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Serretti A. Focus on neurodevelopmental conditions and antipsychotics prescription patterns. Int Clin Psychopharmacol 2024; 39:215-219. [PMID: 38813690 DOI: 10.1097/yic.0000000000000555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
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Verdoux H, Quiles C, de Leon J. Optimizing antidepressant and clozapine co-prescription in clinical practice: A systematic review and expert recommendations. Schizophr Res 2024; 268:243-251. [PMID: 37852856 DOI: 10.1016/j.schres.2023.10.003] [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: 05/28/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES To synthesize the information relevant for clinical practice on clozapine-antidepressant co-prescription concerning pharmacokinetic drug-drug interactions (DDI), adverse drug reactions (ADRs) associated with the co-prescription, antidepressant add-on for clozapine-resistant symptoms and antidepressant add-on for clozapine-induced ADRs. METHODS Articles were identified with MEDLINE, Web of Sciences and PsycINFO search from inception through April 2023. Data were synthesized narratively. RESULTS ADRs are most often induced by the co-prescription of antidepressants that inhibit CYP enzymes (fluvoxamine, fluoxetine, paroxetine). Fluvoxamine add-on is hazardous because of its potent inhibition of clozapine metabolism and has few indications (lowering daily number of clozapine tablets, reducing norclozapine-induced metabolic disturbances and other dose-dependent clozapine-induced ADRs). ADR frequency may be reduced by therapeutic drug monitoring and knowledge of other factors impacting clozapine metabolism (pneumonia, inflammation, smoking, etc.). Improvement of negative symptoms is the most documented beneficial effect of antidepressant add-on for clozapine-resistant psychotic symptoms. The add-on antidepressant should be chosen according to its safety profile regarding DDI with clozapine: antidepressants inhibiting clozapine metabolism or increasing the anticholinergic load should be avoided. Other indications of antidepressant add-on (affective or obsessive compulsive symptoms, sialorrhea, and enuresis) are poorly documented. CONCLUSION Antidepressant add-on to clozapine is associated with potential benefits in clozapine users as this strategy may contribute to reduce the burden of clozapine-resistant symptoms or of clozapine-induced ADRs. Further studies are needed to determine whether antidepressant add-on can reduce the risk of clozapine discontinuation.
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Affiliation(s)
- Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France.
| | - Clélia Quiles
- Centre Hospitalier Charles Perrens, F-33000 Bordeaux, France
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, Psychiatry and Neurosciences Research Group (CTS-549), USA; 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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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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Abstract
BACKGROUND Several augmentation strategies have been used to improve symptomatology in patients not adequately responding to clozapine. Several randomised controlled trials (RCTs) have evaluated the efficacy of different strategies to augment clozapine. This systematic review and meta-analysis reviewed the available RCTs that have evaluated the clinical efficacy of various pharmacological agents, non-pharmacological strategies (occupational therapy, cognitive behaviour therapy), and somatic treatment [electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation, etc.)] as augmenting agents to clozapine. METHODS Data were extracted using standard procedures, and risk of bias was evaluated. Effect sizes were computed for the individual studies. RESULTS Forty-five clinical trials were evaluated. The pooled effect size for various antipsychotic medications was 0.103 (95% CI: 0.288-0.493, p < 0.001); when the effect size was evaluated for specific antipsychotics for which more than one trial was available, the effect size for risperidone was -0.27 and that for aripiprazole was 0.57. The effect size for lamotrigine was 0.145, and that for topiramate was 0.392. The effect size for ECT was 0.743 (CI: 0.094-1.392). Risk of bias was low (mean Jadad score - 3.93). Largest effect sizes were seen for mirtazapine (effect size of 5.265). Most of the studies can be considered underpowered and limited by small sample sizes. CONCLUSIONS To conclude, based on the findings of the present systematic review and meta-analysis, it can be said that compared to other treatment strategies, clozapine non-responsive patients respond maximum to mirtazapine followed by ECT.
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Kappel DB, Legge SE, Hubbard L, Willcocks IR, O'Connell KS, Smith RL, Molden E, Andreassen OA, King A, Jansen J, Helthuis M, Owen MJ, O'Donovan MC, Walters JTR, Pardiñas AF. Genomic Stratification of Clozapine Prescription Patterns Using Schizophrenia Polygenic Scores. Biol Psychiatry 2023; 93:149-156. [PMID: 36244804 PMCID: PMC10804961 DOI: 10.1016/j.biopsych.2022.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/14/2022] [Accepted: 07/19/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Treatment-resistant schizophrenia affects approximately 30% of individuals with the disorder. Clozapine is the medication of choice in treatment-resistant schizophrenia, but optimizing administration and dose titration is complex. The identification of factors influencing clozapine prescription and response, including genetics, is of interest in a precision psychiatry framework. METHODS We used linear regression models accounting for demographic, pharmacological, and clinical covariates to determine whether a polygenic risk score (PRS) for schizophrenia would be associated with the highest dose recorded during clozapine treatment. Analyses were performed across 2 independent multiancestry samples of individuals from a UK patient monitoring system, CLOZUK2 (n = 3133) and CLOZUK3 (n = 909), and a European sample from a Norwegian therapeutic drug monitoring service (n = 417). In a secondary analysis merging both UK cohorts, logistic regression models were used to estimate the relationship between schizophrenia PRSs and clozapine doses classified as low, standard, or high. RESULTS After controlling for relevant covariates, the schizophrenia PRS was correlated with the highest clozapine dose on record for each individual across all samples: CLOZUK2 (β = 12.22, SE = 3.78, p = .001), CLOZUK3 (β = 12.73, SE = 5.99, p = .034), and the Norwegian cohort (β = 46.45, SE = 18.83, p = .014). In a secondary analysis, the schizophrenia PRS was associated with taking clozapine doses >600 mg/day (odds ratio = 1.279, p = .006). CONCLUSIONS The schizophrenia PRS was associated with the highest clozapine dose prescribed for an individual in records from 3 independent samples, suggesting that the genetic liability for schizophrenia might index factors associated with therapeutic decisions in cohorts of patients with treatment-resistant schizophrenia.
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Affiliation(s)
- Djenifer B Kappel
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Sophie E Legge
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Leon Hubbard
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Isabella R Willcocks
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Kevin S O'Connell
- Norwegian Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Robert L Smith
- Norwegian Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo and Oslo University Hospital, Oslo, Norway; Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Espen Molden
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway; Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Ole A Andreassen
- Norwegian Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Adrian King
- Magna Laboratories Ltd., Ross-on-Wye, United Kingdom
| | | | | | - Michael J Owen
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Michael C O'Donovan
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - James T R Walters
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Antonio F Pardiñas
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom.
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Yeh TC, Correll CU, Yang FC, Chen MH, Tseng PT, Hsu CW, Carvalho AF, Stubbs B, Thompson T, Chu CS, Yu CL, Il Shin J, Yang SN, Tu YK, Liang CS. Pharmacological and nonpharmacological augmentation treatments for clozapine-resistant schizophrenia: A systematic review and network meta-analysis with normalized entropy assessment. Asian J Psychiatr 2023; 79:103375. [PMID: 36470132 DOI: 10.1016/j.ajp.2022.103375] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/30/2022] [Accepted: 10/29/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To integrate all evidence derived from randomized controlled trials (RCTs) of both pharmacological and nonpharmacological augmentation interventions for clozapine-resistant schizophrenia (CRS). METHODS Six major electronic databases were systematically searched for RCTs published until July 10, 2021. The primary outcome was change in overall symptoms, and the secondary outcomes were positive and negative symptoms and acceptability. We performed random-effects network meta-analysis. Normalized entropy was calculated to examine the uncertainty of treatment ranking. RESULTS We identified 35 RCTs (1472 patients with 23 active augmentation treatments) with a mean daily clozapine dose of 440.80 (91.27) mg for 1168.22 (710.28) days. Network meta-analysis of overall symptoms (reported as standardized mean difference; 95 % confidence interval) with consistent results indicated that mirtazapine (-4.41; -5.61, -3.21), electroconvulsive therapy (ECT) (-4.32; -5.43, -3.21), and memantine (-2.02; -3.14, -0.91) were ranked as the best three treatments. For positive symptoms, ECT (-5.18; -5.86, -4.49) was ranked the best with less uncertainty. For negative symptoms, memantine (-3.38; -4.50, -2.26), duloxetine (-3.27; -4.25, -2.29), and mirtazapine (-1.73; -2.71, -0.74) were ranked the best three treatments with less uncertainty. All antipsychotics, N-methyl d-aspartate receptor agonists, and antiepileptics were not associated with more efficacy than placebo. Compared to placebo, only amisulpride had statistically significant lower discontinuation rate (risk ratio: 0.21; 95 % CI: 0.05, 0.93). CONCLUSION Add-on mirtazapine, ECT, and memantine were the most efficacious augmentation options for CRS. Data on other important outcomes such as cognitive functioning or quality of life were rarely reported, making further large-scale, well-designed RCTs necessary. (PROSPERO number, CRD42021262197.).
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Affiliation(s)
- Ta-Chuan Yeh
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department of Psychiatry, Penghu Branch, Tri-Service General Hospital, Penghu, Taiwan; Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Christoph U Correll
- Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Hofstra Northwell School of Medicine, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; Charité Universitätsmedizin, Department of Child and Adolescent Psychiatry, Berlin, Germany
| | - Fu-Chi Yang
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Mu-Hong Chen
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ping-Tao Tseng
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung City, Taiwan; Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan; Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College, Taiwan
| | - Andre F Carvalho
- IMPACT (Innovation in Mental and Physical Health and Clinical Treatment) Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, VIC, Australia
| | - Brendon Stubbs
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Trevor Thompson
- Centre for Chronic Illness and Ageing, University of Greenwich, London, UK
| | - Che-Sheng Chu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan; Center for Geriatric and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Ling Yu
- Department of Pharmacy, Chang-Gung Memorial Hospital, Linkou, Taiwan
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Szu-Nian Yang
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department of Psychiatry, Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan; Graduate Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology & Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
| | - Chih-Sung Liang
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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Abstract
Antipsychotic polypharmacy in psychotic disorders is widespread despite international guidelines favoring monotherapy. Previous evidence indicates the utility of low-dose partial dopamine agonist (PDAs) add-ons to mitigate antipsychotic-induced metabolic adverse effects or hyperprolactinemia. However, clinicians are often concerned about using PDAs combined with high-potency, full dopaminergic antagonists (FDAs) due to the risk of psychosis relapse. We, therefore, conducted a literature review to find studies investigating the effects of combined treatment with PDAs (i.e. aripiprazole, cariprazine and brexpiprazole) and FDAs having a strong D 2 receptor binding affinity. Twenty studies examining the combination aripiprazole - high-potency FDAs were included, while no study was available on combinations with cariprazine or brexpiprazole. Studies reporting clinical improvement suggested that this may require a relatively long time (~11 weeks), while studies that found symptom worsening observed this happening in a shorter timeframe (~3 weeks). Patients with longer illness duration who received add-on aripiprazole on ongoing FDA monotherapy may be at greater risk for symptomatologic worsening. Especially in these cases, close clinical monitoring is therefore recommended during the first few weeks of combined treatment. These indications may be beneficial to psychiatrists who consider using this treatment strategy. Well-powered randomized clinical trials are needed to derive more solid clinical recommendations.
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Wadoo O, Latoo J, Alabdulla M, Eltorki Y, Riaz S, Karim MA, Abu-Hafizah M, Reagu S. Clozapine prescribing practice and trends in Qatar: First national observational study. Brain Behav 2022; 12:e2617. [PMID: 35647930 PMCID: PMC9304832 DOI: 10.1002/brb3.2617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 03/13/2022] [Accepted: 04/24/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Clozapine is the gold standard in the management of treatment-resistant schizophrenia. Despite its clinically proven efficacy clozapine utilization is variable globally and published evidence is suggestive of its underutilization. Research from the Arab region on clozapine utilization is limited. The aim of our descriptive observational study was to evaluate the prescribing practice of clozapine and its sociodemographic and clinical corelates in the State of Qatar. METHODS The study is a retrospective case-note review of all patients maintained on clozapine, in the calendar year 2020. Data were collected on sociodemographic characteristics of the patients; antipsychotic trials before initiating clozapine; and clinical characteristics of the patients, including their diagnoses leading to prescription of clozapine, duration of illness, psychiatric hospitalizations, and co-morbidities. RESULTS During the study period, 100 patients were maintained on clozapine. Patients were mostly Qatari and non-Qatari Arab males. Prescription rates were significantly different for Qatari patients when compared to non-Qatari patients. Most patients had a chronic illness with the age of onset of illness in early adulthood and were diagnosed with schizophrenia or schizoaffective disorder. The mean daily dose of clozapine was 325 mg. Eighty percent of the patients received two or more antipsychotic trials before initiating clozapine. Sixty-eight percent of the patients had more than two antipsychotic trials before initiating Clozapine. One third of patients had no history of psychiatric hospitalizations, and one quarter had five or more previous psychiatric hospitalizations. Of the psychiatric comorbidities, mood and substance use disorders were common. Of medical comorbidities, endocrine and metabolic disorders were common. CONCLUSION Despite apparent underutilization, the Clozapine prescribing rates in Qatar are comparable to countries with plasma monitoring systems when framed within Qatar's unique demographic context. However, there still is a significant delay in Clozapine initiation despite its clinical superiority. STRENGTHS AND LIMITATIONS OF THIS STUDY First study on Clozapine utilization from the Middle-East and North-Africa region. This study examined prescribing of clozapine in a national cohort of patients in Qatar. Provides insight into sociodemographic and clinical correlates of clozapine prescribing in a country with 90% migrants. Limited by the completeness of the information contained in the patients' medical charts.
