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Verdoux H, Quiles C, de Leon J. Optimizing co-prescription of clozapine and antiseizure medications: a systematic review and expert recommendations for clinical practice. Expert Opin Drug Metab Toxicol 2024; 20:347-358. [PMID: 38613254 DOI: 10.1080/17425255.2024.2343020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 04/10/2024] [Indexed: 04/14/2024]
Abstract
INTRODUCTION Antiseizure medication (ASM) add-on to clozapine may be efficient to target clozapine-resistant mood or psychotic symptoms or clozapine-related adverse drug reactions (ADR) such as seizures. We aimed to synthesize the information relevant for clinical practice on the risks and benefits of clozapine-ASM co-prescription. AREAS COVERED Articles were identified with MEDLINE, Web of Sciences and PsycINFO search from inception through October 2023. The review was restricted to ASM with mood-stabilizing properties or with potential efficacy for resistant psychotic symptoms (valproate (VPA), lamotrigine, topiramate, carbamazepine, oxcarbazepine). EXPERT OPINION VPA add-on to clozapine is associated with a high risk of serious ADR (myocarditis, neutropenia, pneumonia) mostly explained by complex time-dependent drug-drug interactions. The initial inhibitory effects on clozapine metabolism require slow titration to avoid immuno-allergic reactions. After the titration period, VPA has mainly inductive effects on clozapine metabolism that are more marked in smokers requiring therapeutic drug monitoring. Lamotrigine and topiramate add-on may be recommended as the first-line treatment for clozapine-related seizures, but there is limited evidence regarding the efficacy of this strategy for clozapine-resistant psychotic symptoms. Carbamazepine should not be co-prescribed with clozapine because of its potential for agranulocytosis and for inducing clozapine metabolism.
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Affiliation(s)
- Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team pharmacoepidemiology, Bordeaux, France
| | - Clélia Quiles
- Centre Hospitalier Charles Perrens, Bordeaux, France
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, USA
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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Mossé U, Chaumette B, Wils J, Imbert L, Lamoureux F, Ferrafiat V. Evidence of pharmacogenetics-based fluvoxamine use as an add-on to clozapine treatment in psychiatry. Pharmacogenomics 2022; 23:649-654. [PMID: 35916148 DOI: 10.2217/pgs-2022-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Pharmacological treatments used for psychiatric disorders, such as clozapine, demonstrate large interindividual variability in terms of possible adverse effects and therapeutic benefit. This variability can be explained by multiple factors, including pharmacogenetic factors. Clozapine efficacy can be impacted by CYP polymorphisms. A growing body of literature on pharmacogenetics suggests the clinical benefit of concomitant use of clozapine and fluvoxamine to improve global pharmacotherapeutic management. This article reviews and discusses available clinical and pharmacological data and limitations of clozapine augmentation with fluvoxamine based on pharmacogenetic rationale and clinical experience. The aim is to provide an updated approach on how to use the pharmacological and pharmacogenetic profile to improve clozapine efficacy and tolerance in severely ill patients.
