Haematological side effects associated with clozapine: A retrospective study from India

Relationship between anemia and its correlates and cognitive function in Chinese patients with chronic schizophrenia: A large cross-sectional study

Background

Although both anemia and schizophrenia (SCZ) can cause cognitive decline, it is unclear whether anemia worsens cognitive decline in patients with SCZ. The primary objective of this study was to investigate the prevalence of anemia and the relationship between anemia, SCZ symptom severity, and cognitive function in patients with SCZ.

Methods

We obtained demographic and clinical data from 1690 inpatients with SCZ. All psychiatric symptoms and cognitive functioning were assessed by the Positive and Negative Syndrome Scale (PANSS), the Mini-Mental State Examination (MMSE), and the Repeated Battery for the Assessment of Neuropsychological Status (RBANS). Hemoglobin (HGB) values as well as red blood cell (RBC) counts were collected by routine blood tests.

Results

The proportion of anemia in patients with SCZ was 26.36 % (383/1453). Compared to SCZ patients without anemia, SCZ patients with anemia were older, had a lower bodyweight, a smaller waist circumference and lower apolipoprotein B levels, but longer QT intervals. Further logistic regression analysis revealed that anemia was associated with age, gender, and weight. In addition, there was no difference in cognitive function between SCZ patients with and without anemia.

Conclusion

Our findings suggest a high proportion of anemia in patients with chronic SCZ in the Han Chinese population. Several demographic and clinical variables are associated with anemia in SCZ patients.

Adverse hematological profiles associated with chlorpromazine antipsychotic treatment in male rats: Preventive and reversal mechanisms of taurine and coenzyme-Q10

Chlorpromazine (CPZ) is one of the most effective antipsychotic drugs used for managing psychotic related disorders owing to its dopamine receptor blocking action. However, pharmacological investigations against CPZ's cytotoxic effect have remained scarce. Hence, this study investigated the preventive and reversal effects of taurine and coenzyme-Q10 (COQ-10), which are compounds with proven natural antioxidant properties, against CPZ-induced hematological impairments in male rats. In the preventive study, rats received oral saline (10 ml/kg), taurine (150 mg/kg/day), COQ-10 (10 mg/kg/day) or in combination for 56 days, alongside CPZ (30 mg/kg, p.o.) between days 29-56. In the reversal protocol, rats had CPZ repeatedly for 56 days before taurine and COQ-10 treatments or their combination from days 29-56. Rats were also given taurine (150 mg/kg/day), and COQ-10 (10 mg/kg/day) alone for 56 days. Serums were extracted and assayed for hematological, with oxidative and inflammatory markers. CPZ induced decreased red/white blood cells, erythropoietin, platelet count, packed cell volume and hemoglobin, neutrophil, and lymphocyte, which were prevented and reversed by taurine and COQ-10, or their combination. Taurine and COQ-10 improved mean corpuscular volume, hemoglobin concentration, with increased erythropoietin levels relative to CPZ groups. CPZ-induced increased malondialdehyde, tumor necrosis factor-alpha and interleukin-6 levels with decreased interleukin-10, glutathione, and superoxide-dismutase were prevented and reversed by taurine and COQ-10 in comparison with CPZ groups. Taurine and COQ-10 alone notably improved the antioxidant/anti-inflammatory status relative to controls. Among other mechanisms, taurine and COQ-10 abated CPZ-induced hematological deficiencies, via decreased serum levels of oxidative stress, and pro-inflammatory cytokines release, with increased antioxidants and anti-inflammation function.

Hematological and inflammatory markers in Han Chinese patients with drug-free schizophrenia: relationship with symptom severity

Background

There is a growing amount of evidence suggesting that immunity and inflammation play an important role in the pathophysiology of schizophrenia. In this study, we aimed to examine the relationship between hematological and inflammatory markers with symptom severity in Han Chinese patients with drug-free schizophrenia.

Methods

This retrospective study was conducted at Chaohu Hospital of Anhui Medical University and data were extracted from the electronic medical record system over a 5-year period (May 2017 to April 2022), including participants' general and clinical information as well as Brief Psychiatric Rating Scale (BPRS) scores and hematological parameters.