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Affiliation(s)
- Ovais Wadoo
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar.,College of Medicine, Qatar University, Doha, Qatar
| | - Javed Latoo
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar
| | - Majid Alabdulla
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar.,College of Medicine, Qatar University, Doha, Qatar
| | - Yassin Eltorki
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar
| | - Sadaf Riaz
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar
| | - Mustafa Abdul Karim
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar.,Department of Psychiatry, College of Medicine, Weill Cornell Medicine, Doha, Qatar
| | | | - Shuja Reagu
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar.,Department of Psychiatry, College of Medicine, Weill Cornell Medicine, Doha, Qatar
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Factors Associated With Poor Response to Clozapine in Schizophrenia: A Study From Northern India. J Clin Psychopharmacol 2022; 42:345-349. [PMID: 35763756 DOI: 10.1097/jcp.0000000000001548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE/BACKGROUND Limited numbers of studies have assessed the predictors of clozapine nonresponse. This study aimed to assess the demographic and clinical factors associated with an inadequate response to clozapine in patients with treatment-resistant schizophrenia (TRS). METHODS/PROCEDURES Two hundred eighty-seven outpatients with TRS receiving clozapine for more than 1 year were divided into 2 groups based on the need for a second antipsychotic medication and/or electroconvulsive therapy after receiving clozapine in the maximum tolerable dose for at least 3 months. RESULTS/FINDINGS One hundred two patients (35.4%) were considered to be clozapine nonresponders. Compared with responders, clozapine nonresponders were more often unemployed at the time of starting clozapine (P = 0.04), had a longer duration of untreated psychosis (P = 0.007), had received significantly higher number of adequate antipsychotic trials in the past (P = 0.02), had received antipsychotic polypharmacy in the past (P = 0.01), had experienced adverse effects with first- (P < 0.001) and second-generation antipsychotics (P = 0.01), and had more medical comorbidities (P = 0.03). The nonresponders more frequently had visual hallucinations (P = 0.001), and feelings/acts or impulses attributed to some external source (P = 0.03) in the lifetime, and had a significantly higher Clinical Global Impression severity score at the time of starting of clozapine (P < 0.001). While on clozapine, nonresponders received significantly higher dose of clozapine (P = 0.001) and higher proportion of them experienced constipation (P = 0.04), hypersalivation (P = 0.002), and obsessive-compulsive symptoms (P = 0.05) as adverse effects of clozapine. CONCLUSIONS/IMPLICATIONS The present study shows that approximately one-third of patients with TRS do not respond to clozapine. However, clozapine nonresponders, although broadly similar in sociodemographic profile to clozapine responders, differ from clozapine responders on past treatment profile.
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A case report of clozapine-treatment-resistant schizophrenia successfully managed with brexpiprazole combination therapy. Asian J Psychiatr 2022; 72:103121. [PMID: 35427934 DOI: 10.1016/j.ajp.2022.103121] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/07/2022] [Indexed: 11/24/2022]
Abstract
Clozapine-resistant schizophrenia (CRS) occurs in 40%- 70% of clozapine-treated schizophrenic patients. Hereby we describe a 20-year-old CRS subject with comorbid cannabinoid use disorder, successfully treated with clozapine-brexpiprazole combination, subsequently switched to clozapine plus long-acting injectable aripiprazole.
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Llorca PM, Nuss P, Fakra É, Alamome I, Drapier D, Hage WE, Jardri R, Mouchabac S, Rabbani M, Simon N, Vacheron MN, Azorin JM. Place of the partial dopamine receptor agonist aripiprazole in the management of schizophrenia in adults: a Delphi consensus study. BMC Psychiatry 2022; 22:364. [PMID: 35643542 PMCID: PMC9142729 DOI: 10.1186/s12888-022-04008-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/16/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Aripiprazole is a second-generation antipsychotic, efficacious in patients with schizophrenia during acute episodes. Due to its pharmacological profile, aripiprazole may be of interest in patients with specific clinical profiles who have not been studied extensively in randomised clinical trials. OBJECTIVES To capture experience with aripiprazole in everyday psychiatric practice using the Delphi method in order to inform decision-making on the use of aripiprazole for the treatment of patients with schizophrenia in clinical situations where robust evidence from clinical trials is lacking. METHODS The scope of the survey was defined as the management of schizophrenia in adults. A systematic literature review was performed to identify the different clinical situations in which aripiprazole has been studied, and to describe the level of clinical evidence. Clinical profiles to include in the Delphi survey were selected if there was a clear interest in terms of medical need but uncertainty over the efficacy of aripiprazole. For each clinical profile retained, five to seven specific statements were generated and included in a questionnaire. The final 41-item questionnaire was proposed to a panel of 406 French psychiatrists with experience in the treatment of schizophrenia. Panellists rated their level of agreement using a Likert scale. A second round of voting on eleven items was organised to clarify points for which a consensus was not obtained in the first round. RESULTS Five clinical profiles were identified in the literature review (persistent negative symptoms, pregnancy, cognitive dysfunction, addictive comorbidity and clozapine resistance). Sixty-two psychiatrists participated in the first round of the Delphi survey and 33 in the second round. A consensus was obtained for 11 out of 41 items in the first round and for 9/11 items in the second round. According to the panellists' clinical experience, aripiprazole can be used as maintenance treatment for pregnant women, is relevant to preserve cognitive function and can be considered an option in patients with a comorbid addictive disorder or with persistent negative symptoms. CONCLUSION These findings may help physicians in choosing relevant ways to use aripiprazole and highlight areas where more research is needed to widen the evidence base.
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Affiliation(s)
- Pierre-Michel Llorca
- Department of Psychiatry, Clermont-Ferrand University Hospital, Clermont Auvergne University, Clermont-Ferrand, France.
| | - Philippe Nuss
- grid.412370.30000 0004 1937 1100Psychiatry and Medical Psychology Department, Saint-Antoine Hospital, Paris Sorbonne University, Paris, France
| | - Éric Fakra
- grid.412954.f0000 0004 1765 1491University Hospital Psychiatry Group, Saint-Étienne University Hospital, Saint-Étienne, France
| | - Isabelle Alamome
- Department of Psychiatry, Polyclinic of Limoges, Limoges, France
| | - Dominique Drapier
- grid.410368.80000 0001 2191 9284University Hospital Adult Psychiatry Group, Guillaume-Régnier Hospital, University of Rennes 1, Rennes, France
| | - Wissam El Hage
- grid.12366.300000 0001 2182 6141UMR 1253, iBrain, Tours University, Inserm, Tours, France
| | - Renaud Jardri
- grid.410463.40000 0004 0471 8845Lille Neuroscience & Cognition Centre, INSERM U1172, Fontan Hospital, Lille University Hospital, Lille, France
| | - Stéphane Mouchabac
- grid.412370.30000 0004 1937 1100Psychiatry and Medical Psychology Department, Saint-Antoine Hospital, Paris Sorbonne University, Paris, France
| | - Marc Rabbani
- Medical Affairs Department, Lundbeck SAS, Puteaux, France
| | - Nicolas Simon
- grid.464064.40000 0004 0467 0503Department of Clinical Pharmacology, Aix Marseille University, INSERM, SESSTIM, Hospital Sainte Marguerite, CAP, Marseille, IRD France
| | | | - Jean-Michel Azorin
- grid.414438.e0000 0000 9834 707XDepartment of Psychiatry, Sainte Marguerite Hospital, Marseille, France
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Effect of add-on alpha lipoic acid on psychopathology in patients with treatment-resistant schizophrenia: a pilot randomized double-blind placebo-controlled trial. Psychopharmacology (Berl) 2022; 239:3525-3535. [PMID: 36069950 PMCID: PMC9449282 DOI: 10.1007/s00213-022-06225-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022]
Abstract
RATIONALE Alpha lipoic acid is known to reverse NMDA receptor hypofunction in addition to dopamine receptor blockade activity. It also enhances neurotrophic factors and has antioxidant potential. These properties combined together may be beneficial for treatment-resistant schizophrenia (TRS). OBJECTIVES This study evaluates the effect of alpha lipoic acid (ALA) on psychopathological scores (positive, negative, cognitive), neurotrophic factors and oxidative stress in TRS. METHODS A pilot randomized double-blind placebo-controlled parallel design trial was conducted in 20 patients with TRS. After initial screening, participants were randomized into test (add-on ALA) and control (add-on placebo) groups. After recruitment, clinical evaluations with scale for assessment of positive symptoms and negative symptoms (SAPS and SANS), schizophrenia cognitive rating scale (SCoRS), UKU side effect rating scale were done. Serum levels of BDNF, MDA, and GSH were estimated. Patients were followed up for 8 weeks, and clinical and biochemical evaluations were repeated. Adherence to medication was evaluated at follow-up. RESULTS A significantly greater improvement was found in SANS score in the test group when compared to control (Mann-Whitney U = 17.0; p = 0.021), whereas there was no significant improvement in SAPS score (Mann-Whitney U = 41.5; p = 0.780). A significant increase in BDNF levels was observed in the control group when compared to ALA (U = 20.0; p = 0.041). No significant differences were found between the test and control groups in serum MDA (U = 30.0; p = 0.221), serum GSH (U = 40.0; p = 0.683), and medication adherence rating scale (MARS) scores (U = 44.0; p = 0.934). CONCLUSIONS ALA supplementation improved psychopathology and decreased oxidative stress in patients with TRS. This study thus shows the potential of adjunctive ALA in TRS. TRIAL REGISTRATION The study was prospectively registered in Clinical Trial Registry of India (CTRI/2020/03/023707 dated 02.03.2020).
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13
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Chakrabarti S. Clozapine resistant schizophrenia: Newer avenues of management. World J Psychiatry 2021; 11:429-448. [PMID: 34513606 PMCID: PMC8394694 DOI: 10.5498/wjp.v11.i8.429] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/12/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
About 40%-70% of the patients with treatment-resistant schizophrenia have a poor response to adequate treatment with clozapine. The impact of clozapine-resistant schizophrenia (CRS) is even greater than that of treatment resistance in terms of severe and persistent symptoms, relapses and hospitalizations, poorer quality of life, and healthcare costs. Such serious consequences often compel clinicians to try different augmentation strategies to enhance the inadequate clozapine response in CRS. Unfortunately, a large body of evidence has shown that antipsychotics, antidepressants, mood stabilizers, electroconvulsive therapy, and cognitive-behavioural therapy are mostly ineffective in augmenting clozapine response. When beneficial effects of augmentation have been found, they are usually small and of doubtful clinical significance or based on low-quality evidence. Therefore, newer treatment approaches that go beyond the evidence are needed. The options proposed include developing a clinical consensus about the augmentation strategies that are most likely to be effective and using them sequentially in patients with CRS. Secondly, newer approaches such as augmentation with long-acting antipsychotic injections or multi-component psychosocial interventions could be considered. Lastly, perhaps the most effective way to deal with CRS would be to optimize clozapine treatment, which might prevent clozapine resistance from developing. Personalized dosing, adequate treatment durations, management of side effects and non-adherence, collaboration with patients and caregivers, and addressing clinician barriers to clozapine use are the principal ways of ensuring optimal clozapine treatment. At present, these three options could the best way to manage CRS until research provides more firm directions about the effective options for augmenting clozapine response.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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14
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Shalimova A, Babasieva V, Chubarev VN, Tarasov VV, Schiöth HB, Mwinyi J. Therapy response prediction in major depressive disorder: current and novel genomic markers influencing pharmacokinetics and pharmacodynamics. Pharmacogenomics 2021; 22:485-503. [PMID: 34018822 DOI: 10.2217/pgs-2020-0157] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Major depressive disorder is connected with high rates of functional disability and mortality. About a third of the patients are at risk of therapy failure. Several pharmacogenetic markers especially located in CYP450 genes such as CYP2D6 or CYP2C19 are of relevance for therapy outcome prediction in major depressive disorder but a further optimization of predictive tools is warranted. The article summarizes the current knowledge on pharmacogenetic variants, therapy effects and side effects of important antidepressive therapeutics, and sheds light on new methodological approaches for therapy response estimation based on genetic markers with relevance for pharmacokinetics, pharmacodynamics and disease pathology identified in genome-wide association study analyses, highlighting polygenic risk score analysis as a tool for further optimization of individualized therapy outcome prediction.