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Affiliation(s)
- Ulysse Mossé
- Child and Adolescent Psychiatric Unit, L'Unité Régionale d'Hospitalisation Psychiatrique pour Enfants et Adolescents, Centre Hospitalier du Rouvray Sotteville-les Rouen, Rouen, 76000, France
| | - Boris Chaumette
- Institut National de la Santé et de la Recherche Médicale U1266, Institute of Psychiatry and Neuroscience of Paris, Paris, 75000, France.,Groupe Hospitalier Universitaire Paris, Psychiatrie et Neurosciences, Paris, 75000, France.,Department of Psychiatry, McGill University, Montreal, H3A 0G4, Canada
| | - Julien Wils
- Department of Pharmacology, Toxicology and Pharmacogenetics, Rouen University Hospital, Rouen, 76000, France.,Institut National de la Santé et de la Recherche Médicale U1096, Université de Rouen Normandie, Rouen, 76000, France
| | - Laurent Imbert
- Department of Pharmacology, Toxicology and Pharmacogenetics, Rouen University Hospital, Rouen, 76000, France
| | - Fabien Lamoureux
- Department of Pharmacology, Toxicology and Pharmacogenetics, Rouen University Hospital, Rouen, 76000, France.,Institut National de la Santé et de la Recherche Médicale U1096, Université de Rouen Normandie, Rouen, 76000, France
| | - Vladimir Ferrafiat
- Intensive Care Unit, Department of Child and Adolescent Psychiatry, Marseille-Nord University Hospital, Marseille, 13000, France.,Reference Center for Inborn Errors of Metabolism, La Timone University Hospital, Assistance Publique - Hopitaux de Marseille, Marseille, 13000, France
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Raymond N, Lizano P, Kelly S, Hegde R, Keedy S, Pearlson GD, Gershon ES, Clementz BA, Tamminga CA, Keshavan M. What can clozapine’s effect on neural oscillations tell us about its therapeutic effects? A scoping review and synthesis. Biomark Neuropsychiatry 2022. [DOI: 10.1016/j.bionps.2022.100048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Fahanik-Babaei J, Baluchnejadmojarad T, Roghani M. Differential Effect of Amyloid Beta1-40 on Short-term and Long-term Plasticity in Dentate Gyrus of a Rat Model of Alzheimer Disease. Basic Clin Neurosci 2021; 11:517-524. [PMID: 33613890 PMCID: PMC7878034 DOI: 10.32598/bcn.9.10.190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 06/10/2018] [Accepted: 07/24/2018] [Indexed: 11/24/2022] Open
Abstract
Introduction: Synaptic plasticity is inappropriately affected by neurodegenerative diseases, including Alzheimer Disease (AD). In this study, we examined the effect of intrahippocampal amyloid-beta (Aβ1-40) on dentate gyrus Long-term Potentiation (LTP) and presynaptic short-term plasticity in a rat model of AD. Methods: The experimental groups in this research included the control with no treatment, sham-operated receiving the vehicle (normal saline), and Aβ-lesioned groups. For modeling AD, aggregated Aβ1-40 (10 μg/2 μl on each side) was injected into the hippocampal CA1. Three weeks later, Population Spike (PS) amplitude and slope ratios were determined at different Inter-pulse Intervals (IPI) of 10, 20, 30, and 50 ms as a valid indicator of the short-term presynaptic facilitation and/or depression. In addition, PS amplitude and slope were taken as an index of long-term synaptic plasticity after application of High-frequency Stimulation (HFS) to induce LTP in the medial perforant-dentate gyrus pathway. Results: No significant differences were noted amongst the experimental groups regarding fEPSP slope and paired-pulse indices as indicators of short-term plasticity. In contrast, fEPSP slope and PS amplitude significantly decreased following the application of HFS in Aβ-injected group. In addition, there was no significant difference between the control and sham-operated groups regarding the mentioned parameters. Conclusion: Findings of this study clearly demonstrated that microinjection of Aβ1-40 into the CA1 could impair LTP in dentate gyrus but could not modify short-term plasticity.