Results

A total of 2,899 patients with schizophrenia were identified through the initial search. After screening, 91 patients and 141 healthy controls (HCs) were included. The patients had a higher value of neutrophils/lymphocytes ratio (NLR), monocyte/lymphocyte ratio (MLR), and platelet/lymphocyte ratio (PLR) than HCs (all P < 0.001). MLR was positively correlated with BPRS total score (r = 0.337, P = 0.001) and resistance subscale score (r = 0.350, P = 0.001). Binary logistic regression analyses revealed that severely ill was significantly associated with being male and a higher value of MLR (Natural Logaruthm, Ln) (all P < 0.05), and the receiver operating characteristic (ROC) analysis showed good performance of a regression model with an area under the curve (AUC) value of 0.787.

Conclusion

Patients with drug-free schizophrenia have an unbalanced distribution of peripheral blood granulocytes, and elevated NLR, MLR and PLR. Patients with higher value of MLR tend to have more psychotic symptoms, especially those symptoms of hostility, uncooperativeness, and suspiciousness. Our study gives a preliminary indication that MLR is a potential predictor of disease severity in patients with drug-free schizophrenia.

Clozapine-Associated Agranulocytosis: A Systematic Review. Is It Really So Frighteningly Common?

BACKGROUND

Clozapine is a very effective therapeutic option for schizophrenic disorders that have been refractory to most other therapies. This extremely positive aspect clashes easily with an adverse effect of the drug that is deemed to be a very dangerous one: agranulocytosis. We asked whether the mandatory strict hematological follow-up prescribed in the black box warning of clozapine's label is proportioned to the actual incidence of agranulocytosis, considering that is the main reason that such a drug is often used only late in the treatment course.

METHODS

We carried out a systematic review of reports examining clozapine administration and agranulocytosis incidence. We specifically selected those where mild and moderate neutropenia was not used as a trigger to stop administration of clozapine, to better estimate the sheer incidence of agranulocytosis when clozapine was continued even with mild hematological effect, where detected. We used PubMed, MEDLINE, EMBASE, Cochrane, and ScienceDirect databases to identify clinical studies conducted between January 1975 and April 2023.

RESULTS

We included 14 studies, mostly retrospective ones, that examined the incidence of hematological adverse effects in patients using clozapine. A total of 2354 subjects were included. The mean age of the subjects was 33.5 years. The mean duration of observation of subjects who took clozapine was 800 days, with a mean daily dose of 319.5 mg per day. Of the 2354 subjects examined, we found that 11 of them experienced agranulocytosis (0.47%).

CONCLUSIONS

These results suggest the evidence of a lower incidence of agranulocytosis than previously estimated and are in line with more recent meta-analyses. We may therefore think that clinical practice may demand a revision of the approach that both psychiatrists and supervising organizations often take when talking about clozapine.

Clinician Reasons for Stopping Clozapine: A Retrospective Cohort Study

BACKGROUND

Little information is available on clozapine discontinuation rates in developing country settings.

AIM

The present study aimed to evaluate the incidence and reasons clinicians stopped clozapinine in patients after initiating treatment with the same. In addition, the study also aimed to assess the rechallenge rate, that is, restarting clozapine after a decision to discontinue the same by the clinicians.

METHODOLOGY

The treatment records of 859 patients started on clozapine were reviewed to identify the patients for whom the clinician stopped clozapine at least once because of any reason. The reasons for stopping clozapine were reviewed. In addition, the treatment records were also examined for rechallenge with clozapine at a later date.

RESULTS

Clozapine was stopped by the clinicians in 44 of the 859 patients (5.12%). The most common reason for stopping clozapine was blood dyscrasias (n = 12), followed by poor adherence making the hematological monitoring difficult (n = 9), and intolerable sedation (n = 7). In half of the patients (n = 22), clozapine was restarted by the clinicians for further management of schizophrenia. Successful rechallenge was done in 58.33% of patients with blood dyscrasias, 44.44% with poor adherence, and 71.4% with intolerable sedation.

CONCLUSIONS

The present study suggests clinicians stop clozapine in only 5.14% of cases. The most common reasons for clozapine discontinuation by clinicians include blood dyscrasias, poor medication adherence making it challenging to monitor the hemogram, and sedation. However, in half of the patient's clozapine was rechallenged, and all the attempts of rechallenging were successful.

