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Dell’Osso L, Bonelli C, Nardi B, Giovannoni F, Pronestì C, Cremone IM, Amatori G, Pini S, Carpita B. Rethinking Clozapine: Lights and Shadows of a Revolutionary Drug. Brain Sci 2024; 14:103. [PMID: 38275523 PMCID: PMC10813979 DOI: 10.3390/brainsci14010103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
The current literature globally highlights the efficacy of Clozapine in several psychiatric disorders all over the world, with an FDA indication for reducing the risk of repeated suicidal behavior in patients with schizophrenia or schizoaffective disorder. A growing field of research is also stressing a possible broader beneficial effect of Clozapine in promoting neuroprotection and neurotrophism. However, this drug is linked to several life-threatening side effects, such as agranulocytosis, myocarditis and seizures, that limit its use in daily clinical practice. For this work, a search was performed on PubMed using the terms "Clozapine indications", "Clozapine adverse effects", "Clozapine regenerative effects", and "Clozapine neuroplasticity" with the aim of reviewing the scientific literature on Clozapine's treatment indications, adverse effects and potential regenerative role. The results confirmed the efficacy of clozapine in clinical practice, although limited by its adverse effects. It appears crucial to raise awareness among clinicians about the potential benefits of using Clozapine, as well educating medical personnel about its risks and the early identification of possible adverse effects and their management.
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Affiliation(s)
| | - Chiara Bonelli
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 67 Via Roma, 56126 Pisa, Italy; (L.D.); (B.N.); (F.G.); (C.P.); (I.M.C.); (G.A.); (S.P.); (B.C.)
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Chandru P, Gunja N. Toxicity and Adverse Effects in Clozapine-Related Presentations to a Medical Toxicology Service in Western Sydney. J Med Toxicol 2023; 19:374-380. [PMID: 37624540 PMCID: PMC10522536 DOI: 10.1007/s13181-023-00963-1] [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: 04/18/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Clozapine is an anti-psychotic agent, reserved for treatment-resistant schizophrenia, with demonstrated efficacy in an otherwise therapeutically challenging patient population. We aimed to review the full spectrum casemix of clozapine presentations to our tertiary toxicology service. METHODS In this retrospective study, we reviewed consecutive clozapine related toxicity presentations to a tertiary medical toxicology inpatient and consultation service-including deliberate self-poisoning (DSP), adverse drug reaction (ADR), recreational use, and therapeutic misadventure over a 10-year period from 2011 to 2021. Data were extracted for demographics, ingested dose, exposure characteristics, and patient outcome. RESULTS We identified 83 patients with clozapine-related presentations over the 10-year period. Twenty-two patients were excluded. Of the remaining 61 patients, 28 patients presented with DSP, 20 patients with accidental overdose, and 13 patients with an ADR; no patients presented with recreational use. It was noted that ADRs were largely idiosyncratic reactions and not always related to dose adjustments. In the context of therapeutic misadventure and DSP, we noted that a lower mean dose achieved a higher poison severity score (PSS) in clozapine-naive patients when compared to those patients on regular clozapine. CONCLUSIONS The presentation of clozapine-related toxicity differs depending on the modality of ingestion, whether DSP, accidental, or as a result of ADR. Patients naive to clozapine therapy tend to experience higher PSS with lower doses ingested either in a deliberate self-poisoning or accidental ingestion context. This is likely due to tolerance to the sedative properties of clozapine. No patients manifested clinical toxicity greater than 8 hours after ingestion, with an observation period of 6 hours accurately identifying toxicity in most patients.
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Affiliation(s)
- Pramod Chandru
- Department of Clinical Pharmacology & Toxicology, Western Sydney Health, Sydney, Australia.
| | - Naren Gunja
- Department of Clinical Pharmacology & Toxicology, Western Sydney Health, Sydney, Australia
- Discipline of Emergency Medicine, Sydney Medical School, University of Sydney, New South Wales, Australia
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Speers LJ, Chin P, Bilkey DK. No evidence that acute clozapine administration alters CA1 phase precession in rats. Brain Res 2023; 1814:148446. [PMID: 37301424 DOI: 10.1016/j.brainres.2023.148446] [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: 07/27/2022] [Revised: 05/25/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023]
Abstract
Hippocampal phase precession, wherein there is a systematic shift in the phase of neural firing against the underlying theta activity, is proposed to play an important role in the sequencing of information in memory. Previous research shows that the starting phase of precession is more variable in rats following maternal immune activation (MIA), a known risk factor for schizophrenia. Since starting phase variability has the potential to disorganize the construction of sequences of information, we tested whether the atypical antipsychotic clozapine, which ameliorates some cognitive deficits in schizophrenia, alters this aspect of phase precession. Either saline or clozapine (5 mg/kg) was administered to rats and then CA1 place cell activity was recorded from the CA1 region of the hippocampus as the animals ran around a rectangular track for food reward. When compared to saline trials, acute administration of clozapine did not affect any place cell properties, including those related to phase precession, in either control or MIA animals. Clozapine did, however, produce a reduction in locomotion speed, indicating that its presence had some effect on behaviour. These results help to constrain explanations of phase precession mechanisms and their potential role in sequence learning deficits.