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Affiliation(s)
| | - Tourandokht Baluchnejadmojarad
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran.,Department of Physiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mehrdad Roghani
- Neurophysiology Research Center, Shahed University, Tehran, Iran
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Schoretsanitis G, Kane JM, Ruan CJ, Spina E, Hiemke C, de Leon J. A comprehensive review of the clinical utility of and a combined analysis of the clozapine/norclozapine ratio in therapeutic drug monitoring for adult patients. Expert Rev Clin Pharmacol 2019; 12:603-621. [DOI: 10.1080/17512433.2019.1617695] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Georgios Schoretsanitis
- Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Hofstra Northwell School of Medicine, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - John M. Kane
- Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Hofstra Northwell School of Medicine, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology & The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Mainz, Germany
| | - Jose de Leon
- University of Kentucky Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA
- Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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Piatkov I, Caetano D, Assur Y, Lau SL, Coelho M, Jones T, Nguyen T, Boyages S, McLean M. CYP2C19*17 protects against metabolic complications of clozapine treatment. World J Biol Psychiatry 2017; 18:521-527. [PMID: 28664816 DOI: 10.1080/15622975.2017.1347712] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Clozapine (CZ) is the most effective drug for managing treatment-resistant schizophrenic disorders. Its use has been limited due to adverse effects, which include weight gain and new-onset diabetes, but the incidence of these varies between patients. METHODS We investigated 187 Clozapine Clinic patients (of whom 137 consented for genotyping) for the presence of CYP2C19*17 and its association with CZ and norclozapine (NCZ) levels, and clinical outcomes. RESULTS Thirty-nine percent of genotyped patients were carriers of the CYP2C 19*17 polymorphism. This group demonstrated significantly higher NCZ serum levels, and significantly lower fasting glucose (5.66 ± 1.19 vs 6.72 ± 3.01 mmol/l, P = 0.009) and Hb1Ac (35.36 ± 4.78 vs 49.40 ± 20.60 mmol/mol, P = 0.006) levels compared to non-carriers of this polymorphism. CZ-treated patients with CYP2C19*17/*17 had a significantly lower prevalence of diabetes as well as a higher likelihood of clinical improvement of their schizophrenia, compared to those without this polymorphism (P = 0.012 and P = 0.031, respectively). CONCLUSIONS Our data suggest that CYP2C19*17 ultra-rapid-metaboliser status is a protective factor against the development of diabetes during clozapine treatment, and increases the likelihood of improvement in schizophrenia. The role of NCZ in treatment response and side effects, including metabolic syndrome, warrants further pharmacogenetic, pharmacokinetic and pharmacodynamic studies.
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Affiliation(s)
- Irina Piatkov
- a Molecular Research Laboratory, Blacktown Clinical School and Research Centre , Blacktown Hospital, WSU/WSLHD , Blacktown , Australia
| | - Dorgival Caetano
- b Western Sydney University School of Medicine , Campbelltown , NSW , Australia.,c Blacktown Mental Health Service , Blacktown Hospital, WSLHD , Blacktown , Australia
| | - Yolinda Assur
- c Blacktown Mental Health Service , Blacktown Hospital, WSLHD , Blacktown , Australia
| | - Sue Lynn Lau
- b Western Sydney University School of Medicine , Campbelltown , NSW , Australia
| | - Micheline Coelho
- a Molecular Research Laboratory, Blacktown Clinical School and Research Centre , Blacktown Hospital, WSU/WSLHD , Blacktown , Australia
| | - Trudi Jones
- a Molecular Research Laboratory, Blacktown Clinical School and Research Centre , Blacktown Hospital, WSU/WSLHD , Blacktown , Australia
| | - Tristan Nguyen
- a Molecular Research Laboratory, Blacktown Clinical School and Research Centre , Blacktown Hospital, WSU/WSLHD , Blacktown , Australia
| | - Steven Boyages
- b Western Sydney University School of Medicine , Campbelltown , NSW , Australia
| | - Mark McLean
- b Western Sydney University School of Medicine , Campbelltown , NSW , Australia
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Sugawara Y, Kikuchi Y, Yoneda M, Ohno-Shosaku T. Electrophysiological evidence showing muscarinic agonist-antagonist activities of N-desmethylclozapine using hippocampal excitatory and inhibitory neurons. Brain Res 2016; 1642:255-262. [PMID: 27048752 DOI: 10.1016/j.brainres.2016.03.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/25/2016] [Accepted: 03/31/2016] [Indexed: 11/18/2022]
Abstract
The atypical antipsychotic clozapine is widely used for treatment-resistant schizophrenic patients. Clozapine and its major active metabolite, N-desmethylclozapine (NDMC), have complex pharmacological properties, and interact with various neurotransmitter receptors. There are several biochemical studies reporting that NDMC exhibits a partial agonist profile at the human recombinant M1 muscarinic receptors. However, direct electrophysiological evidence showing the ability of NDMC to activate native M1 receptors in intact neurons is poor. Using rat hippocampal neurons, we previously demonstrated that activation of muscarinic receptors by a muscarinic agonist, oxotremorine M (oxo-M), induces a decrease in outward K(+)current at -40mV. In the present study, using this muscarinic current response we assessed agonist and antagonist activities of clozapine and NDMC at native muscarinic receptors in intact hippocampal excitatory and inhibitory neurons. Suppression of the oxo-M-induced current response by the M1 antagonist pirenzepine was evident only in excitatory neurons, while the M3 antagonist darifenacin was effective in both types of neurons. Muscarinic agonist activity of NDMC was higher than that of clozapine, higher in excitatory neurons than in inhibitory neurons, sensitive to pirenzepine, and partially masked when co-applied with clozapine. Muscarinic antagonist activity of clozapine as well as NDMC was not different between excitatory and inhibitory neurons, but clozapine was more effective than NDMC. These results demonstrate that NDMC has the ability to activate native M1 receptors expressed in hippocampal excitatory neurons, but its agonist activity might be limited in clozapine-treated patients because of the presence of excessive clozapine with muscarinic antagonist activity.