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Affiliation(s)
- Alena Shalimova
- Department of Neuroscience, Functional Pharmacology, University of Uppsala, Uppsala, 751 24, Sweden.,Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, 119991, Russia
| | - Viktoria Babasieva
- Department of Neuroscience, Functional Pharmacology, University of Uppsala, Uppsala, 751 24, Sweden.,Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, 119991, Russia
| | - Vladimir N Chubarev
- Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, 119991, Russia
| | - Vadim V Tarasov
- Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, 119991, Russia.,Institute of Translational Medicine & Biotechnology, I. M. Sechenov First Moscow State Medical University, Moscow, 119991, Russia
| | - Helgi B Schiöth
- Department of Neuroscience, Functional Pharmacology, University of Uppsala, Uppsala, 751 24, Sweden.,Institute of Translational Medicine & Biotechnology, I. M. Sechenov First Moscow State Medical University, Moscow, 119991, Russia
| | - Jessica Mwinyi
- Department of Neuroscience, Functional Pharmacology, University of Uppsala, Uppsala, 751 24, Sweden
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15
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Annu, Baboota S, Ali J. Combination antipsychotics therapy for schizophrenia and related psychotic disorders interventions: Emergence to nanotechnology and herbal drugs. J Drug Deliv Sci Technol 2021. [DOI: 10.1016/j.jddst.2020.102272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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16
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Hjorth S. The More, the Merrier…? Antipsychotic Polypharmacy Treatment Strategies in Schizophrenia From a Pharmacology Perspective. Front Psychiatry 2021; 12:760181. [PMID: 34899422 PMCID: PMC8652414 DOI: 10.3389/fpsyt.2021.760181] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/22/2021] [Indexed: 12/11/2022] Open
Abstract
Antipsychotic polypharmacy/drug combination treatment (APP) is a remarkably common practice in the schizophrenia context, given the lack of general support in treatment Guidelines. There is also a vast literature on APP outcomes, but a paucity of high-quality evidence-based data to guide and optimize adequate use of APP. This seems particularly true regarding many pharmacology-based considerations involved in APP treatment strategies. This paper first briefly summarizes clinical literature related to the use of APP. Against this backdrop, the pharmacological target profile features are then described of frequently used antipsychotic agents, in relation to estimated free plasma exposure levels at clinically efficacious dosing. APP strategies based on the properties of these drugs are then scrutinized and gauged within the background literature framework. The anticipated usefulness of APP from the pharmacological standpoint is detailed regarding efficacy, adverse effect (AE)/tolerability, and safety perspective, including why, when, and how it may be used to its advantage. For the purpose, a number of theoretically beneficial combinations as well as instances with suboptimal-and even futile-APP approaches are exemplified and discussed from the rational pharmacodynamic and pharmacokinetic pros and cons point-of-view. In this exposé, particular attention is paid to the utility and features of 3rd Generation Antipsychotic dopamine (DA) D2-D3 agonists within an APP setting.
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Affiliation(s)
- Stephan Hjorth
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Pharmacilitator AB (Inc.), Vallda, Sweden
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17
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Clozapine: An Updated Overview of Pharmacogenetic Biomarkers, Risks, and Safety-Particularities in the Context of COVID-19. Brain Sci 2020; 10:brainsci10110840. [PMID: 33187329 PMCID: PMC7697202 DOI: 10.3390/brainsci10110840] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 12/11/2022] Open
Abstract
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.
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18
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Azorin JM, Simon N. Antipsychotic polypharmacy in schizophrenia: evolving evidence and rationale. Expert Opin Drug Metab Toxicol 2020; 16:1175-1186. [DOI: 10.1080/17425255.2020.1821646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
| | - Nicolas Simon
- Department of Clinical Pharmacology, Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France
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19
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Wagner E, Oviedo-Salcedo T, Pelzer N, Strube W, Maurus I, Gutwinski S, Schreiter S, Kleymann P, Morgenroth CL, Okhuijsen-Pfeifer C, Luykx JJ, Falkai P, Schneider-Axmann T, Hasan A. Effects of Smoking Status on Remission and Metabolic and Cognitive Outcomes in Schizophrenia Patients Treated with Clozapine. PHARMACOPSYCHIATRY 2020; 53:273-283. [PMID: 32757178 DOI: 10.1055/a-1208-0045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Even though clozapine is the recommended last-resort antipsychotic, many patients fail to respond and show treatment-refractory psychotic symptoms. Smoking has been suggested as a possible risk factor for poor clozapine response, hampering remission and negatively impacting somatic outcomes. METHODS Our aim was to test whether smoking status is associated with remission rates and other symptomatic and somatic outcomes. We therefore assessed remission rates according to The Remission in Schizophrenia Working Group (RSWG) criteria, and metabolic and cognitive outcomes among patients with schizophrenia-spectrum disorders treated with clozapine for at least 6 months. For analyses, we grouped our cohort into 3 groups according to clozapine treatment duration (6 months, 2 years, 5 years). RESULTS One hundred five patients were included in our analyses and grouped according to their clozapine treatment duration. In the 6-months analyses, patients who smoked were significantly more likely to be younger of age (p=0.002) despite on average shorter duration of clozapine treatment (p=0.041) and significantly more likely to be treated with mood-stabilizing co-medication (p=0.030) compared to nonsmokers. Remission rates (p=0.490), as well as a set of metabolic and cognitive variables did not differ between the 2 groups. A related pattern could be observed for the 2- and 5-years analyses. CONCLUSIONS Smoking behavior among clozapine-treated schizophrenia patients might delineate a cohort with an earlier onset of the disease. Nevertheless, most findings comparing disease-specific and clinical outcomes among smokers and nonsmokers were negative. Further research is needed to identify strategies to overcome insufficient remission rates in this patient group.
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Affiliation(s)
- Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Tatiana Oviedo-Salcedo
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Nicola Pelzer
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang Strube
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Isabel Maurus
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Stefan Gutwinski
- Department of Psychiatry and Psychotherapy, Charité Berlin, Berlin, Germany
| | - Stefanie Schreiter
- Department of Psychiatry and Psychotherapy, Charité Berlin, Berlin, Germany
| | - Phillip Kleymann
- Department of Psychiatry and Psychotherapy, Charité Berlin, Berlin, Germany
| | | | - Cynthia Okhuijsen-Pfeifer
- Department of Psychiatry, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jurjen J Luykx
- Department of Psychiatry, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Translational Neuroscience, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,GGNet Mental Health, second opinion outpatient clinic
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Thomas Schneider-Axmann
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.,Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, University of Augsburg, Augsburg, Germany
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20
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Morrison AP, Pyle M, Gumley A, Schwannauer M, Turkington D, MacLennan G, Norrie J, Hudson J, Bowe S, French P, Hutton P, Byrne R, Syrett S, Dudley R, McLeod HJ, Griffiths H, Barnes TR, Davies L, Shields G, Buck D, Tully S, Kingdon D. Cognitive-behavioural therapy for clozapine-resistant schizophrenia: the FOCUS RCT. Health Technol Assess 2020; 23:1-144. [PMID: 30806619 DOI: 10.3310/hta23070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clozapine (clozaril, Mylan Products Ltd) is a first-choice treatment for people with schizophrenia who have a poor response to standard antipsychotic medication. However, a significant number of patients who trial clozapine have an inadequate response and experience persistent symptoms, called clozapine-resistant schizophrenia (CRS). There is little evidence regarding the clinical effectiveness of pharmacological or psychological interventions for this population. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of cognitive-behavioural therapy (CBT) for people with CRS and to identify factors predicting outcome. DESIGN The Focusing on Clozapine Unresponsive Symptoms (FOCUS) trial was a parallel-group, randomised, outcome-blinded evaluation trial. Randomisation was undertaken using permuted blocks of random size via a web-based platform. Data were analysed on an intention-to-treat (ITT) basis, using random-effects regression adjusted for site, age, sex and baseline symptoms. Cost-effectiveness analyses were carried out to determine whether or not CBT was associated with a greater number of quality-adjusted life-years (QALYs) and higher costs than treatment as usual (TAU). SETTING Secondary care mental health services in five cities in the UK. PARTICIPANTS People with CRS aged ≥ 16 years, with an International Classification of Diseases, Tenth Revision (ICD-10) schizophrenia spectrum diagnoses and who are experiencing psychotic symptoms. INTERVENTIONS Individual CBT included up to 30 hours of therapy delivered over 9 months. The comparator was TAU, which included care co-ordination from secondary care mental health services. MAIN OUTCOME MEASURES The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months and the primary secondary outcome was PANSS total score at the end of treatment (9 months post randomisation). The health benefit measure for the economic evaluation was the QALY, estimated from the EuroQol-5 Dimensions, five-level version (EQ-5D-5L), health status measure. Service use was measured to estimate costs. RESULTS Participants were allocated to CBT (n = 242) or TAU (n = 245). There was no significant difference between groups on the prespecified primary outcome [PANSS total score at 21 months was 0.89 points lower in the CBT arm than in the TAU arm, 95% confidence interval (CI) -3.32 to 1.55 points; p = 0.475], although PANSS total score at the end of treatment (9 months) was significantly lower in the CBT arm (-2.40 points, 95% CI -4.79 to -0.02 points; p = 0.049). CBT was associated with a net cost of £5378 (95% CI -£13,010 to £23,766) and a net QALY gain of 0.052 (95% CI 0.003 to 0.103 QALYs) compared with TAU. The cost-effectiveness acceptability analysis indicated a low likelihood that CBT was cost-effective, in the primary and sensitivity analyses (probability < 50%). In the CBT arm, 107 participants reported at least one adverse event (AE), whereas 104 participants in the TAU arm reported at least one AE (odds ratio 1.09, 95% CI 0.81 to 1.46; p = 0.58). CONCLUSIONS Cognitive-behavioural therapy for CRS was not superior to TAU on the primary outcome of total PANSS symptoms at 21 months, but was superior on total PANSS symptoms at 9 months (end of treatment). CBT was not found to be cost-effective in comparison with TAU. There was no suggestion that the addition of CBT to TAU caused adverse effects. Future work could investigate whether or not specific therapeutic techniques of CBT have value for some CRS individuals, how to identify those who may benefit and how to ensure that effects on symptoms can be sustained. TRIAL REGISTRATION Current Controlled Trials ISRCTN99672552. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 7. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Anthony P Morrison
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Melissa Pyle
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Andrew Gumley
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Matthias Schwannauer
- Department of Clinical Psychology, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Douglas Turkington
- Academic Psychiatry, Northumberland, Tyne and Wear NHS Foundation Trust, Centre for Ageing and Vitality, Newcastle General Hospital, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Clinical Trials Unit, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Jemma Hudson
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Samantha Bowe
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK
| | - Paul French
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Paul Hutton
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Rory Byrne
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Suzy Syrett
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Robert Dudley
- School of Psychology, Newcastle University, Newcastle upon Tyne, UK
| | - Hamish J McLeod
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Helen Griffiths
- Department of Clinical Psychology, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | | | - Linda Davies
- Division of Population Health, University of Manchester, Manchester, UK
| | - Gemma Shields
- Division of Population Health, University of Manchester, Manchester, UK
| | - Deborah Buck
- Division of Population Health, University of Manchester, Manchester, UK
| | - Sarah Tully
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - David Kingdon
- Department of Psychiatry, University of Southampton, Academic Centre, Southampton, UK
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21
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Zhou X, Cai G, Mao S, Xu D, Xu X, Zhang R, Yao Z. Modulating NMDA receptors to treat MK-801-induced schizophrenic cognition deficit: effects of clozapine combining with PQQ treatment and possible mechanisms of action. BMC Psychiatry 2020; 20:106. [PMID: 32143671 PMCID: PMC7060539 DOI: 10.1186/s12888-020-02509-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 02/24/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Clozapine has remarkable efficacy on both negative and cognitive symptoms of schizophrenia due to its slight activation of NMDA receptor. In fact, much evidence to the contrary. NMDAR is a complex containing specific binding sites, which are regulated to improve negative symptoms and cognitive deficits associated with individuals affected by schizophrenia. PQQ is a powerful neuroprotectant that specifically binds with NMDA receptors in the brain to produce beneficial physiological and cognitive outcomes. The aim of this study was to enhance NMDAR function and improve cognitive ability in schizophrenia by PQQ combined with clozapine. METHODS Rats were divided into four groups (n = 5) including control (saline), model (MK-801, 0.5 mg·kg- 1·d- 1), atypical antipsychotic (MK-801 (0.5 mg·kg- 1·d- 1) + Clozapine (1.0 mg·kg- 1·d- 1), and co-agonist NMDA receptor (MK-801 (0.5 mg·kg- 1·d- 1) + Clozapine (0.5 mg·kg- 1·d- 1) + PQQ (1.0 μg·kg- 1·d- 1) group. Each group of rats was injected subcutaneously every day for 6 weeks. Behavior test, including stereotyped behavior, locomotor hyperactivity, learning and memory, was performed. The Western blot assay was performed to analyze the expression of GSK-3β, Akt, NMDAR1, and MGLUR in rat hippocampus. RESULTS Results indicated that clozapine and PQQ combination therapy can improve MK801-induced schizophrenia behavior including stereotyped behavior, locomotor hyperactivity and cognitive impairment. Furthermore, we found that modulating NMDA receptors could ameliorate the memory impairments in Mk-801 induced schizophrenia rats by reducing the expression of NMDAR1 and MGLUR3, decreasing hippocampal tau hyperphosphorylation and inhibiting apoptosis through Akt /GSK-3β signaling pathway. CONCLUSIONS These findings suggest that combination therapy for enhancing NMDA receptors may be able to rescue cognition deficit in schizophrenia. More studies are needed to better elucidate these mechanisms.