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Affiliation(s)
| | - Phoebe Chin
- Psychology Dept., Otago Univ., Dunedin, New Zealand
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Qubad M, Bittner RA. Second to none: rationale, timing, and clinical management of clozapine use in schizophrenia. Ther Adv Psychopharmacol 2023; 13:20451253231158152. [PMID: 36994117 PMCID: PMC10041648 DOI: 10.1177/20451253231158152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/24/2023] [Indexed: 03/31/2023] Open
Abstract
Despite its enduring relevance as the single most effective and important evidence-based treatment for schizophrenia, underutilization of clozapine remains considerable. To a substantial degree, this is attributable to a reluctance of psychiatrists to offer clozapine due to its relatively large side-effect burden and the complexity of its use. This underscores the necessity for continued education regarding both the vital nature and the intricacies of clozapine treatment. This narrative review summarizes all clinically relevant areas of evidence, which support clozapine's wide-ranging superior efficacy - for treatment-resistant schizophrenia (TRS) and beyond - and make its safe use eminently feasible. Converging evidence indicates that TRS constitutes a distinct albeit heterogeneous subgroup of schizophrenias primarily responsive to clozapine. Most importantly, the predominantly early onset of treatment resistance and the considerable decline in response rates associated with its delayed initiation make clozapine an essential treatment option throughout the course of illness, beginning with the first psychotic episode. To maximize patients' benefits, systematic early recognition efforts based on stringent use of TRS criteria, a timely offer of clozapine, thorough side-effect screening and management as well as consistent use of therapeutic drug monitoring and established augmentation strategies for suboptimal responders are crucial. To minimize permanent all-cause discontinuation, re-challenges after neutropenia or myocarditis should be considered. Owing to clozapine's unique efficacy, comorbid conditions including substance use and most somatic disorders should not dissuade but rather encourage clinicians to consider clozapine. Moreover, treatment decisions need to be informed by the late onset of clozapine's full effects, which for reduced suicidality and mortality rates may not even be readily apparent. Overall, the singular extent of its efficacy combined with the high level of patient satisfaction continues to distinguish clozapine from all other available antipsychotics.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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Wickramarachchi P, Boyd JM, Orton DJ. Biological Variation in Clozapine and Metabolite Reporting During Therapeutic Drug Monitoring. Clin Chim Acta 2022; 531:183-187. [DOI: 10.1016/j.cca.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/01/2022] [Accepted: 04/05/2022] [Indexed: 11/29/2022]
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Tanzer T, Warren N, McMahon L, Barras M, Kisely S, Brooks E, Wong E, Siskind D. Treatment strategies for clozapine-induced nocturnal enuresis and urinary incontinence: a systematic review. CNS Spectr 2022; 28:1-12. [PMID: 35086595 DOI: 10.1017/s1092852922000050] [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] [Indexed: 11/07/2022]
Abstract
BACKGROUND Clozapine is the most effective medication for treatment-refractory schizophrenia but is associated with significant adverse drug reactions, including nocturnal enuresis and urinary incontinence. This side effect can be burdensome and lead to medication nonadherence and psychotic relapse. Evidence to guide treatment of clozapine-induced nocturnal enuresis and urinary incontinence is sparse. We therefore aimed to synthesize the evidence base to guide management for clinicians, patients, and their carers. METHODS We systematically searched PubMed, Embase, PsycInfo, CINAHL, and the Cochrane Trial Registry databases from inception to May 2021 for publications on management of clozapine-induced nocturnal enuresis and urinary incontinence using a PROSPERO preregistered search strategy. RESULTS We identified 22 case reports and case series describing 74 patients. Interventions included clozapine dose reduction, nonpharmacological treatment, and pharmacological treatments. Among pharmacological treatments, desmopressin, oxybutynin, trihexyphenidyl, tolterodine, imipramine, amitriptyline, ephedrine, pseudoephedrine, aripiprazole, and verapamil were associated with complete resolution of nocturnal enuresis and urinary incontinence. Balancing evidence for effectiveness against risk of adverse effects, we developed a management framework for clozapine-induced nocturnal enuresis and urinary incontinence. CONCLUSIONS Following assessment of urological, psychiatric, pharmacological, and common comorbid medical issues, first-line treatments should be nonpharmacological, including bathroom alarms, voiding before bedtime, and nocturnal fluid restriction. If these interventions do not provide adequate relief, aripiprazole should be trialed. Desmopressin may be considered for severe refractory cases, but monitoring for hyponatremia is essential.
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Affiliation(s)
- Timothy Tanzer
- Department of Pharmacy, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - Nicola Warren
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Queensland, Australia
| | - Laura McMahon
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Michael Barras
- Department of Pharmacy, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - Steve Kisely
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Queensland, Australia
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Emily Brooks
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Emily Wong
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Dan Siskind
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Queensland, Australia
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Abstract
BACKGROUND Valproic acid (VPA) is frequently used with clozapine (CLZ) as mood stabilizer and/or seizure prophylaxis. Valproic acid is known to reduce N-desmethylclozapine (N-DMC) but not CLZ levels. This leads to the hypothesis that VPA induces the CLZ metabolism via non-N-desmethylation pathways. Therefore, we aimed to investigate the effect of concurrent VPA use on the serum concentrations of a spectrum of CLZ metabolites in patients, adjusting for smoking. METHODS In total, 288 patients with an overall number of 737 serum concentration measurements of CLZ and metabolites concurrently using VPA (cases, n = 22) or no interacting drugs (controls, n = 266) were included from a routine therapeutic drug monitoring service. Linear mixed model analyses were performed to compare the dose-adjusted concentrations (C/D) of CLZ, N-DMC, CLZ 5N/N+-glucuronides, and metabolite-to-parent ratios in cases versus controls. RESULTS After adjusting for covariates, the N-DMC (-40%, P < 0.001) and N+-glucuronide C/Ds (-78%, P < 0.001) were reduced in cases versus controls, while the CLZ C/D was unchanged (P > 0.7). In contrast, the 5N-glucuronide C/D (+250%, P < 0.001) and 5N-glucuronide-to-CLZ ratios (+120%, P = 0.01) were increased in cases versus controls. CONCLUSIONS Our findings show that complex changes in CLZ metabolism underly the pharmacokinetic interaction with VPA. The lower levels of N-DMC seem to be caused by VPA-mediated induction of CLZ 5N-glucuronide formation, subsequently leading to reduced substrate availability for N-desmethylation. Whether the changes in CLZ metabolism caused by VPA affects the clinical outcome warrants further investigation.
