction prowess, current graph neural network (GNN) methods are mainly optimized for prediction on the basis of direct similarity between interacting nodes. In biological networks, however, similarity between nodes that do not directly interact has proved incredibly useful in the last decade across a variety of interaction networks. Here, we present SkipGNN, a graph neural network approach for the prediction of molecular interactions. SkipGNN predicts molecular interactions by not only aggregating information from direct interactions but also from second-order interactions, which we call skip similarity. In contrast to existing GNNs, SkipGNN receives neural messages from two-hop neighbors as well as immediate neighbors in the interaction network and non-linearly transforms the messages to obtain useful information for prediction. To inject skip similarity into a GNN, we construct a modified version of the original network, called the skip graph. We then develop an iterative fusion scheme that optimizes a GNN using both the skip graph and the original graph. Experiments on four interaction networks, including drug–drug, drug–target, protein–protein, and gene–disease interactions, show that SkipGNN achieves superior and robust performance. Furthermore, we show that unlike popular GNNs, SkipGNN learns biologically meaningful embeddings and performs especially well on noisy, incomplete interaction networks.

Clozapine: An Updated Overview of Pharmacogenetic Biomarkers, Risks, and Safety-Particularities in the Context of COVID-19

BACKGROUND

clozapine (CLZ) use is precarious due to its neurological, cardiovascular, and hematological side effects; however, it is the gold standard in therapy-resistant schizophrenia (TRS) in adults and is underused.

OBJECTIVE

to examine the most recent CLZ data on (a) side effects concerning (b) recent pharmacological mechanisms, (c) therapy benefits, and (d) the particularities of the COVID-19 pandemic.

DATA SOURCES

a search was performed in two databases (PubMed and Web of Science) using the specific keywords "clozapine" and "schizophrenia", "side effects", "agranulocytosis", "TRS", or "bipolar affective disorder (BAF)" for the last ten years.

STUDY ELIGIBILITY CRITERIA

clinical trials on adults with acute symptoms of schizophrenia or related disorders.

RESULTS

we selected 37 studies, randomized controlled trials (RCTs), and clinical case series (CCS), centered on six main topics in the search area: (a) CLZ in schizophrenia, (b) CLZ in bipolar disorder, (c) side effects during the clozapine therapy, (d) CLZ in pregnancy, (e) CLZ in early-onset schizophrenia, and (f) CLZ therapy and COVID-19 infection.

LIMITATIONS

we considered RCTs and CCS from two databases, limited to the search topics. Conclusions and implications of key findings: (a) clozapine doses should be personalized for each patient based on pharmacogenetics testing when available; the genetic vulnerability postulates predictors of adverse reactions' severity; patients with a lower genetic risk could have less frequent hematological monitoring; (b) a CLZ-associated risk of pulmonary embolism imposes prophylactic measures for venous thromboembolism; (c) convulsive episodes are not an indication for stopping treatment; the plasma concentration of clozapine is a better side effect predictor than the dosage; (d) COVID-19 infection may enhance clozapine toxicity, generating an increased risk of pneumonia. Therapy must be continued with the proper monitoring of the white blood count, and the clozapine dose decreased by half until three days after the fever breaks; psychiatrists and healthcare providers must act together.

How to identify and manage non-response to clozapine?

Clozapine is the only approved treatment for Treatment-Refractory Schizophrenia. Here we describe a case series of three hospitalized patients with clozapine nonresponse. One of them responded to clozapine after dose adjustments were made for an interaction between clozapine and ciprofloxacin. The other two cases remained clozapine nonresponders despite optimizing clozapine treatment. However, both these patients responded to other antipsychotic medications (APMs) with better tolerability than observed with clozapine treatment. This case series focuses on diagnosing a genuine from a pseudo-nonresponse to clozapine and to consider other APMs in genuine nonresponse before switching to invasive interventions, such as ECT.

Meloxicam-desmopressin drug-drug interaction producing hyponatremia

BACKGROUND

People with schizophrenia and medical comorbidities are often on multiple medications to manage their symptoms. Herein we present a case of drug-drug interaction (meloxicam and desmopressin), in a patient also on clozapine, that ultimately resulted in hyponatremia and seizure.

METHODS

The patient provided consent to have his case published. We searched PubMed and after reviewing 321 articles, 11 were chosen for relevance.

RESULTS

Meloxicam enhanced the adverse effect (hyponatremia) of desmopressin and was the likely culprit.