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Affiliation(s)
- Xingqin Zhou
- grid.412676.00000 0004 1799 0784Key Laboratory of Nuclear Medicine, Ministry of Health, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, Jiangsu Province 214063 PR China
| | - Gangming Cai
- grid.412676.00000 0004 1799 0784Key Laboratory of Nuclear Medicine, Ministry of Health, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, Jiangsu Province 214063 PR China
| | - Shishi Mao
- grid.412676.00000 0004 1799 0784Key Laboratory of Nuclear Medicine, Ministry of Health, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, Jiangsu Province 214063 PR China
| | - Dong Xu
- grid.412676.00000 0004 1799 0784Key Laboratory of Nuclear Medicine, Ministry of Health, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, Jiangsu Province 214063 PR China
| | - Xijie Xu
- grid.412676.00000 0004 1799 0784Key Laboratory of Nuclear Medicine, Ministry of Health, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, Jiangsu Province 214063 PR China
| | - Rongjun Zhang
- grid.412676.00000 0004 1799 0784Key Laboratory of Nuclear Medicine, Ministry of Health, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, Jiangsu Province 214063 PR China
| | - Zhiwen Yao
- Department of Neurology, Yangpu Hospital, Tongji University School of Medicine, Shanghai, 200090, PR China.
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22
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Clozapine-induced transcriptional changes in the zebrafish brain. NPJ SCHIZOPHRENIA 2020; 6:3. [PMID: 32015324 PMCID: PMC6997376 DOI: 10.1038/s41537-019-0092-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/12/2019] [Indexed: 12/20/2022]
Abstract
Clozapine is an atypical antipsychotic medication that is used to treat schizophrenia patients who are resistant to other antipsychotic drugs. The molecular mechanisms mediating the effects of clozapine are not well understood and its use is often associated with severe side-effects. In this study, we exposed groups of wild-type zebrafish to two doses of clozapine (‘low’ (20 µg/L) and ‘high’ (70 µg/L)) over a 72-h period, observing dose-dependent effects on behaviour. Using RNA sequencing (RNA-seq) we identified multiple genes differentially expressed in the zebrafish brain following exposure to clozapine. Network analysis identified co-expression modules characterised by striking changes in module connectivity in response to clozapine, and these were enriched for regulatory pathways relevant to the etiology of schizophrenia. Our study highlights the utility of zebrafish as a model for assessing the molecular consequences of antipsychotic medications and identifies genomic networks potentially involved in schizophrenia.
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23
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Baandrup L. Polypharmacy in schizophrenia. Basic Clin Pharmacol Toxicol 2020; 126:183-192. [PMID: 31908124 DOI: 10.1111/bcpt.13384] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/26/2019] [Accepted: 12/27/2019] [Indexed: 12/16/2022]
Abstract
Schizophrenia is a severe mental disorder characterized by a heterogeneous symptom profile which comprises a clinical platform for widespread use of polypharmacy even though antipsychotic monotherapy is the recommended treatment regimen. This narrative review provides a summary of the current gap between evidence and practice for use of antipsychotic combination therapy in patients with schizophrenia. Antipsychotic polypharmacy is frequently prescribed instead of following international consensus of clozapine monotherapy in treatment-resistant patients. Antipsychotic-benzodiazepine combination therapy clearly has a role in the treatment of acute agitation whereas there is no evidence to support an effect on core schizophrenia symptoms when chronically prescribed. Antidepressants are typically added to antipsychotic treatment in case of persistent negative symptoms. Available evidence suggests that antidepressants may improve negative symptom control in schizophrenia. Combining an antipsychotic with an antiepileptic is not supported by any firm evidence, but individual mood stabilizers have come out positively in single trials. Generally, the evidence base for polypharmacy in schizophrenia maintenance treatment is sparse but may be warranted in certain clinical situations. Therapeutic benefits and side effects should be carefully monitored and considered to ensure a beneficial risk-benefit ratio if prescribing polypharmacy for specific clinical indications.
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Affiliation(s)
- Lone Baandrup
- Centre for Neuropsychiatric Schizophrenia Research (CNSR), Mental Health Centre Glostrup, Glostrup, Denmark.,Mental Health Centre Copenhagen, Hellerup, Denmark
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Barnes TR, Drake R, Paton C, Cooper SJ, Deakin B, Ferrier IN, Gregory CJ, Haddad PM, Howes OD, Jones I, Joyce EM, Lewis S, Lingford-Hughes A, MacCabe JH, Owens DC, Patel MX, Sinclair JM, Stone JM, Talbot PS, Upthegrove R, Wieck A, Yung AR. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2020; 34:3-78. [PMID: 31829775 DOI: 10.1177/0269881119889296] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.
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Affiliation(s)
- Thomas Re Barnes
- Emeritus Professor of Clinical Psychiatry, Division of Psychiatry, Imperial College London, and Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Richard Drake
- Clinical Lead for Mental Health in Working Age Adults, Health Innovation Manchester, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Carol Paton
- Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Stephen J Cooper
- Emeritus Professor of Psychiatry, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Bill Deakin
- Professor of Psychiatry, Neuroscience & Psychiatry Unit, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - I Nicol Ferrier
- Emeritus Professor of Psychiatry, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine J Gregory
- Honorary Clinical Research Fellow, University of Manchester and Higher Trainee in Child and Adolescent Psychiatry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Peter M Haddad
- Honorary Professor of Psychiatry, Division of Psychology and Mental Health, University of Manchester, UK and Senior Consultant Psychiatrist, Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Oliver D Howes
- Professor of Molecular Psychiatry, Imperial College London and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ian Jones
- Professor of Psychiatry and Director, National Centre of Mental Health, Cardiff University, Cardiff, UK
| | - Eileen M Joyce
- Professor of Neuropsychiatry, UCL Queen Square Institute of Neurology, London, UK
| | - Shôn Lewis
- Professor of Adult Psychiatry, Faculty of Biology, Medicine and Health, The University of Manchester, UK, and Mental Health Academic Lead, Health Innovation Manchester, Manchester, UK
| | - Anne Lingford-Hughes
- Professor of Addiction Biology and Honorary Consultant Psychiatrist, Imperial College London and Central North West London NHS Foundation Trust, London, UK
| | - James H MacCabe
- Professor of Epidemiology and Therapeutics, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and Honorary Consultant Psychiatrist, National Psychosis Service, South London and Maudsley NHS Foundation Trust, Beckenham, UK
| | - David Cunningham Owens
- Professor of Clinical Psychiatry, University of Edinburgh. Honorary Consultant Psychiatrist, Royal Edinburgh Hospital, Edinburgh, UK
| | - Maxine X Patel
- Honorary Clinical Senior Lecturer, King's College London, Institute of Psychiatry, Psychology and Neuroscience and Consultant Psychiatrist, Oxleas NHS Foundation Trust, London, UK
| | - Julia Ma Sinclair
- Professor of Addiction Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James M Stone
- Clinical Senior Lecturer and Honorary Consultant Psychiatrist, King's College London, Institute of Psychiatry, Psychology and Neuroscience and South London and Maudsley NHS Trust, London, UK
| | - Peter S Talbot
- Senior Lecturer and Honorary Consultant Psychiatrist, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Rachel Upthegrove
- Professor of Psychiatry and Youth Mental Health, University of Birmingham and Consultant Psychiatrist, Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Angelika Wieck
- Honorary Consultant in Perinatal Psychiatry, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Alison R Yung
- Professor of Psychiatry, University of Manchester, School of Health Sciences, Manchester, UK and Centre for Youth Mental Health, University of Melbourne, Australia, and Honorary Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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Abstract
Clozapine is established as the gold standard for antipsychotic treatment of patients suffering from treatment-resistant schizophrenia. Over virtually 3 decades, the level of inadequate response to clozapine was found to range from 40% to 60%. A heightened interest developed in the augmentation of clozapine to try to achieve response or maximize partial response. A large variety of drug groups have been investigated. This article focuses on the meta-analyses of these trials to discover reasonable evidence-based approaches to the management of patients not responding to clozapine.
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Extended Requirement of Granulocyte Colony-Stimulating Factor for Clozapine-Associated Neutropenia. J Clin Psychopharmacol 2019; 39:169-172. [PMID: 30811374 DOI: 10.1097/jcp.0000000000001017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Leung CCY, Gadelrab R, Ntephe CU, McGuire PK, Demjaha A. Clinical Course, Neurobiology and Therapeutic Approaches to Treatment Resistant Schizophrenia. Toward an Integrated View. Front Psychiatry 2019; 10:601. [PMID: 31551822 PMCID: PMC6735262 DOI: 10.3389/fpsyt.2019.00601] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 07/29/2019] [Indexed: 12/19/2022] Open
Abstract
Despite considerable psychotherapeutic advancement since the discovery of chlorpromazine, almost one third of patients with schizophrenia remain resistant to dopamine-blocking antipsychotics, and continue to be exposed to unwanted and often disabling side effects, but little if any clinical benefit. Even clozapine, the superior antipsychotic treatment, is ineffective in approximately half of these patients. Thus treatment resistant schizophrenia (TRS), continues to present a major therapeutic challenge to psychiatry. The main impediment to finding novel treatments is the lack of understanding of precise molecular mechanisms leading to TRS. Not only has the neurobiology been enigmatic for decades, but accurate and early detection of patients who are at risk of not responding to dopaminergic blockade remains elusive. Fortunately, recent work has started to unravel some of the neurobiological mechanisms underlying treatment resistance, providing long awaited answers, at least to some extent. Here we focus on the scientific advances in the field, from the clinical course of TRS to neurobiology and available treatment options. We specifically emphasize emerging evidence from TRS imaging and genetic literature that implicates dysregulation in several neurotransmitters, particularly dopamine and glutamate, and in addition genetic and neural alterations that concertedly may lead to the formation of TRS. Finally, we integrate available findings into a putative model of TRS, which may provide a platform for future studies in a bid to open the avenues for subsequent development of effective therapeutics.