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Safety profile of clozapine: Analysis using national registry data in Japan. J Psychiatr Res 2021; 141:116-123. [PMID: 34192602 DOI: 10.1016/j.jpsychires.2021.06.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 02/05/2023]
Abstract
Clozapine is the only effective antipsychotic drug used for the treatment of treatment-resistant schizophrenia. Although it has been shown that the frequency of clozapine use is very low in Japan, our previous study revealed that the number of clozapine prescriptions has been increasing in recent years, and that risk factors leading to discontinuation of clozapine were also identified as age ≥40 years, poor tolerability to olanzapine, previous treatment with clozapine, and white blood cell count <6000/mm3. The main cause for discontinuation of clozapine is the occurrence of a wide range of adverse events, including neutropenia/leukopenia and fatal cardiac disorders. In this study, we analyzed the physical details and backgrounds of patients with adverse events that led to clozapine discontinuation using a national registry database of more than 8000 Japanese patients. The physical adverse events that led to discontinuation of clozapine were neutropenia/leukopenia, glucose intolerance, cardiac disorders, gastrointestinal disorders, neuroleptic malignant syndrome, pleurisy, pulmonary embolism, sedation/somnolence, and seizures. Neutropenia/leukopenia had the highest incidence (5.0%). Neutropenia/leukopenia and cardiac disorders tended to occur early in the treatment period, indicating the need for careful monitoring for these adverse events in the early stages of clozapine treatment. Gastrointestinal disorders occurred over a long period of time, suggesting the need for careful observation during the maintenance period. The data obtained in our study will lead to the optimal and safe use of clozapine treatment.
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The Effect of Clozapine on Self-reported Duration of Sleep and Its Interaction With 23 Other Medications: A 5-Year Naturalistic Study. J Clin Psychopharmacol 2021; 41:534-539. [PMID: 34519455 DOI: 10.1097/jcp.0000000000001432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sedation is a common and incapacitating clozapine adverse effect, but the factors associated with sedation and its pharmacological management remain poorly studied. METHODS We conducted a retrospective cohort study based on deidentified electronic clinical records of clozapine-treated patients from the secondary mental health care provider for Cambridgeshire and Peterborough, United Kingdom. We first evaluated cross-sectionally the influence of clozapine dose, clozapine, and norclozapine plasma levels on self-reported hours slept, as a proxy for sedation, using bivariate correlation and then the longitudinal effect of changes in clozapine dose and other 23 medications using linear mixed effect models. We followed 241 clozapine-treated patients for 56 months on average, with 2237 face-to-face assessments in total. RESULTS Patients slept for a mean of 9.35 h/d, with 46% reporting 10 h/d or more. Cross-sectionally, sleep duration did not correlate with clozapine dose (r = 0.14, P = 0.106), but with clozapine plasma levels (r = 0.38, P < 0.0001) and norclozapine plasma levels (r = 0.25, P = 0.005). Longitudinally, the final mixed-effects model revealed 4 pharmacological variables that had a significant impact on hours slept: clozapine, risperidone augmentation, and atenolol were associated with increased sleep, whereas aripiprazole augmentation was associated with decreased sleep. We found that 20 other psychotropic medications measured were not associated with changes in sleep when added to clozapine. Excess sleep is a clozapine level-dependent adverse effect. CONCLUSIONS The impact of different augmentation strategies might help clinicians decide on the most adequate strategy, albeit further studies should confirm our results.
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Reeve S, Sheaves B, Freeman D. Excessive sleepiness in patients with psychosis: An initial investigation. PLoS One 2021; 16:e0245301. [PMID: 33449971 PMCID: PMC7810297 DOI: 10.1371/journal.pone.0245301] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/24/2020] [Indexed: 01/26/2023] Open
Abstract
Clinical experience indicates that excessive sleepiness and hypersomnia may be a common issue for patients with psychosis. Excessive sleepiness is typically ascribed to the sedating effects of antipsychotic medications but there may be other potential contributors such as sleep disorders and depression. Furthermore, the impact of excessive sleepiness itself on patients' symptoms and general wellbeing is yet to be examined. The current study reports an exploratory cross-sectional between-groups comparison of patients with early psychosis fulfilling criteria assessed in a diagnostic interview for problematic excessive sleepiness (n = 14), compared with those not reporting excessive sleepiness (n = 46). There were no differences between the groups in diagnosis, medication type, or antipsychotic medication dosage. There were no significant group differences in sleep duration. Significantly lower activity levels were found in the excessive sleepiness group. Insomnia and nightmares were common in those reporting excessive sleepiness. No significant differences were found in psychiatric symptoms, although data did indicate more severe cognitive disorganisation and grandiosity, but less severe paranoia and hallucinations, in the excessive sleepiness group. Wide confidence intervals and small sample size mean that care should be taken interpreting these results. Overall, this study indicates that excessive sleepiness may not be solely related to medication but also to low levels of activity and other sleep disorders. This is a novel finding that, if replicated, could indicate routes of intervention for this clinical issue. Future research should aim to disentangle directions of effect amongst sleepiness, mood, activity, and psychotic symptoms and investigate possible interventions for excessive sleepiness in psychosis.