CONCLUSIONS

In a patient with higher ADH levels, as in our patient taking desmopressin, the addition of an NSAID could further increase water retention and worsen hyponatremia; indeed, meloxicam was the only new medication added to the patient's regimen, and a drug interaction calculator supports the desmopressin-meloxicam drug-drug interaction as the culprit. We urge clinicians to avoid the use of desmopressin in patients with schizophrenia as this can lead to water intoxication. As meloxicam may worsen desmopressin-induced hyponatremia and could result in seizure, one should avoid using NSAIDs in patients with schizophrenia whom are also prescribed vasopressin/desmopressin. Serum sodium levels should be closely monitored in patients with schizophrenia whose regimen includes desmopressin.

Psychotic disorders in late life: a narrative review

Psychotic disorders are not uncommon in late life. These disorders often have varied etiologies, different clinical presentations, and are associated with significant morbidity and mortality among the older adult population. Psychotic disorders in late life develop due to the complex interaction between various biological, psychological, social, and environmental factors. Given the significant morbidity and mortality associated with psychotic disorders in late life, a comprehensive work-up should be conducted when they are encountered. The assessment should not only identify the potential etiologies for the psychotic disorders, but also recognize factors that predicts possible outcomes for these disorders. Treatment approaches for psychotic disorders in late life should include a combination of nonpharmacological management strategies with the judicious use of psychotropic medications. When antipsychotic medications are necessary, they should be used cautiously with the goal of optimizing outcomes with regular monitoring of their efficacy and adverse effects.

[Diseases of the schizophrenia spectrum disorder in old age : Diagnostic and therapeutic challenges]

BACKGROUND

The number of people with diseases of the schizophrenia spectrum in old age will increase significantly in the coming years. In the literature the topics of schizophrenia and delusional disorders in older and old people are inadequately represented.

AIM

This article gives an overview of the most important diagnostic and differential diagnostic characteristics. Another important aspect is the pharmacological and non-pharmacological treatment options in old age.

MATERIAL AND METHODS

The S3 guidelines of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) from 2006, the guidelines of the World Federation of Societies of Biological Psychiatry (WFSBP) from 2012, 2013, 2015 and the consensus statement of the Austrian Association for Neuro-Psychopharmacology and Biological Psychiatry (ÖGPB) from 2016 formed the basic literature for this review. In addition, a targeted search in the databases PubMed, PubPsych and Cochrane Library as well as in German Journals, such as DerNervenarzt, Neuropsychiatrie, Psychiatrische Praxis and Zeitschrift für Gerontologie und Geriatrie concerning the keywords schizophrenia, delusional disorder, diagnostics, therapy and older people was carried out.

RESULTS

Besides aspects on epidemiology, clinical manifestation, diagnostics, differential diagnostics and course of the illness, pharmacological and non-pharmacological treatment options are presented.

CONCLUSION/DISCUSSION

In clinical practice a clear diagnostic assignment is often a challenge in older and very old people with psychotic symptoms, The necessary pharmacological treatment is available but is limited by tolerability, comorbidities and polypharmacy. Non-pharmacological treatment options have hardly been investigated.

[Psychiatric pharmacotherapy of older individuals with severe mental illness]

BACKGROUND

Chronic schizophrenia, depression, and bipolar disorders, among other chronic psychiatric disorders with onset at youth or early adulthood are often referred to as severe mental illness (SMI). Aging with SMI is associated with various psychosocial, physiological, and medical problems with potential impact on psychiatric pharmacotherapy.

OBJECTIVES

Determination and discussion of problems and special features of the psychopharmacological treatment of older persons with SMI and presentation of treatment recommendations for the distinct diagnoses.

MATERIALS AND METHODS

International literature and guidelines were searched. In addition, the basic literature and expert opinions are discussed.

RESULTS

General problems that influence the psychiatric pharmacotherapy of older persons with SMI include nonadherence, nonresponse, polypharmacy, and distinct pharmacokinetic changes with aging and somatic comorbidity. Psychotropic drugs may exhibit cardiovascular, metabolic, and neuropsychiatric risks, among others. The literature regarding effectiveness of psychotropic drugs, drug groups, or combination of drugs in older patients with SMI is scarce to nonexistent.

CONCLUSIONS

Drug treatment of older persons with SMI should be part of an overall treatment plan that also has to include social and psychotherapeutic components that address the specific problems of this population. Most importantly, psychiatric pharmacotherapy should consider these risks and the treatment should be tailored to a patient's individual risk profile. Due to a general lack of evidence in this special population, treatment strategies of standard guidelines should be adjusted with special consideration to physiological changes of age.