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Affiliation(s)
- Cheryl Cheuk-Yan Leung
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology, and Neuroscience (IoPPN), King’s College London, London, United Kingdom
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Romayne Gadelrab
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | | | - Philip K. McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience (IoPPN), King’s College London, London, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Arsime Demjaha
- Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience (IoPPN), King’s College London, London, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), South London and Maudsley NHS Foundation Trust, London, United Kingdom
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Rothärmel M, Krir MW, Moulier V, Védrine MG, Compere V, Guillin O. Electroconvulsive therapy in ultra-resistant schizophrenia: A case series. Asian J Psychiatr 2019; 44:6-7. [PMID: 31302441 DOI: 10.1016/j.ajp.2019.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/30/2019] [Accepted: 07/05/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Maud Rothärmel
- Rouvray Hospital of Rouen, University Department of Psychiatry, France
| | | | - Virginie Moulier
- Ville Evrard Mental Health Center, Clinical Research Unit, France
| | | | - Vincent Compere
- Rouen University Hospital, Department of Anaesthesiology and Intensive Care, France
| | - Olivier Guillin
- Rouvray Hospital of Rouen, University Department of Psychiatry, France
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Mohamed MA, Atty SA, Asran AM, Boukherroub R. One-pot green synthesis of reduced graphene oxide decorated with β-Ni(OH)2-nanoflakes as an efficient electrochemical platform for the determination of antipsychotic drug sulpiride. Microchem J 2019. [DOI: 10.1016/j.microc.2019.03.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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30
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Wagner E, Löhrs L, Siskind D, Honer WG, Falkai P, Hasan A. Clozapine augmentation strategies - a systematic meta-review of available evidence. Treatment options for clozapine resistance. J Psychopharmacol 2019; 33:423-435. [PMID: 30696332 DOI: 10.1177/0269881118822171] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Treatment options for clozapine resistance are diverse whereas, in contrast, the evidence for augmentation or combination strategies is sparse. AIMS We aimed to extract levels of evidence from available data and extrapolate recommendations for clinical practice. METHODS We conducted a systematic literature search in the PubMed/MEDLINE database and in the Cochrane database. Included meta-analyses were assessed using Scottish Intercollegiate Guidelines Network criteria, with symptom improvement as the endpoint, in order to develop a recommendation grade for each clinical strategy identified. RESULTS Our search identified 21 meta-analyses of clozapine combination or augmentation strategies. No strategies met Grade A criteria. Strategies meeting Grade B included combinations with first- or second-generation antipsychotics, augmentation with electroconvulsive therapy for persistent positive symptoms, and combination with certain antidepressants (fluoxetine, duloxetine, citalopram) for persistent negative symptoms. Augmentation strategies with mood-stabilisers, anticonvulsants, glutamatergics, repetitive transcranial magnetic stimulation, transcranial direct current stimulation or cognitive behavioural therapy met Grades C-D criteria only. CONCLUSION More high-quality clinical trials are needed to evaluate the efficacy of add-on treatments for symptom improvement in patients with clozapine resistance. Applying definitions of clozapine resistance would improve the reporting of future clinical trials. Augmentation with second-generation antipsychotics and first-generation antipsychotics can be beneficial, but the supporting evidence is from low-quality studies. Electroconvulsive therapy may be effective for clozapine-resistant positive symptoms.
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Affiliation(s)
- Elias Wagner
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Lisa Löhrs
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Dan Siskind
- 2 School of Medicine, University of Queensland, Brisbane, QLD, Australia.,3 Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - William G Honer
- 4 Department of Psychiatry, The University of British Columbia, Vancouver, BC, Canada
| | - Peter Falkai
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Alkomiet Hasan
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
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Tréhout M, Zhang N, Blouet M, Borha A, Dollfus S. Dandy-Walker Malformation-Like Condition Revealed by Refractory Schizophrenia: A Case Report and Literature Review. Neuropsychobiology 2019; 77:59-66. [PMID: 30448844 DOI: 10.1159/000494695] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/17/2018] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Dandy-Walker malformation is a rare congenital malformation involving cystic dilatation of the fourth ventricle, enlarged posterior fossa, complete or partial agenesis of the cerebellar vermis, elevated tentorium cerebelli, and hydrocephalus. Previous research highlighted a possible role for the cerebellum in schizophrenia as well as the contribution of underlying brain malformations to treatment resistance. Here, we present a case of a Dandy-Walker malformation-like condition revealed by a refractory schizophrenia in a 24-year-old male patient. We also conduct a literature review of all previously published case reports or case series of co-occurring posterior fossa abnormalities and schizophrenia or psychosis using a PubMed search query to better understand the potential link between these two disorders. CASE PRESENTATION A 9-month hospital stay was needed to address the treatment-resistant psychotic symptoms, and the patient continued to experience moderate symptoms despite the prescription of various antipsychotic and antidepressant medications. After an irregular initial medical follow-up, the patient is currently treated with 350 mg daily clozapine and 20 mg daily prazepam and still exhibits moderate anxiety without delirious thoughts, however allowing him to re-enroll at the university. Regarding the literature, 24 cases published between 1996 and 2017 were identified, reviewed and compared to the present case report. DISCUSSION This case report and literature review further illuminates the pathophysiology of psychotic disorders including the potential role of the cerebellum, reinforces the importance of a multidisciplinary approach for the neurological and psychiatric management of patients with schizophrenia, and highlights optimal pharmacological management strategies for treatment-resistant schizophrenia.
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Affiliation(s)
- Maxime Tréhout
- Service de Psychiatrie, CHU de Caen, Caen, France, .,UFR de Médecine, UNICAEN, Normandie Université, Caen, France, .,ISTS, UNICAEN, Normandie Université, Caen, France,
| | | | - Marie Blouet
- Service de Radiologie, CHU de Caen, Caen, France
| | - Alin Borha
- Service de Neurochirurgie, CHU de Caen, Caen, France
| | - Sonia Dollfus
- Service de Psychiatrie, CHU de Caen, Caen, France.,UFR de Médecine, UNICAEN, Normandie Université, Caen, France.,ISTS, UNICAEN, Normandie Université, Caen, France
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Davarinejad O, Hendesi K, Shahi H, Brand S, Khazaie H. A Pilot Study on Daily Intensive ECT over 8 Days Improved Positive and Negative Symptoms and General Psychopathology of Patients with Treatment-Resistant Schizophrenia up to 4 Weeks after Treatment. Neuropsychobiology 2019; 77:83-91. [PMID: 30463074 DOI: 10.1159/000494698] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 10/17/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE For patients with treatment-resistant schizophrenia (TRS) who do not respond to drug therapy, electroconvulsive therapy (ECT) is often employed as an additional treatment. The aims of the present study were to investigate to what extent an 8-day daily ECT treatment might reduce symptoms of schizophrenia among patients with TRS both in the short term (end of the treatment) and medium term, that is 4 and 12 weeks after the treatment. METHODS Fourteen patients with TRS based on DSM-5 criteria took part in the present study. ECT consisted of daily sessions for 8 consecutive days. At baseline, at the end of the intervention, and 4 and 12 weeks after study completion, trained psychiatrists assessed the patients' disease severity (positive and negative symptoms; psychopathology) and cognitive functions. RESULTS Disease symptoms (positive and negative symptoms; psychopathology) became reduced from baseline to the end of the intervention and to 4 weeks after treatment. Twelve weeks after the intervention symptoms again increased. Cognitive functions decreased from baseline to the end of the study and 4 weeks after treatment. However, by 12 weeks after the intervention, cognitive functions had returned to baseline levels. CONCLUSION The pattern of results suggests that an intensive 8-day daily course of ECT reduced psychiatric symptoms (positive and negative symptoms, psychopathology) in both the short and medium term among patients with TRS. The increase in symptoms between 4 and 12 weeks following intervention suggests that booster sessions of ECT could be beneficial.
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Affiliation(s)
- Omran Davarinejad
- Department of Psychiatry, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Koorosh Hendesi
- Department of Psychiatry, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Hassan Shahi
- Department of Psychiatry, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Serge Brand
- Department of Psychiatry, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran, .,Department of Psychiatry, Substance Abuse Prevention Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran, .,Center for Affective, Stress and Sleep Disorders (ZASS), Psychiatric Clinics (UPK), University of Basel, Basel, Switzerland, .,Division of Sport Science and Psychosocial Health, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland,
| | - Habibolah Khazaie
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Youn T, Jeong SH, Kim YS, Chung IW. Long-term clinical efficacy of maintenance electroconvulsive therapy in patients with treatment-resistant schizophrenia on clozapine. Psychiatry Res 2019; 273:759-766. [PMID: 31207863 DOI: 10.1016/j.psychres.2019.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/04/2019] [Accepted: 02/04/2019] [Indexed: 12/21/2022]
Abstract
Electroconvulsive therapy (ECT) has been suggested as a treatment for augmenting the response to clozapine in patients that do not respond well to clozapine alone and maintenance ECT (M-ECT) had also been recommended to sustain improvement. This retrospective study of up to 2 years of observation was conducted to explore whether M-ECT is beneficial for long-term maintenance of the symptom remission elicited by acute ECT. Positive and Negative Syndrome Scale (PANSS) were plotted for each patient and compared using a linear mixed-effect model. A total of thirty-eight patients were followed and classified into three groups: (1) clozapine alone (CZP, n = 15), (2) acute ECT only (A-ECT, n = 11), and (3) acute ECT with M-ECT (M-ECT, n = 12). The mean number and interval of ECT sessions during the maintenance period in the M-ECT group were 39.0 ± 26.7 and 15.6 ± 8.4 days, respectively. The slope of the M-ECT group eventually declined, but that of the A-ECT group gradually increased back to the pre-ECT level. No persistent or serious adverse effects were observed. In conclusion, A-ECT augmented the effect of clozapine, but M-ECT was required for sustaining symptom improvement.
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Affiliation(s)
- Tak Youn
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, South Korea; Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, South Korea
| | - Seong Hoon Jeong
- Department of Psychiatry, Eulji University Hospital, Daejeon, South Korea
| | - Yong Sik Kim
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, South Korea; Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, South Korea
| | - In Won Chung
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, South Korea; Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, South Korea.
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Bartoli F, Crocamo C, Di Brita C, Esposito G, Tabacchi TI, Verrengia E, Clerici M, Carrà G. Adjunctive second-generation antipsychotics for specific symptom domains of schizophrenia resistant to clozapine: A meta-analysis. J Psychiatr Res 2019; 108:24-33. [PMID: 30447508 DOI: 10.1016/j.jpsychires.2018.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/26/2018] [Accepted: 11/02/2018] [Indexed: 02/06/2023]
Abstract
A fair amount of subjects with schizophrenia do not respond to clozapine and are defined 'ultra-resistant'. In this systematic review and meta-analysis, we tested the efficacy of adjunctive second-generation antipsychotics (SGAs) for main symptom domains (positive, negative, and depressive symptoms) in individuals with clozapine-resistant schizophrenia. We searched main electronic databases till December 2017. We included twelve double-blind, randomized, placebo-controlled trials (RCTs), evaluating the efficacy of SGAs for clozapine non/partial responders. We did not find any difference between SGAs and placebo (standardized mean difference, SMD = -0.21; p = 0.170; I2 = 68.0%) in improving positive symptoms. The effect size varied according to RCT duration (p = 0.025) and assessment methods (p = 0.016). Low-moderate effects of SGAs on both negative (SMD = -0.38; p = 0.005; I2 = 62.7%) and depressive symptoms (SMD = -0.35; p = 0.003; I2 = 4.9%), were estimated. In sum, our meta-analysis highlights the lack of efficacy of SGAs as add-on treatment for positive symptoms in clozapine-resistant schizophrenia. A small benefit of SGAs was estimated for both negative and depressive symptoms. Further RCTs are needed to establish efficacy and tolerability of SGAs or other augmentation strategies for different symptoms of clozapine-resistant schizophrenia.
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Affiliation(s)
- Francesco Bartoli
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy.
| | - Cristina Crocamo
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | - Carmen Di Brita
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | | | | | - Enrica Verrengia
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | - Massimo Clerici
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | - Giuseppe Carrà
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy; Division of Psychiatry, University College London, London, W1T 7NF, UK
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Faden J, Citrome L. Resistance is not futile: treatment-refractory schizophrenia - overview, evaluation and treatment. Expert Opin Pharmacother 2018; 20:11-24. [PMID: 30407873 DOI: 10.1080/14656566.2018.1543409] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Schizophrenia is a debilitating condition with three main symptom domains: positive, negative, and cognitive. Approximately one-third of persons with schizophrenia will fail to respond to treatment. Growing evidence suggests that treatment-resistant (refractory) schizophrenia (TRS) may be a distinct condition from treatment-respondent schizophrenia. There is limited evidence on effective treatments for TRS, and a lack of standardized diagnostic criteria for TRS has hampered research. Areas covered: A literature search was conducted using Pubmed.gov and the EMBASE literature database. The authors discuss the pragmatic definitions of TRS and review treatments consisting of antipsychotic monotherapy and augmentation strategies. Expert opinion: Currently available first-line antipsychotic medications are generally effective at treating the positive symptoms of schizophrenia, leaving residual negative and cognitive symptoms. Before diagnosing TRS, rule out any pharmacodynamic or pharmacokinetic failures. Most evidence supports clozapine as having the most efficacy for TRS. If clozapine is used, it should be optimized, and serum levels should be at least 350-420 ng/ml. If clozapine is unable to be tolerated, some evidence suggests olanzapine at dosages up to 40mg/day can be useful. Augmentation strategies have weak evidence. Tailoring treatment to the specific domain is the preferred approach, and the use of a structured assessment/outcome measure is encouraged.