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Affiliation(s)
- Sarah Reeve
- Department of Clinical, Educational, and Health Psychology, University College London, London, United Kingdom
| | - Bryony Sheaves
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
| | - Daniel Freeman
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
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Nomura N, Kitagawa K, So R, Misawa F, Kodama M, Takeuchi H, Bies R, Straubinger T, Banker C, Mizuno Y, Mimura M, Uchida H. Comprehensive assessment of exposure to clozapine in association with side effects among patients with treatment-resistant schizophrenia: a population pharmacokinetic study. Ther Adv Psychopharmacol 2021; 11:20451253211016189. [PMID: 34046160 PMCID: PMC8138292 DOI: 10.1177/20451253211016189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/20/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There have been scarce data on the distribution of clozapine concentrations in comparison with the recommended range (350-600 ng/ml) or their relationship with side effects among patients with treatment-resistant schizophrenia. Furthermore, no studies have assessed the association between side effects and overall exposure to the drug by calculating the 24-h area-under-curve (AUC). METHODS In- and outpatients with schizophrenia or schizoaffective disorder (ICD-10) who were receiving a stable dose of clozapine for ⩾2 weeks were included. Side effects were assessed using the Glasgow antipsychotic side-effects scale for clozapine (GASS-C). Using two collected plasma samples, plasma clozapine and norclozapine concentrations at peak and trough and their 24-h AUC were estimated using population pharmacokinetic models. RESULTS A total of 108 patients completed the study (mean ± SD age, 43.0 ± 10.1 years; clozapine dose, 357.5 ± 136.9 mg/day); 33 patients (30.6%) showed estimated trough concentrations of clozapine within the recommended range (350-600 ng/ml) whereas the concentrations were higher and lower than this range among 37 (43.5%) and 28 (25.9%) patients (%), respectively. There were no significant correlations between estimated peak or trough concentrations or 24-h AUC of both clozapine or norclozapine, and GASS-C total or individual scores. No significant differences were found between GASS-C total or individual item scores between the patients with estimated trough concentrations of clozapine of >600 ng/ml and the other subjects. CONCLUSION The results suggest that clozapine or norclozapine concentrations are not linked directly to the extent of side effects experienced in clozapine-treated patients with treatment-resistant schizophrenia while the cross-sectional study design limits the interpretation of any causal relationships. These findings indicate that side effects associated with clozapine may occur at any dose or concentration.
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Affiliation(s)
- Nobuyuki Nomura
- Department of Neuropsychiatry, Yamanashi Prefectural Kita Hospital, Yamanashi, Japan
| | - Kohei Kitagawa
- Department of Neuropsychiatry, Okayama Psychiatric Medical Center, 3-16, Shikatahonmachi, Kita-ku, Okayama-shi, Okayama, 700-0915, Japan
| | - Ryuhei So
- Department of Neuropsychiatry, Okayama Psychiatric Medical Center, 3-16, Shikatahonmachi, Kita-ku, Okayama-shi, Okayama, 700-0915, Japan
| | - Fuminari Misawa
- Department of Neuropsychiatry, Yamanashi Prefectural Kita Hospital, Yamanashi, Japan
| | - Masafumi Kodama
- Department of Neuropsychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Yamanashi Prefectural Kita Hospital, Yamanashi, Japan
| | - Robert Bies
- Department of Pharmaceutical Sciences, University at Buffalo, New York, USA
| | - Thomas Straubinger
- Department of Pharmaceutical Sciences, University at Buffalo, New York, USA
| | - Christopher Banker
- Department of Pharmaceutical Sciences, University at Buffalo, New York, USA
| | - Yuya Mizuno
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Liao IM, Chen JC. Lack of dopamine D4 receptor participation in mouse hyperdopaminergic locomotor response. Behav Brain Res 2020; 396:112925. [PMID: 32971195 DOI: 10.1016/j.bbr.2020.112925] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/26/2020] [Accepted: 09/17/2020] [Indexed: 12/21/2022]
Abstract
Chronic methamphetamine (METH) treatment induces behavioral sensitization in rodents. During this process, hyperactivation of the mesolimbic dopamine system plays a central role, and dopamine D2-like receptor-based antipsychotics are known to alleviate the behavioral hyperactivity. The atypical antipsychotic, clozapine (Clz), acts partially as a dopamine D4 receptor (D4R) antagonist and mitigates hyperdopaminergic drug addiction and/or comorbid psychotic symptoms; however, it remains unclear whether D4R blockade contributes to the therapeutic effects of Clz. Here, we evaluated the potential role of D4R in regulating hyperdopaminergia-induced behavioral hyperactivity in METH behavioral sensitization and dopamine transporter (DAT) knockdown (KD) mice. Clz or a D4R-selective antagonist, L-745,870, were co-administered to mice with daily METH in a METH sensitization model, and Clz or L-745,870 were administered alone in a DAT KD hyperactivity model. Locomotor activity and accumbal D4R expression were analyzed. Clz suppressed both the initiation and expression of METH behavioral sensitization, as well as DAT KD hyperactivity. However, repetitive Clz treatment induced tolerance to the suppression effect on METH sensitization initiation. In contrast, D4R inhibition by L-745,870 had no effect on METH sensitization or DAT KD hyperactivity. Accumbal D4R expression was similar between METH-sensitized mice with and without Clz co-treatment. In sum, our results suggest the mesolimbic D4R does not participate in behavioral sensitization encoded by hyperdopaminergia, a finding which likely extends to the therapeutic effects of Clz. Therefore, molecular targets other than D4R should be prioritized in the development of future therapeutics for treatment of hyperdopaminergia-dependent neuropsychiatric disorders.
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Affiliation(s)
- I-Mei Liao
- Department of Physiology and Pharmacology, Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Neuroscience, Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, 75390-9111, United States
| | - Jin-Chung Chen
- Department of Physiology and Pharmacology, Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Chang Gung Memorial Hospital, Keelung, Taiwan; Healthy Ageing Research Center, Chang Gung University, Taoyuan, Taiwan; Neuroscience Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan.