De Novo Seizures, Obsessive Compulsive Symptoms and Neutropenias in Patients on Clozapine: A Retrospective Cohort Study

BACKGROUND

Clozapine has well-documented inter-ethnic variations in pharmacokinetics. There is a paucity of data about clozapine use and associated adverse events such as seizures, obsessive compulsive symptoms, neutropenia, and agranulocytosis, from India.

METHODS

This retrospective cohort study followed up 228 patients initiated on clozapine in a tertiary care referral center in India for an average of 10 years. We calculated incidence rates of new-onset seizures, new-onset obsessive compulsive symptoms, agranulocytosis, and neutropenia. We collected data on doses of clozapine used and serum assays and calculated concentration-to-dose (C/D) ratios. We also collected relevant clinical details about clozapine-induced seizures.

RESULTS

In the sample, 16.8% had new-onset seizures, 12.3% had new-onset OC symptoms, 2.7% had neutropenia, and 0.9% had agranulocytosis. The mean C/D ratio was 2.09 (SD = 1.8). Almost half (46.3%) of available serum assays were in the supra-therapeutic range. Seizures were associated with a higher clozapine dose at one year (OR = 1.003; 95%CI = 1.000-1.006; P value = 0.045) and the presence of positive psychotic symptoms at one year (OR = 4.214; 95%CI = 1.894-9.373; P < 0.001).

CONCLUSION

Compared to existing literature, Indians have a higher rate of clozapine- related seizures and need lower doses to reach therapeutic serum levels.

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.

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.

Leukocytosis Associated with Clozapine Treatment: A Case Series and Systematic Review of the Literature

BACKGROUND AND OBJECTIVES

Clozapine is the only antipsychotic approved for treatment-resistant schizophrenia. Despite its superior efficacy profile as compared with other antipsychotics, clozapine remains underutilized. Clozapine monitoring systems clearly describe the proposed management of clozapine-induced neutropenia; however, no specific mention is made of how to interpret neutrophilic leukocytosis, despite that being a relatively frequent finding. Prescribers unfamiliar with this molecule may misjudge its clinical significance, potentially leading to untimely treatment interruption. Here, we systematically review the literature on the risk of neutrophilic leukocytosis during clozapine treatment, and describe eight additional cases among our patient cohort.

MATERIALS AND METHODS

We performed a systematic review of the literature on PubMed and Embase using the PRISMA 2020 guidelines, and selected all original reports describing either (1) the prevalence of neutrophilic leukocytosis during clozapine treatment, or (2) the clinical significance of neutrophilic leukocytosis. We described eight additional cases of neutrophilic leukocytosis during clozapine treatment while attending an outpatient psychiatric clinic.

RESULTS

Our research ultimately yielded the selection of 13 articles included in this systematic review. The case series highlighted the presence of stable and clinically unremarkable neutrophilia during a follow-up ranging from one to ten years.

CONCLUSIONS

Existing evidence indicates that leukocytosis associated with clozapine treatment can be considered as an asymptomatic and benign condition, suggesting that no change in clozapine treatment is needed upon its detection.

Clozapine-associated severe eosinophilia following lithium rebound neutropenia: A case report

Background

Clozapine use is complicated by an increased risk of hematological adverse effects such as neutropenia and, rarely, eosinophilia.

Case presentation

We present the case of a 48‐year‐old man with treatment‐resistant schizophrenia. On day 12 after clozapine initiation, he had a cough with a temperature of 39.8°C. On day 16, his leukocyte count had increased to 9320 cells/mm³ (neutrophils 7550 cells/mm³ and eosinophils 680 cells/mm³). We discontinued lithium because of neutrophilia and damage to renal function on day 20. His eosinophil count increased until day 29, reaching 6750 cells/mm³. We suspected a drug‐induced reaction and discontinued clozapine on day 30. His eosinophil count gradually decreased, reaching the normal range by day 40. However, his leukocyte and neutrophil counts also gradually decreased to below than the normal range by day 40. His leukocytes and neutrophil counts had recovered by day 55.

Conclusion

We concluded that this patient had clozapine‐associated severe eosinophilia following lithium rebound neutropenia.

The eosinophil count increased reaching 6750 cells/mm³ with bronchitis and hepatitis during clozapine treatment. The leukocyte and neutrophil counts gradually decreased to below than the normal range by day 40 after discontinuation of lithium.