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Affiliation(s)
- Justin Faden
- a Psychiatry , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
| | - Leslie Citrome
- b Psychiatry & Behavioral Sciences , New York Medical College , Valhalla , NY , USA
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ECT augmentation of clozapine for clozapine-resistant schizophrenia: A meta-analysis of randomized controlled trials. J Psychiatr Res 2018; 105:23-32. [PMID: 30144667 DOI: 10.1016/j.jpsychires.2018.08.002] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 07/05/2018] [Accepted: 08/01/2018] [Indexed: 01/13/2023]
Abstract
UNLABELLED Treatment-resistant schizophrenia (TRS) is common and debilitating. A subgroup of patients even has clozapine-resistant schizophrenia (CRS). We aimed to evaluate the efficacy and safety of electroconvulsive therapy (ECT) augmentation of clozapine for CRS. Systematic literature search of randomized controlled trials (RCTs) reporting on ECT augmentation of clozapine in CRS. Co-primary outcomes included symptomatic improvement at post-ECT assessment and study endpoint. Eighteen RCTs (n = 1769) with 20 active treatment arms were identified and meta-analyzed. Adjunctive ECT was superior to clozapine regarding symptomatic improvement at post-ECT assessment (Standardized Mean Difference (SMD) = -0.88, 95% Confidence Interval (CI): -1.33 to -0.44; I2 = 86%, P = 0.0001) and endpoint assessment (SMD: -1.44, 95%CI: -2.05 to -0.84; I2 = 95%, P < 0.00001), separating as early as week 1-2 (SMD = -0.54, 95%CI: -0.88 to -0.20; I2 = 77%, P = 0.002). Adjunctive ECT was also superior regarding study-defined response at post-ECT assessment (53.6% vs. 25.4%, Risk Ratio (RR) = 1.94, 95%CI: 1.59-2.36; I2 = 0%, P < 0.00001, number-needed-to-treat (NNT) = 3, 95%CI: 3-5) and endpoint assessment (67.7% vs. 41.4%, RR = 1.66, 95%CI: 1.38-1.99; I2 = 47%, P < 0.00001, NNT = 4, 95%CI: 3-8), and remission at post-ECT assessment (13.3% vs. 3.7%, RR = 3.28, 95%CI: 1.80-5.99; I2 = 0%, P = 0.0001, NNT = 13, 95%CI: 6-100) and endpoint assessment (23.6% vs. 13.3%, RR = 1.80, 95%CI: 1.39 to 2.35; I2 = 5%, P < 0.0001, NNT = 14, 95%CI: 6-50). Patient-reported memory impairment (24.2% vs. 0%; RR = 16.10 (95%CI: 4.53-57.26); I2 = 0%, P < 0.0001, number-needed-to-harm (NNH) = 4, 95%CI: 2-14) and headache (14.5% vs 1.6%; RR = 4.03 (95%CI: 1.54-10.56); I2 = 0%, P = 0.005, NNH = 8, 95%CI: 4-50) occurred more frequently with adjunctive ECT. No significant group differences were found regarding discontinuation and other adverse effects. Despite increased frequency of self-reported memory impairment and headache, ECT augmentation of clozapine is a highly effective and relatively safe treatment for CRS. REGISTRATION NUMBER CRD42018089959.
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Lin CH, Lin CH, Chang YC, Huang YJ, Chen PW, Yang HT, Lane HY. Sodium Benzoate, a D-Amino Acid Oxidase Inhibitor, Added to Clozapine for the Treatment of Schizophrenia: A Randomized, Double-Blind, Placebo-Controlled Trial. Biol Psychiatry 2018; 84:422-432. [PMID: 29397899 DOI: 10.1016/j.biopsych.2017.12.006] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 12/06/2017] [Accepted: 12/08/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Clozapine is the last-line antipsychotic agent for refractory schizophrenia. To date, there is no convincing evidence for augmentation on clozapine. Activation of N-methyl-D-aspartate receptors, including inhibition of D-amino acid oxidase that may metabolize D-amino acids, has been reported to be beneficial for patients receiving antipsychotics other than clozapine. This study aimed to examine the efficacy and safety of a D-amino acid oxidase inhibitor, sodium benzoate, for schizophrenia patients who had poor response to clozapine. METHODS We conducted a randomized, double-blind, placebo-controlled trial. Sixty schizophrenia inpatients that had been stabilized with clozapine were allocated into three groups for 6 weeks' add-on treatment of 1 g/day sodium benzoate, 2 g/day sodium benzoate, or placebo. The primary outcome measures were Positive and Negative Syndrome Scale (PANSS) total score, Scale for the Assessment of Negative Symptoms, Quality of Life Scale, and Global Assessment of Functioning. Side effects and cognitive functions were also measured. RESULTS Both doses of sodium benzoate produced better improvement than placebo in the Scale for the Assessment of Negative Symptoms. The 2 g/day sodium benzoate also produced better improvement than placebo in PANSS-total score, PANSS-positive score, and Quality of Life Scale. Sodium benzoate was well tolerated without evident side effects. The changes of catalase, an antioxidant, were different among the three groups and correlated with the improvement of PANSS-total score and PANSS-positive score in the sodium benzoate group. CONCLUSIONS Sodium benzoate adjuvant therapy improved symptomatology of patients with clozapine-resistant schizophrenia. Further studies are warranted to elucidate the optimal dose and treatment duration as well as the mechanisms of sodium benzoate for clozapine-resistant schizophrenia.
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Affiliation(s)
- Chieh-Hsin Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan; Center for General Education, Cheng Shiu University, Kaohsiung, Taiwan; Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Ching-Hua Lin
- Department of Adult Psychiatry, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
| | - Yue-Cune Chang
- Department of Mathematics, Tamkang University, Taipei, Taiwan
| | - Yu-Jhen Huang
- Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan
| | - Po-Wei Chen
- Department of Psychiatry, Taichung Chin-Ho Hospital, Taichung, Taiwan
| | - Hui-Ting Yang
- Department of Nutrition, China Medical University, Taichung, Taiwan
| | - Hsien-Yuan Lane
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan; Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan.
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Nucifora FC, Woznica E, Lee BJ, Cascella N, Sawa A. Treatment resistant schizophrenia: Clinical, biological, and therapeutic perspectives. Neurobiol Dis 2018; 131:104257. [PMID: 30170114 DOI: 10.1016/j.nbd.2018.08.016] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 08/07/2018] [Accepted: 08/26/2018] [Indexed: 12/16/2022] Open
Abstract
Treatment resistant schizophrenia (TRS) refers to the significant proportion of schizophrenia patients who continue to have symptoms and poor outcomes despite treatment. While many definitions of TRS include failure of two different antipsychotics as a minimum criterion, the wide variability in inclusion criteria has challenged the consistency and reproducibility of results from studies of TRS. We begin by reviewing the clinical, neuroimaging, and neurobiological characteristics of TRS. We further review the current treatment strategies available, addressing clozapine, the first-line pharmacological agent for TRS, as well as pharmacological and non-pharmacological augmentation of clozapine including medication combinations, electroconvulsive therapy, repetitive transcranial magnetic stimulation, deep brain stimulation, and psychotherapies. We conclude by highlighting the most recent consensus for defining TRS proposed by the Treatment Response and Resistance in Psychosis Working Group, and provide our overview of future perspectives and directions that could help advance the field of TRS research, including the concept of TRS as a potential subtype of schizophrenia.
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Affiliation(s)
- Frederick C Nucifora
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, MD 21287, USA.
| | - Edgar Woznica
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | - Brian J Lee
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | - Nicola Cascella
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | - Akira Sawa
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, MD 21287, USA
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Kim JH, Youn T, Choi JG, Jeong SH, Jung HY, Kim YS, Chung IW. Combination of Electroconvulsive Therapy and Clozapine in Treatment-Resistant Schizophrenia. Psychiatry Investig 2018; 15:829-835. [PMID: 30086612 PMCID: PMC6111217 DOI: 10.30773/pi.2018.05.15] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/15/2018] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE This study aimed to investigate the effectiveness and tolerability of the combination of electroconvulsive therapy (ECT) in patients with clozapine-treated schizophrenia. METHODS Patients with clozapine-treated schizophrenia during five years of pre-determined period were recruited from Electronic Medical Record. Clinical effects of acute ECT on psychotic symptoms were investigated. We also tried to identify predictive variables requiring maintenance treatment of ECT. RESULTS Fourteen patients received ECT and clozapine and sixteen were treated with clozapine alone. In the ECT group, which could be refined as clozapine-resistance, PANSS total score was significantly reduced by 19.0±9.9 points, corresponding to a reduction rate of 18.5±8.3%. The clinical remission defined as 20% PANSS reduction criteria was achieved at 42.9%. The subscale factors were significantly reduced, among which the negative symptom was the least. There was no difference in demographic and clinical information between patients receiving and not receiving maintenance ECT, and not all patients seemed to need maintenance ECT if clozapine is continued. CONCLUSION Combination of ECT and clozapine in patients with clozapine-resistant schizophrenia resulted in a rapid and substantial reduction of psychotic symptoms. Further studies are needed to improve the effectiveness and tolerability of ECT.
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Affiliation(s)
- Jung Hyun Kim
- Department of Psychiatry & Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Tak Youn
- Department of Psychiatry & Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea.,Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - Jun Gwon Choi
- Department of Anesthesiology and Pain Medicine, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Seong Hoon Jeong
- Department of Psychiatry, Eulji University Hospital, Daejeon, Republic of Korea
| | - Hee Yeon Jung
- Department of Psychiatry, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea.,Department of Psychiatry and Behavioral Science and Institute of Human Behavioral Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yong Sik Kim
- Department of Psychiatry & Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea.,Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - In Won Chung
- Department of Psychiatry & Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea.,Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
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41
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Siskind DJ, Lee M, Ravindran A, Zhang Q, Ma E, Motamarri B, Kisely S. Augmentation strategies for clozapine refractory schizophrenia: A systematic review and meta-analysis. Aust N Z J Psychiatry 2018; 52:751-767. [PMID: 29732913 DOI: 10.1177/0004867418772351] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although clozapine is the most effective medication for treatment refractory schizophrenia, only 40% of people will meet response criteria. We therefore undertook a systematic review and meta-analysis of global literature on clozapine augmentation strategies. METHODS We systematically reviewed PubMed, PsycInfo, Embase, Cochrane Database, Chinese Biomedical Literature Service System and China Knowledge Resource Integrated Database for randomised control trials of augmentation strategies for clozapine resistant schizophrenia. We undertook pairwise meta-analyses of within-class interventions and, where possible, frequentist mixed treatment comparisons to differentiate treatment effectiveness Results: We identified 46 studies of 25 interventions. On pairwise meta-analyses, the most effective augmentation agents for total psychosis symptoms were aripiprazole (standardised mean difference: 0.48; 95% confidence interval: -0.89 to -0.07) fluoxetine (standardised mean difference: 0.73; 95% confidence interval: -0.97 to -0.50) and, sodium valproate (standardised mean difference: 2.36 95% confidence interval: -3.96 to -0.75). Memantine was effective for negative symptoms (standardised mean difference: -0.56 95% confidence interval: -0.93 to -0.20). However, many of these results included poor-quality studies. Single studies of certain antipsychotics (penfluridol), antidepressants (paroxetine, duloxetine), lithium and Ginkgo biloba showed potential, while electroconvulsive therapy was highly promising. Mixed treatment comparisons were only possible for antipsychotics, and these gave similar results to the pairwise meta-analyses. CONCLUSIONS On the basis of the limited data available, the best evidence is for the use of aripiprazole, fluoxetine and sodium valproate as augmentation agents for total psychosis symptoms and memantine for negative symptoms. However, these conclusions are tempered by generally short follow-up periods and poor study quality.