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Dal Santo F, Jarratt-Barnham I, González-Blanco L, García-Portilla MP, Bobes J, Fernández-Egea E. Longitudinal effects of clozapine concentration and clozapine to N-desmethylclozapine ratio on cognition: A mediation model. Eur Neuropsychopharmacol 2020; 33:158-163. [PMID: 32057590 DOI: 10.1016/j.euroneuro.2020.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 01/08/2020] [Accepted: 01/26/2020] [Indexed: 11/20/2022]
Abstract
Previous cross-sectional studies have found clozapine to N-desmethylclozapine (CLZ:NDMC) ratio to be negatively correlated with cognition in clozapine-treated patients with schizophrenia. However, no work has examined the association between CLZ:NDMC ratio and cognition using a within-subjects design. Here, we investigate the longitudinal effects of changes in the clozapine load and the CLZ:NDMC ratio on cognition whilst controlling for a range of independent factors. We analyzed data from a cohort of seventeen clozapine-treated patients who have been repeatedly assessed with the Brief Assessment of Cognition for Schizophrenia (BACS). The Positive symptoms sub-score of the Clinical Global Impression for Schizophrenia (CGI-P) was used to assess severity of psychosis. Blood samples were collected to measure the plasmatic levels of clozapine (CLZ) and of N-desmethylclozapine, allowing calculation of the CLZ:NDMC ratio. Our analyses included bivariate and partial correlations, along with a mediation model analysis. We found that both plasmatic levels of CLZ and the CLZ:NDMC ratio were negatively correlated with cognitive performance, and that these associations were independent of changes in both daily clozapine dose and severity of psychotic symptoms. Mediation analyses further revealed the association between CLZ concentration and cognition to be partially mediated by changes in the CLZ:NDMC ratio. This is the first longitudinal analysis of the influence of CLZ concentration and CLZ:NDMC ratio on cognition. Our findings suggest that reduction of CLZ concentration and the CLZ:NDMC ratio might favorably affect cognition. Thus, the CLZ:NDMC ratio may represent a promising target for novel therapeutic strategies aiming to ameliorate cognitive impairment in clozapine-treated patients.
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Affiliation(s)
- Francesco Dal Santo
- Servicio de Salud del Principado de Asturias (SESPA), Oviedo, Spain; Área de Psiquiatría, Universidad de Oviedo, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Instituto de Neurociencias del Principado de Asturias (INEUROPA), Oviedo, Spain; Department of Psychiatry and Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK
| | - Isaac Jarratt-Barnham
- Department of Psychiatry and Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK
| | - Leticia González-Blanco
- Servicio de Salud del Principado de Asturias (SESPA), Oviedo, Spain; Área de Psiquiatría, Universidad de Oviedo, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Instituto de Neurociencias del Principado de Asturias (INEUROPA), Oviedo, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - María Paz García-Portilla
- Servicio de Salud del Principado de Asturias (SESPA), Oviedo, Spain; Área de Psiquiatría, Universidad de Oviedo, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Instituto de Neurociencias del Principado de Asturias (INEUROPA), Oviedo, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - Julio Bobes
- Servicio de Salud del Principado de Asturias (SESPA), Oviedo, Spain; Área de Psiquiatría, Universidad de Oviedo, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Instituto de Neurociencias del Principado de Asturias (INEUROPA), Oviedo, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - Emilio Fernández-Egea
- Department of Psychiatry and Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK; Cambridgeshire and Peterborough NHS Foundation Trust, 128 Tenison Road, CB1 2DP Cambridge, UK.
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Abstract
OBJECTIVE Clozapine is the only approved strategy for treatment-resistant schizophrenia, although it is highly underutilized. We aim to generate practical and actionable evidence-based recommendations for the use of this drug considering prescription barriers. METHOD Narrative review. RESULTS A consistent body of evidence supports the efficacy of clozapine reducing morbidity and mortality in schizophrenia. The main obstacles to its use are the lack of experience by prescribers and perceived treatment burden. Systematic screening of eligibility, utilization of available resources for consultation, developing a professional network with other stakeholders, as well as optimizing how clozapine is presented to patients is discussed. Furthermore, specific evidence-based recommendations for initiation, maintenance, and safety monitoring with clozapine are provided. CONCLUSION Clozapine prescription is one of the areas in psychiatry with the greatest mismatch between efficacy and utilization in clinical practice. Although multiple barriers to the use of clozapine exist, some of these may be overcome by updates of routine clinical practice.
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Affiliation(s)
- J M Rubio
- Donald and Barbara Zucker School of Medicine, Hofstra/Northwell, Glen Oaks, NY, USA.,Feinstein Institute for Medical Research, Northwell Health, Glen Oaks, NY, USA.,The Zucker Hillside Hospital - Northwell Health, Glen Oaks, NY, USA
| | - J M Kane
- Donald and Barbara Zucker School of Medicine, Hofstra/Northwell, Glen Oaks, NY, USA.,Feinstein Institute for Medical Research, Northwell Health, Glen Oaks, NY, USA.,The Zucker Hillside Hospital - Northwell Health, Glen Oaks, NY, USA
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15
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Shukla RP, Ben‐Yoav H. A Chitosan-Carbon Nanotube-Modified Microelectrode for In Situ Detection of Blood Levels of the Antipsychotic Clozapine in a Finger-Pricked Sample Volume. Adv Healthc Mater 2019; 8:e1900462. [PMID: 31240866 DOI: 10.1002/adhm.201900462] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/07/2019] [Indexed: 01/06/2023]
Abstract
The antipsychotic clozapine is the most effective medication available for schizophrenia and it is the only antipsychotic with a known efficacious clinical range. However, it is dramatically underutilized due to the inability to test clozapine blood levels in finger-pricked patients' samples. This prevents obtaining immediate blood levels information, resulting in suboptimal treatment. The development of an electrochemical microsensor is presented, which enables, for the first time, clozapine detection in microliters volume whole blood. The sensor is based on a microelectrode modified with micrometer-thick biopolymer chitosan encapsulating carbon nanotubes. The developed sensor detects clozapine oxidation current, in the presence of other electroactive species in the blood, which generate overlapping electrochemical signals. Clozapine detection, characterized in whole blood from healthy volunteers, displays a sensitivity of 32 ± 3.0 µA cm-2 µmol-1 L and a limit-of-detection of 0.5 ± 0.03 µmol L-1 . Finally, the developed sensor displays a reproducible electrochemical signal (0.6% relative standard deviation) and high storage stability (9.8% relative standard deviation after 8 days) in serum samples and high repeatability (9% relative standard deviation for the 5th repetition) in whole blood samples. By enabling the rapid and minimally invasive clozapine detection at the point-of-care, an optimal schizophrenia treatment is provided.