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Affiliation(s)
- Yuto Sugawara
- Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa 920-0942, Japan
| | - Yui Kikuchi
- Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa 920-0942, Japan
| | - Mitsugu Yoneda
- Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa 920-0942, Japan
| | - Takako Ohno-Shosaku
- Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa 920-0942, Japan.
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Gigout S, Wierschke S, Dehnicke C, Deisz RA. Different pharmacology of N-desmethylclozapine at human and rat M2 and M 4 mAChRs in neocortex. Naunyn Schmiedebergs Arch Pharmacol 2015; 388:487-96. [PMID: 25592256 DOI: 10.1007/s00210-014-1080-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 12/10/2014] [Indexed: 01/20/2023]
Abstract
Cholinergic transmission plays a pivotal role in learning, memory and cognition, and disturbances of cholinergic transmission have been implicated in neurological disorders including Alzheimer's disease, epilepsy and schizophrenia. Pharmacological alleviation of these diseases by drugs including N-desmethylclozapine (NDMC), promising in animal models, often fails in patients. We therefore compared the effects of NDMC on glutamatergic and GABAergic transmission in slices from rat and human neocortex. We used carbachol (CCh; an established agonist at metabotropic muscarinic acetylcholine (ACh) receptors (mAChRs)) as a reference. Standard electrophysiological methods including intracellular and field potential recordings were used. In the rat neocortex, NDMC prevented the CCh-induced decrease of GABAA and GABAB receptor-mediated responses but not the CCh-induced increase of the paired-pulse depression. NDMC reduced neither the amplitude of the excitatory postsynaptic potentials (EPSP) nor antagonized the CCh-induced depression of EPSP. In the human neocortex, however, NDMC failed to prevent CCh-induced decrease of the GABAB responses and directly reduced the amplitude of EPSP. These data suggest distinct effects of NDMC in rat and human at M2 and M4 mAChRs underlying presynaptic modulation of GABA and glutamate release, respectively. In particular, NDMC might be a M2 mAChR antagonist in the rat but has no activity at this receptor in human neocortex. However, NDMC has an agonistic effect at M4 mAChR in the human but no such effect in the rat neocortex. The present study confirms that pharmacology at mAChRs can differ between species and emphasizes the need of studies in human tissue.
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Affiliation(s)
- S Gigout
- Centre for Anatomy, Institute for Cell Biology and Neurobiology, Charité Universitätsmedizin Berlin, Philippstrasse, 12, 10115, Berlin, Germany
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Kohlrausch FB, Severino-Gama C, Lobato MI, Belmonte-de-Abreu P, Carracedo A, Hutz MH. The CYP1A2 -163C>A polymorphism is associated with clozapine-induced generalized tonic-clonic seizures in Brazilian schizophrenia patients. Psychiatry Res 2013; 209:242-5. [PMID: 23601795 DOI: 10.1016/j.psychres.2013.02.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 02/04/2013] [Accepted: 02/21/2013] [Indexed: 11/26/2022]
Abstract
We evaluated two polymorphisms at CYP1A2 (*1C and *1F) in a sample of 108 European-derived patients with schizophrenia and their influence on the pro-convulsive effect of clozapine. We found the *1F/*1F genotype to be significantly associated with seizures, and no relationship was observed with combinations of *1F and *1C alleles.
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