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Affiliation(s)
- Dan J Siskind
- 1 Addiction and Mental Health Services and MIRT, Metro South Health, Brisbane, QLD, Australia.,2 MIRT, Woolloongabba Community Health Centre, Metro South Health, Woolloongabba, QLD, Australia.,3 School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Michael Lee
- 3 School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Arul Ravindran
- 3 School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Qichen Zhang
- 3 School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Evelyn Ma
- 3 School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Balaji Motamarri
- 1 Addiction and Mental Health Services and MIRT, Metro South Health, Brisbane, QLD, Australia.,3 School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Steve Kisely
- 1 Addiction and Mental Health Services and MIRT, Metro South Health, Brisbane, QLD, Australia.,3 School of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Morrison AP, Pyle M, Gumley A, Schwannauer M, Turkington D, MacLennan G, Norrie J, Hudson J, Bowe SE, French P, Byrne R, Syrett S, Dudley R, McLeod HJ, Griffiths H, Barnes TRE, Davies L, Kingdon D. Cognitive behavioural therapy in clozapine-resistant schizophrenia (FOCUS): an assessor-blinded, randomised controlled trial. Lancet Psychiatry 2018; 5:633-643. [PMID: 30001930 PMCID: PMC6063993 DOI: 10.1016/s2215-0366(18)30184-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/30/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although clozapine is the treatment of choice for treatment-refractory schizophrenia, 30-40% of patients have an insufficient response, and others are unable to tolerate it. Evidence for any augmentation strategies is scarce. We aimed to determine whether cognitive behavioural therapy (CBT) is an effective treatment for clozapine-resistant schizophrenia. METHODS We did a pragmatic, parallel group, assessor-blinded, randomised controlled trial in community-based and inpatient mental health services in five sites in the UK. Patients with schizophrenia who were unable to tolerate clozapine, or whose symptoms did not respond to the drug, were randomly assigned 1:1 by use of randomised-permuted blocks of size four or six, stratified by centre, to either CBT plus treatment as usual or treatment as usual alone. Research assistants were masked to allocation to protect against rater bias and allegiance bias. The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months, which provides a continuous measure of symptoms of schizophrenia; PANSS total was also assessed at the end of treatment (9 months). The primary analysis was by randomised treatment based on intention to treat, for all patients for whom data were available. This study was prospectively registered, number ISRCTN99672552. The trial is closed to accrual. FINDINGS From Jan 1, 2013, to May 31, 2015, we randomly assigned 487 participants to either CBT and treatment as usual (n=242) or treatment as usual alone (n=245). Analysis included 209 in the CBT group and 216 in the treatment as usual group. No difference occurred in the primary outcome (PANSS total at 21 months, mean difference -0·89, 95% CI -3·32 to 1·55; p=0·48), although the CBT group improved at the end of treatment (PANSS total at 9 months, mean difference -2·40, -4·79 to -0·02; p=0·049). During the trial, 107 (44%) of 242 participants in the CBT arm and 104 (42%) of 245 in the treatment as usual arm had at least one adverse event (odds ratio 1·09, 95% CI 0·81 to 1·46; p=0·58). Only two (1%) of 242 participants in the CBT arm and one (<1%) of 245 in the treatment as usual arm had a trial-related serious adverse event. INTERPRETATION At 21-month follow-up, CBT did not have a lasting effect on total symptoms of schizophrenia compared with treatment as usual; however, CBT produced statistically, though not clinically, significant improvements on total symptoms by the end of treatment. There was no indication that the addition of CBT to treatment as usual caused adverse effects. The results of this trial do not support a recommendation to routinely offer CBT to all people who meet criteria for clozapine-resistant schizophrenia; however, a pragmatic individual trial might be indicated for some. FUNDING National Institute for Health Research Technology Assessment programme.
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Affiliation(s)
- Anthony P Morrison
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK; Zochonis Building, University of Manchester, Manchester, UK; Division of Psychology and Mental Health, Zochonis Building, University of Manchester, Manchester, UK.
| | - Melissa Pyle
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK; Zochonis Building, University of Manchester, Manchester, UK; Division of Psychology and Mental Health, Zochonis Building, University of Manchester, Manchester, UK
| | - Andrew Gumley
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - Matthias Schwannauer
- Department of Clinical Psychology, School of Health in Social Science, Old Medical School, The University of Edinburgh, Edinburgh, UK
| | - Douglas Turkington
- Academic Psychiatry, Northumberland, Tyne and Wear NHS Foundation Trust, Centre for Aging and Vitality, Newcastle General Hospital, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences & Informatics, Nine Edinburgh BioQuarter, The University of Edinburgh, Edinburgh, UK
| | - Jemma Hudson
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Samantha E Bowe
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK; Zochonis Building, University of Manchester, Manchester, UK
| | - Paul French
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK; Zochonis Building, University of Manchester, Manchester, UK; Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Rory Byrne
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK; Zochonis Building, University of Manchester, Manchester, UK; Division of Psychology and Mental Health, Zochonis Building, University of Manchester, Manchester, UK
| | - Suzy Syrett
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - Robert Dudley
- School of Psychology, Newcastle University, Newcastle Upon Tyne, UK; Early Intervention in Psychosis Service, Northumberland, Tyne and Wear NHS Foundation Trust, Tranwell Unit, Queen Elizabeth Hospital, Gateshead, UK
| | - Hamish J McLeod
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - Helen Griffiths
- Department of Clinical Psychology, School of Health in Social Science, Old Medical School, The University of Edinburgh, Edinburgh, UK
| | | | - Linda Davies
- Division of Population Health, Zochonis Building, University of Manchester, Manchester, UK
| | - David Kingdon
- University Department of Psychiatry, Academic Centre, University of Southampton, Southampton, UK
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Raynsford J, Dada C, Stansfield D, Cullen T. Impact of a specialist mental health pharmacy team on medicines optimisation in primary care for patients on a severe mental illness register: a pilot study. Eur J Hosp Pharm 2018; 27:31-35. [PMID: 32064086 DOI: 10.1136/ejhpharm-2018-001514] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/22/2018] [Accepted: 06/14/2018] [Indexed: 11/03/2022] Open
Abstract
Objective Medication arrangements for patients with severe mental illness (SMI), including schizophrenia and bipolar disorder, can be complex. Some have shared care between primary and secondary services while others have little specialist input. This study investigated the contribution a specialist mental health clinical pharmacy team could make to medicines optimisation for patients on the SMI register in primary care. Research shows that specialist mental health pharmacists improve care in inpatient settings. However, little is known about their potential impact in primary care. Method Five general practice surgeries were allocated half a day per week of a specialist pharmacist and technician for 12 months. The technician reviewed primary and secondary care records for discrepancies. Records were audited for high-dose or multiple antipsychotics, physical health monitoring and adherence. Issues were referred to the pharmacist for review. Surgery staff were encouraged to refer psychotropic medication queries to the team. Interventions were recorded and graded. Results 316/472 patients on the SMI register were prescribed antipsychotics or mood stabilisers. 23 (7%) records were updated with missing clozapine and depot information. Interventions by the pharmacist included clarifying discharge information (12/104), reviewing high-dose and multiple antipsychotic prescribing (18/104), correcting errors (10/104), investigating adherence issues (16/104), following up missing health checks (22/104) and answering queries from surgery staff (23/104). Five out of six interventions possibly preventing hospital admission were for referral of non-adherent patients. Conclusion The pharmacy team found a variety of issues including incomplete medicines reconciliation, adherence issues, poor communication, drug errors and the need for specialist advice. The expertise of the team enabled timely resolution of issues and bridges were built between primary and secondary care.
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Affiliation(s)
| | - Caroline Dada
- Pharmacy, Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Donna Stansfield
- Pharmacy, Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Tanya Cullen
- Pharmacy, Leeds and York Partnership NHS Foundation Trust, Leeds, UK
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Barnes TR, Leeson V, Paton C, Marston L, Osborn DP, Kumar R, Keown P, Zafar R, Iqbal K, Singh V, Fridrich P, Fitzgerald Z, Bagalkote H, Haddad PM, Husni M, Amos T. Amisulpride augmentation of clozapine for treatment-refractory schizophrenia: a double-blind, placebo-controlled trial. Ther Adv Psychopharmacol 2018; 8:185-197. [PMID: 29977519 PMCID: PMC6022882 DOI: 10.1177/2045125318762365] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 12/01/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND A second antipsychotic is commonly added to clozapine to treat refractory schizophrenia, notwithstanding the limited evidence to support such practice. METHODS The efficacy and adverse effects of this pharmacological strategy were examined in a double-blind, placebo-controlled, 12-week randomized trial of clozapine augmentation with amisulpride, involving 68 adults with treatment-resistant schizophrenia and persistent symptoms despite a predefined trial of clozapine. RESULTS There were no statistically significant differences between the amisulpride and placebo groups on the primary outcome measure (clinical response defined as a 20% reduction in total Positive and Negative Syndrome Scale score) or other mental state measures. However, the trial under recruited and was therefore underpowered to detect differences in the primary outcome, meaning that acceptance of the null hypothesis carries an increased risk of type II error. The findings suggested that amisulpride-treated participants were more likely to fulfil the clinical response criterion, odds ratio 1.17 (95% confidence interval 0.40-3.42) and have a greater reduction in negative symptoms, but these numerical differences were not statistically significant and only evident at 12 weeks. A significantly higher proportion of participants in the amisulpride group had at least one adverse event compared with the control group (p = 0.014), and these were more likely to be cardiac symptoms. CONCLUSIONS Treatment for more than 6 weeks may be required for an adequate trial of clozapine augmentation with amisulpride. The greater side-effect burden associated with this treatment strategy highlights the need for safety and tolerability monitoring, including vigilance for indicators of cardiac abnormalities, when it is used in either a clinical or research setting.
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Affiliation(s)
- Thomas R.E. Barnes
- Centre for Psychiatry, Hammersmith Hospital Campus, Imperial College London, 7th Floor Commonwealth Building, Du Cane Road, London W12 0NN, UK
| | | | - Carol Paton
- Centre for Psychiatry, Imperial College London, UK
- Oxleas NHS Foundation Trust, UK
| | - Louise Marston
- Department of Primary Care and Population Health, University College London, UK
- PRIMENT Clinical Trials Unit, University College London, UK
| | - David P. Osborn
- Division of Psychiatry, University College London, UK
- Camden and Islington NHS Foundation Trust, London, UK
| | - Raj Kumar
- Tees, Esk and Wear Valley NHS Foundation Trust, Billingham, UK
| | - Patrick Keown
- Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
- Newcastle University, Newcastle-upon-Tyne, UK
| | - Rameez Zafar
- Lincolnshire Partnership NHS Foundation Trust, Lincoln, UK
| | | | - Vineet Singh
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Pavel Fridrich
- North Essex Partnership University NHS Foundation Trust, Harlow, UK
| | | | | | - Peter M. Haddad
- Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Mariwan Husni
- Central and North West London NHS Foundation Trust, London, UK
- Northern Ontario School of Medicine, Ontario, Canada
| | - Tim Amos
- Avon and Wiltshire Mental Health Partnership NHS Trust, Bristol, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Barnes TR, Leeson VC, Paton C, Marston L, Davies L, Whittaker W, Osborn D, Kumar R, Keown P, Zafar R, Iqbal K, Singh V, Fridrich P, Fitzgerald Z, Bagalkote H, Haddad PM, Husni M, Amos T. Amisulpride augmentation in clozapine-unresponsive schizophrenia (AMICUS): a double-blind, placebo-controlled, randomised trial of clinical effectiveness and cost-effectiveness. Health Technol Assess 2018; 21:1-56. [PMID: 28869006 DOI: 10.3310/hta21490] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND When treatment-refractory schizophrenia shows an insufficient response to a trial of clozapine, clinicians commonly add a second antipsychotic, despite the lack of robust evidence to justify this practice. OBJECTIVES The main objectives of the study were to establish the clinical effectiveness and cost-effectiveness of augmentation of clozapine medication with a second antipsychotic, amisulpride, for the management of treatment-resistant schizophrenia. DESIGN The study was a multicentre, double-blind, individually randomised, placebo-controlled trial with follow-up at 12 weeks. SETTINGS The study was set in NHS multidisciplinary teams in adult psychiatry. PARTICIPANTS Eligible participants were people aged 18-65 years with treatment-resistant schizophrenia unresponsive, at a criterion level of persistent symptom severity and impaired social function, to an adequate trial of clozapine monotherapy. INTERVENTIONS Interventions comprised clozapine augmentation over 12 weeks with amisulpride or placebo. Participants received 400 mg of amisulpride or two matching placebo capsules for the first 4 weeks, after which there was a clinical option to titrate the dosage of amisulpride up to 800 mg or four matching placebo capsules for the remaining 8 weeks. MAIN OUTCOME MEASURES The primary outcome measure was the proportion of 'responders', using a criterion response threshold of a 20% reduction in total score on the Positive and Negative Syndrome Scale. RESULTS A total of 68 participants were randomised. Compared with the participants assigned to placebo, those receiving amisulpride had a greater chance of being a responder by the 12-week follow-up (odds ratio 1.17, 95% confidence interval 0.40 to 3.42) and a greater improvement in negative symptoms, although neither finding had been present at 6-week follow-up and neither was statistically significant. Amisulpride was associated with a greater side effect burden, including cardiac side effects. Economic analyses indicated that amisulpride augmentation has the potential to be cost-effective in the short term [net saving of between £329 and £2011; no difference in quality-adjusted life-years (QALYs)] and possibly in the longer term. LIMITATIONS The trial under-recruited and, therefore, the power of statistical analysis to detect significant differences between the active and placebo groups was limited. The economic analyses indicated high uncertainty because of the short duration and relatively small number of participants. CONCLUSIONS The risk-benefit of amisulpride augmentation of clozapine for schizophrenia that has shown an insufficient response to a trial of clozapine monotherapy is worthy of further investigation in larger studies. The size and extent of the side effect burden identified for the amisulpride-clozapine combination may partly reflect the comprehensive assessment of side effects in this study. The design of future trials of such a treatment strategy should take into account that a clinical response may be not be evident within the 4- to 6-week follow-up period usually considered adequate in studies of antipsychotic treatment of acute psychotic episodes. Economic evaluation indicated the need for larger, longer-term studies to address uncertainty about the extent of savings because of amisulpride and impact on QALYs. The extent and nature of the side effect burden identified for the amisulpride-clozapine combination has implications for the nature and frequency of safety and tolerability monitoring of clozapine augmentation with a second antipsychotic in both clinical and research settings. TRIAL REGISTRATION EudraCT number 2010-018963-40 and Current Controlled Trials ISRCTN68824876. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 49. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Thomas Re Barnes
- Centre for Mental Health, Imperial College London, London, UK.,West London Mental Health NHS Trust, London, UK
| | - Verity C Leeson
- Centre for Mental Health, Imperial College London, London, UK
| | - Carol Paton
- Centre for Mental Health, Imperial College London, London, UK.,Oxleas NHS Foundation Trust, London, UK
| | - Louise Marston
- Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Linda Davies
- Centre for Health Economics, Institute of Population Health, University of Manchester, Manchester, UK
| | - William Whittaker
- Centre for Health Economics, Institute of Population Health, University of Manchester, Manchester, UK
| | - David Osborn
- Division of Psychiatry, University College London, London, UK.,Camden and Islington NHS Foundation Trust, London, UK
| | - Raj Kumar
- Tees, Esk and Wear Valley NHS Foundation Trust, Billingham, UK
| | - Patrick Keown
- Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Rameez Zafar
- Lincolnshire Partnership NHS Foundation Trust, Lincoln, UK
| | | | - Vineet Singh
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Pavel Fridrich
- North Essex Partnership University NHS Foundation Trust, Chelmsford, UK
| | | | | | - Peter M Haddad
- Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK.,Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Mariwan Husni
- Central and North West London NHS Foundation Trust, London, UK.,Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Tim Amos
- Avon and Wiltshire Mental Health Partnership NHS Trust, Bristol, UK.,School of Social and Community Medicine, University of Bristol, Bristol, UK
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Lu ML, Chen TT, Kuo PH, Hsu CC, Chen CH. Effects of adjunctive fluvoxamine on metabolic parameters and psychopathology in clozapine-treated patients with schizophrenia: A 12-week, randomized, double-blind, placebo-controlled study. Schizophr Res 2018; 193:126-133. [PMID: 28688742 DOI: 10.1016/j.schres.2017.06.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/17/2017] [Accepted: 06/18/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Numerous studies have demonstrated that fluvoxamine has considerable pharmacokinetic and pharmacodynamic interactions with clozapine. We conducted a 12-week, randomized, double-blind, placebo-controlled study to evaluate the effects of fluvoxamine on metabolic parameters and psychopathology in clozapine-treated patients with schizophrenia. METHODS We recruited 85 patients who received a DSM-IV diagnosis of schizophrenia. Eligible patients were randomized to receive fluvoxamine 50mg/day plus clozapine 100mg/day or clozapine 300mg/day. We studied metabolic parameters, psychopathology, and drug levels at baseline and 4, 8, and 12weeks after the intervention. Plasma levels of clozapine, norclozapine, clozapine N-oxide, and fluvoxamine were determined using high-performance liquid chromatography with ultraviolet detection. RESULTS No significant difference was observed in baseline characteristics between the two groups. Clozapine-fluvoxamine combined treatment significantly attenuated the increments in body weight, insulin resistance, and levels of insulin, glucose, and triglycerides compared with clozapine monotherapy. Both groups exhibited significant improvements in their Positive and Negative Syndrome Scale (PANSS) total and negative scores. The combined treatment group showed significant reduction in the PANSS general psychopathology scores compared with the monotherapy group. No difference was observed in the plasma clozapine level between the two groups. The monotherapy group showed higher levels of norclozapine and clozapine N-oxide than the combined group. CONCLUSIONS Compared with clozapine monotherapy, treatment with adjunctive fluvoxamine with clozapine for 12weeks can alleviate body weight gain and metabolic abnormalities in patients with schizophrenia, without sacrificing the clinical effect. Clinicians should interpret these findings cautiously considering the short duration of this study. The study was registered at www.clinicaltrials.gov (NCT01401491).