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Affiliation(s)
- Rajendra P. Shukla
- Nanobioelectronics LaboratoryDepartment of Biomedical EngineeringBen‐Gurion University of the Negev Beer‐Sheva 8410501 Israel
| | - Hadar Ben‐Yoav
- Nanobioelectronics LaboratoryDepartment of Biomedical EngineeringBen‐Gurion University of the Negev Beer‐Sheva 8410501 Israel
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16
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Pardiñas AF, Nalmpanti M, Pocklington AJ, Legge SE, Medway C, King A, Jansen J, Helthuis M, Zammit S, MacCabe J, Owen MJ, O'Donovan MC, Walters JTR. Pharmacogenomic Variants and Drug Interactions Identified Through the Genetic Analysis of Clozapine Metabolism. Am J Psychiatry 2019; 176:477-486. [PMID: 30922102 DOI: 10.1176/appi.ajp.2019.18050589] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Clozapine is the only effective medication for treatment-resistant schizophrenia, but its worldwide use is still limited because of its complex titration protocols. While the discovery of pharmacogenomic variants of clozapine metabolism may improve clinical management, no robust findings have yet been reported. This study is the first to adopt the framework of genome-wide association studies (GWASs) to discover genetic markers of clozapine plasma concentrations in a large sample of patients with treatment-resistant schizophrenia. METHODS The authors used mixed-model regression to combine data from multiple assays of clozapine metabolite plasma concentrations from a clozapine monitoring service and carried out a genome-wide analysis of clozapine, norclozapine, and their ratio on 10,353 assays from 2,989 individuals. These analyses were adjusted for demographic factors known to influence clozapine metabolism, although it was not possible to adjust for all potential mediators given the available data. GWAS results were used to pinpoint specific enzymes and metabolic pathways and compounds that might interact with clozapine pharmacokinetics. RESULTS The authors identified four distinct genome-wide significant loci that harbor common variants affecting the metabolism of clozapine or its metabolites. Detailed examination pointed to coding and regulatory variants at several CYP* and UGT* genes as well as corroborative evidence for interactions between the metabolism of clozapine, coffee, and tobacco. Individual effects of single single-nucleotide polymorphisms (SNPs) fine-mapped from these loci were large, such as the minor allele of rs2472297, which was associated with a reduction in clozapine concentrations roughly equivalent to a decrease of 50 mg/day in clozapine dosage. On their own, these single SNPs explained from 1.15% to 9.48% of the variance in the plasma concentration data. CONCLUSIONS Common genetic variants with large effects on clozapine metabolism exist and can be found via genome-wide approaches. Their identification opens the way for clinical studies assessing the use of pharmacogenomics in the clinical management of patients with treatment-resistant schizophrenia.
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Affiliation(s)
- Antonio F Pardiñas
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Mariana Nalmpanti
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Andrew J Pocklington
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Sophie E Legge
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Christopher Medway
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Adrian King
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - John Jansen
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Marinka Helthuis
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Stanley Zammit
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - James MacCabe
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Michael J Owen
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - Michael C O'Donovan
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
| | - James T R Walters
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, Wales (Pardiñas, Nalmpanti, Pocklington, Legge, Medway, Zammit, Owen, O'Donovan, Walters); Magna Laboratories, Ross-on-Wye, U.K. (King); Leyden Delta, Nijmegen, the Netherlands (Jansen, Helthuis); the Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K. (Zammit); the National Institute for Health Research, Biomedical Research Centre, University of Bristol, Bristol, U.K. (Zammit); and the Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (MacCabe)
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Schoretsanitis G, Kane JM, Ruan CJ, Spina E, Hiemke C, de Leon J. A comprehensive review of the clinical utility of and a combined analysis of the clozapine/norclozapine ratio in therapeutic drug monitoring for adult patients. Expert Rev Clin Pharmacol 2019; 12:603-621. [DOI: 10.1080/17512433.2019.1617695] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Georgios Schoretsanitis
- Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Hofstra Northwell School of Medicine, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - John M. Kane
- Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Hofstra Northwell School of Medicine, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology & The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Mainz, Germany
| | - Jose de Leon
- University of Kentucky Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA
- Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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18
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Fernandez-Egea E, Worbe Y, Bernardo M, Robbins TW. Distinct risk factors for obsessive and compulsive symptoms in chronic schizophrenia. Psychol Med 2018; 48:2668-2675. [PMID: 29455687 PMCID: PMC6236440 DOI: 10.1017/s003329171800017x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 12/17/2017] [Accepted: 01/11/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Obsessive-compulsive disorder (OCD) is common in clozapine-treated patients although the actual prevalence, phenomenology and risk factors remain unclear. The aim of the present study was to address the three aforementioned questions. METHODS The electronic records of a large cohort of clozapine-medicated schizophrenia patients routinely screened for OCD were used. The Obsessive Compulsive Inventory Revised version (OCI-R) was available from 118 cases and a 21 points cut-off threshold for OCD was defined. RESULTS OCD prevalence was 47%, higher in patients on poly-pharmacy than on monotherapy (64% vs 31%; p = 0.001). Two OCI-R factors had significantly higher scores and distinct risk factors: checking behaviour (mean = 5.1; SD = 3.6) correlated with length of clozapine treatment (r = 0.21; p = 0.026), and obsessing factor (mean = 4.8; SD = 3.6) correlated with psychosis severity (r = 0.59; p = 0.001). These factors along with total OCI-R, did not correlate with either clozapine dose or plasma levels, after correcting for psychosis severity. CONCLUSIONS Screening for OCD in clozapine patients, and probably in those treated with structurally similar drugs with potent antiserotoninergic properties, should be widely adopted by clinicians. Further research is needed to understand the pathophysiology underlying repetitive behavior onset in clozapine-treated patients.
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Affiliation(s)
- Emilio Fernandez-Egea
- Clozapine Clinic, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
- Department of Psychiatry, University of Cambridge, Cambridge, UK
- Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - Yulia Worbe
- Sorbonne Université, 75005 Paris, France; Department of Physiology, Neurophysiology Unit, Hospital Saint-Antoine, Paris, France; Institute du Cerveau et de Moelle Epigniere, Paris, France
| | - Miguel Bernardo
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
- Barcelona Clinic Schizophrenia Unit, Neuroscience Institute, Hospital Clinic of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Psychiatry, University of Barcelona, Barcelona, Spain
| | - Trevor W. Robbins
- Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK
- Department of Psychology, University of Cambridge, Cambridge, UK
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19
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Lee H, Scolieri BB, Mullick PK. Learned lessons from patients who take clozapine: A case study. Perspect Psychiatr Care 2018; 54:457-461. [PMID: 28926097 DOI: 10.1111/ppc.12245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 08/08/2017] [Accepted: 09/03/2017] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The purpose of this report is to provide clinical strategies to manage patients with schizophrenia taking clozapine. CONCLUSIONS Serious side effects and required blood monitoring impede the use of clozapine, despite the benefits of clozapine for managing psychiatric symptoms. Well-managed patients receiving evidence-based interventions exhibit reduced symptoms, improved functioning, and better adherence to treatment. PRACTICE IMPLICATIONS Preexisting medical conditions should be considered before prescribing clozapine. Ongoing education on medication and mental illness for patients and family members is essential to prepare them for adherence to management plans. Healthcare providers are responsible for monitoring the side effects of clozapine.
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Affiliation(s)
- Heeyoung Lee
- Department of Health and Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Britney B Scolieri
- Department of Health and Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Prabir K Mullick
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,P.K. Mullick MD & Associates PC, Pittsburgh, Pennsylvania, USA
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20
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De Berardis D, Rapini G, Olivieri L, Di Nicola D, Tomasetti C, Valchera A, Fornaro M, Di Fabio F, Perna G, Di Nicola M, Serafini G, Carano A, Pompili M, Vellante F, Orsolini L, Martinotti G, Di Giannantonio M. Safety of antipsychotics for the treatment of schizophrenia: a focus on the adverse effects of clozapine. Ther Adv Drug Saf 2018; 9:237-256. [PMID: 29796248 PMCID: PMC5956953 DOI: 10.1177/2042098618756261] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/10/2018] [Indexed: 12/15/2022] Open
Abstract
Clozapine, a dibenzodiazepine developed in 1961, is a multireceptorial atypical antipsychotic approved for the treatment of resistant schizophrenia. Since its introduction, it has remained the drug of choice in treatment-resistant schizophrenia, despite a wide range of adverse effects, as it is a very effective drug in everyday clinical practice. However, clozapine is not considered as a top-of-the-line treatment because it may often be difficult for some patients to tolerate as some adverse effects can be particularly bothersome (i.e. sedation, weight gain, sialorrhea etc.) and it has some other potentially dangerous and life-threatening side effects (i.e. myocarditis, seizures, agranulocytosis or granulocytopenia, gastrointestinal hypomotility etc.). As poor treatment adherence in patients with resistant schizophrenia may increase the risk of a psychotic relapse, which may further lead to impaired social and cognitive functioning, psychiatric hospitalizations and increased treatment costs, clozapine adverse effects are a common reason for discontinuing this medication. Therefore, every effort should be made to monitor and minimize these adverse effects in order to improve their early detection and management. The aim of this paper is to briefly summarize and provide an update on major clozapine adverse effects, especially focusing on those that are severe and potentially life threatening, even if most of the latter are relatively uncommon.