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Affiliation(s)
- Mong-Liang Lu
- Department of Psychiatry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tzu-Ting Chen
- Department of Psychiatry, National Taiwan University Hospital Yun-Lin Branch, Yunlin County, Taiwan
| | - Po-Hsiu Kuo
- Department of Public Health & Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Research Center for Genes, Environment and Human Health, National Taiwan University, Taipei, Taiwan
| | - Ching-Chi Hsu
- Department of Psychiatry, Wizcare Hospital, Taichung, Taiwan
| | - Chun-Hsin Chen
- Department of Psychiatry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Dellazizzo L, Potvin S, Phraxayavong K, Lalonde P, Dumais A. Avatar Therapy for Persistent Auditory Verbal Hallucinations in an Ultra-Resistant Schizophrenia Patient: A Case Report. Front Psychiatry 2018; 9:131. [PMID: 29713292 PMCID: PMC5911828 DOI: 10.3389/fpsyt.2018.00131] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/27/2018] [Indexed: 12/15/2022] Open
Abstract
Effective treatment strategies for schizophrenia remain very challenging and many treatment-resistant patients will suffer from persistent auditory verbal hallucinations (AVH). While clozapine is the gold-standard medication for this complex population, many will not respond to this molecule. For these ultra-resistant patients, limited options are available. Cognitive-behavioral therapy (CBT) is the most widely used psychological intervention, though it offers modest effects. With the interpersonal dimension of AVH being recognized, Avatar Therapy (AT), a novel experiential treatment enabling patients to create an avatar of their persecutor and allowing them to gain control over their symptoms, was developed and tested. Results have shown significant improvements in AVH symptomatology. This paper details a case report showcasing the beneficial results of AT for even the most severe and symptomatic cases of schizophrenia. Mr. Smith has been afflicted with the persistency of all his voices for almost 20 years. To our knowledge, this patient tried almost all possible treatments with little efficacy. This case highlights the difficulty of finding an adequate treatment for ultra-resistant patients. Mr. Smith first followed CBT before initiating AT. With AT, he significantly improved in a way that was not observed with any other intervention and these improvements remained afterward. The severity of his positive symptoms as well as his depressive symptoms diminished, and his most distressing persecutory voice disappeared. He was able to regain a life. The effects of AT went well beyond the patient, the morale of the entire family improved. This ultra-resistant case suggests that AT may be a promising intervention for refractory AVH in schizophrenia.
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Affiliation(s)
- Laura Dellazizzo
- Centre de recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada.,Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada.,Institut Philippe-Pinel de Montréal, Montreal, QC, Canada
| | - Stéphane Potvin
- Centre de recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada.,Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | | | - Pierre Lalonde
- Centre de recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada.,Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Alexandre Dumais
- Centre de recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada.,Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada.,Institut Philippe-Pinel de Montréal, Montreal, QC, Canada.,Services et Recherches Psychiatriques AD, Montreal, QC, Canada
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48
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Clark SR, Schubert KO, Olagunju AT, Lyrtzis EA, Baune BT. Cognitive and Functional Assessment of Psychosis Stratification Study (CoFAPSS): Rationale, Design, and Characteristics. Front Psychiatry 2018; 9:662. [PMID: 30559688 PMCID: PMC6287598 DOI: 10.3389/fpsyt.2018.00662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/19/2018] [Indexed: 11/13/2022] Open
Abstract
Prediction of treatment response and illness trajectory in psychotic disorders including schizophrenia, bipolar affective disorder, schizoaffective disorder, and psychotic depression is difficult due to heterogeneity in presentation and outcome. Consequently, patients may receive prolonged ineffective treatments leading to functional decline, illness chronicity, and iatrogenic physical illness. One approach to addressing these problems is to stratify patients based on historical, clinical, and biological signatures. Such an approach has the potential to improve categorization resulting in better understanding of underlying mechanisms and earlier evidence-based treatment with reduced side effect burden. To investigate these multimodal signatures we developed the Cognitive and Functional Assessment of Psychosis Stratification Study (CoFAPSS) employing a prospective study design and a healthy control group comparison. The main aim of this study is to investigate cognitive, and biological "genomics" markers of psychotic illnesses that can be integrated with clinical data to improve prediction of risk and define functional trajectories. We also aim to identify biological "genomic" signatures underpinning variation in treatment response and adverse medical outcomes. The study commenced in June 2016, including patients with primary diagnosis of psychotic disorders including schizophrenia, bipolar affective disorder, schizoaffective disorder, and psychotic depression according to DSM-5 criteria. The assessment covers a wide range of participant history (life stressors, trauma, and family history), cognitive dimensions (social perception, memory and learning, attention, executive function, and general cognition), measures to assess psychosocial function and quality of life, psychotic symptom severity, clinical course of illness, and parameters for adverse medical outcome. Blood is collected for comprehensive genomic discovery analyses of biological (genomic, transcriptomic, proteomic, and cell-biologic) markers. The CoFAPSS is a novel approach that integrates clinical, cognitive and biological "genomic" markers to clarify clinico-pathological basis of risk, functional trajectories, disease stratification, treatment response, and adverse medical outcome. The CoFAPSS team welcomes collaborations with both national and international investigators.
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Affiliation(s)
- Scott R Clark
- Discipline of Psychiatry, School of Medicine, The University of Adelaide Adelaide, SA, Australia
| | - K Oliver Schubert
- Discipline of Psychiatry, School of Medicine, The University of Adelaide Adelaide, SA, Australia
| | - Andrew T Olagunju
- Discipline of Psychiatry, School of Medicine, The University of Adelaide Adelaide, SA, Australia.,Department of Psychiatry University of Lagos, Lagos, Nigeria
| | - Ellen Alexandra Lyrtzis
- Discipline of Psychiatry, School of Medicine, The University of Adelaide Adelaide, SA, Australia
| | - Bernhard T Baune
- Discipline of Psychiatry, School of Medicine, The University of Adelaide Adelaide, SA, Australia.,Department of Psychiatry, Melbourne Medical School, The University of Melbourne Melbourne, VIC, Australia
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Yoshimura B, Yada Y, So R, Takaki M, Yamada N. The critical treatment window of clozapine in treatment-resistant schizophrenia: Secondary analysis of an observational study. Psychiatry Res 2017; 250:65-70. [PMID: 28142068 DOI: 10.1016/j.psychres.2017.01.064] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 01/20/2017] [Accepted: 01/22/2017] [Indexed: 01/29/2023]
Abstract
Previous studies have suggested that a delay in initiating clozapine is one of the predictors of outcomes in treatment-resistant schizophrenia (TRS). However, whether there is a critical treatment window of clozapine in TRS and the duration of that window remain unclear. We conducted a secondary analysis of a previously published observational study using a retrospective chart review of 105 patients with TRS who were treated with clozapine. We included 90 patients who remained on clozapine for at least 3 months. The delay in initiating clozapine was an independent contributor to symptomatic improvement based on treatment with clozapine by multiple linear regression analysis. A receiver operating characteristic curve analysis (area under the curve: 0.78) confirmed 2.8 years was the best predictive cut-off value of delay in initiating clozapine for responses in patients treated with clozapine (sensitivity: 0.66, specificity: 0.84). In patients with a delay in initiating clozapine of ≤2.8 years and a delay in initiating clozapine of >2.8 years, the response rates were 81.6% and 30.8% (risk ratio=2.65; 95% confidence interval, 1.80, 3.63), respectively. Clinicians should reduce the delay in initiating clozapine to less than 3 years to improve symptomatic outcomes in TRS and to prevent clozapine-resistant schizophrenia.
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Affiliation(s)
- Bunta Yoshimura
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan; Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Yuji Yada
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan.
| | - Ryuhei So
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan.
| | - Manabu Takaki
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Norihito Yamada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
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A Case of Resistant Schizophrenia Successfully Treated With Clozapine/Long-acting Injectable Aripiprazole Combination. Clin Neuropharmacol 2017; 39:322-324. [PMID: 27764052 DOI: 10.1097/wnf.0000000000000191] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Treatment-resistant schizophrenia (TRS) is a condition characterized by intense symptom severity and poor response to different antipsychotic agents. The first therapeutic option in TRS is clozapine, but often high/medium doses are not tolerated. Adding an oral antipsychotic to low doses of clozapine is a promising strategy in the management of TRS. On the contrary, there are few data on combined clozapine/long-acting injectable (LAI) medications, and none on clozapine/LAI-aripiprazole. CASE A 21-year-old male schizophrenic patient, resistant to several oral and LAI medications, partially improved after clozapine 300 mg/d treatment. Unfortunately, he also reported excessive sedation and an episode of myoclonus, so clozapine was reduced to 150 mg/d, but no additional benefits were observed. Subsequently, LAI-aripiprazole (first 200 mg/mo, then 400 mg/mo) was added, and the patient's conditions dramatically improved over time. After 1 year of observation, symptoms reduction was 50% or greater, without significant adverse events. CONCLUSIONS Clozapine use in TRS is often reduced or delayed due to the fear of serious adverse effects. Adding LAI-aripiprazole to low doses of clozapine may be a useful therapeutic option to obtain a good efficacy/tolerability balance.
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