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Affiliation(s)
- Domenico De Berardis
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, p.zza Italia 1, 64100 Teramo, Italy
| | - Gabriella Rapini
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, Teramo, Italy
| | - Luigi Olivieri
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, Teramo, Italy
| | - Domenico Di Nicola
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, Teramo, Italy
| | - Carmine Tomasetti
- Polyedra Research Group, Teramo, Italy Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine ‘Federico II’ Naples, Naples, Italy
| | - Alessandro Valchera
- Polyedra Research Group, Teramo, Italy Villa S. Giuseppe Hospital, Hermanas Hospitalarias, Ascoli Piceno, Italy
| | - Michele Fornaro
- Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine ‘Federico II’ Naples, Naples, Italy
| | - Fabio Di Fabio
- Polyedra Research Group, Teramo, Italy Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Giampaolo Perna
- Hermanas Hospitalarias, FoRiPsi, Department of Clinical Neurosciences, Villa San Benedetto Menni, Albese con Cassano, Como, Italy Department of Psychiatry and Neuropsychology, University of Maastricht, Maastricht, The Netherlands Department of Psychiatry and Behavioral Sciences, Leonard Miller School of Medicine, University of Miami, Florida, USA
| | - Marco Di Nicola
- Institute of Psychiatry and Psychology, Catholic University of Sacred Heart, Rome, Italy
| | - Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy
| | - Alessandro Carano
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, Hospital ‘Madonna Del Soccorso’, San Benedetto del Tronto, Italy
| | - Maurizio Pompili
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Federica Vellante
- Department of Neuroscience, Imaging and Clinical Science, Chair of Psychiatry, University ‘G. D’Annunzio’, Chieti, Italy
| | - Laura Orsolini
- Polyedra Research Group, Teramo, Italy Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Herts, UK
| | - Giovanni Martinotti
- Department of Neuroscience, Imaging and Clinical Science, Chair of Psychiatry, University ‘G. D’Annunzio’, Chieti, Italy
| | - Massimo Di Giannantonio
- Department of Neuroscience, Imaging and Clinical Science, Chair of Psychiatry, University ‘G. D’Annunzio’, Chieti, Italy
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Maurice-Gélinas C, Deslauriers J, Monpays C, Sarret P, Grignon S. The 5α-reductase inhibitor finasteride increases suicide-related aggressive behaviors and blocks clozapine-induced beneficial effects in an animal model of schizophrenia. Physiol Behav 2018; 191:65-72. [PMID: 29630964 DOI: 10.1016/j.physbeh.2018.03.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 03/14/2018] [Accepted: 03/29/2018] [Indexed: 11/28/2022]
Abstract
Death by suicide is 5 times higher among schizophrenia patients than in the general population. There is now compelling evidence suggesting that the pathophysiology of suicide in schizophrenia does not involve central serotonergic neurotransmission disturbances, as has been shown in other contexts. We recently developed and characterized a murine Two-Hit Model of Suicide-related behavior in a schizophrenia-like context (THMS) (gestational inflammation with polyI:C at gestational day 12 followed by post-weaning social isolation). In this THMS model, we have recently shown that the atypical antipsychotic clozapine normalized the prepulse inhibition (PPI) deficits as well suicide-related, impulsive aggressive and anxiety-like behaviors. While the mechanisms underlying the suicide-reducing benefits of clozapine in schizophrenic patients are not well understood, previous works have revealed that clozapine alters brain levels of neurosteroids, such as allopregnanolone. In the present study, we thus investigated the role of endogenous neurosteroids in clozapine action by evaluating whether the 5α-reductase inhibitor finasteride could overturn the ability of clozapine to reduce suicide-related behaviors. We found that clozapine significantly improved the PPI deficits in THMS mice, which could not be reversed by finasteride treatment. However, finasteride counteracted the ability of clozapine to decrease the exploratory behaviors in the open-field test. In the resident-intruder test, THMS mice showed exacerbated aggressiveness and impulsivity following finasteride alone. In this resident-intruder paradigm, clozapine alone effectively blocked the finasteride-enhanced effects on aggression and impulsivity. Altogether, these findings support the existence of a complex interaction between clozapine and neurosteroids in THMS mice. Further investigations are now required to clarify the details of the molecular mechanisms involved.
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Affiliation(s)
- Caroline Maurice-Gélinas
- Departement of Pharmacology and Physiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e avenue Nord, Sherbrooke, QC J1H 5N4, Canada
| | - Jessica Deslauriers
- Department of Psychiatry, University of California San Diego, La Jolla, CA, United States; Center of Excellence for Stress and Mental Health, Veterans Affairs Hospital, La Jolla, CA, United States
| | - Cécile Monpays
- Departement of Pharmacology and Physiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e avenue Nord, Sherbrooke, QC J1H 5N4, Canada
| | - Philippe Sarret
- Departement of Pharmacology and Physiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e avenue Nord, Sherbrooke, QC J1H 5N4, Canada
| | - Sylvain Grignon
- Departement of Pharmacology and Physiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e avenue Nord, Sherbrooke, QC J1H 5N4, Canada; Department of Psychiatry, Centre Hospitalier Universitaire de Sherbrooke, 580 Bowen Sud, Sherbrooke, QC J1G 2E8, Canada.
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Abstract
BACKGROUND Despite being a very effective treatment for resistant schizophrenia and bipolar disorder, use of clozapine is limited by adverse effects. Constipation is a common but potentially life-threatening adverse effect of clozapine that is understudied. The objective was to study the prevalence and factors associated with constipation in those receiving clozapine compared with control subjects. METHODS Fifty patients in age group of 18 to 55 years receiving clozapine were compared with 50 patients in the same age group receiving medications other than clozapine. Presence of constipation was ascertained using the World Gastroenterology Organization Practice Guidelines definition. The severity of constipation was assessed using Constipation Assessment Scale and Bristol Stool Form Scale, and anticholinergic burden was assessed using Anticholinergic Burden Scale. RESULTS Among clozapine-treated patients, 28 (56%) had constipation as compared with 11 (22%) in the control subjects (P < 0.001); the odds of developing constipation was 4.5 (95% confidence interval, 1.9-10.8). Kaplan-Meier survival analysis showed median time to onset of constipation in clozapine-treated patients was 60 days (SE, 13.1 days; 95% confidence interval, 34.3-85.7 days) and median dose of clozapine was 300 mg/d (interquartile range, 312 mg/d). Clozapine group had high Constipation Assessment Scale scores (P = 0.005, Cohen d = 1.17) and higher prevalence of types 1 and 2 Bristol stool types (Fisher exact P = 0.005, Cramer V = 0.59). CONCLUSIONS Constipation was prevalent in more than half of patients receiving clozapine, which was severe and took longer time for recovery. Limitations include using a hospital-based sample and that dietary habits and lifestyle factors were not studied.
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