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Suzuki Y, Watanabe K, Kanno-Nozaki K, Horikoshi S, Ichinose M, Hirata Y, Kobayashi Y, Takeuchi S, Osonoe K, Hoshino S, Miura I. Factors associated with cognitive dysfunction in treatment-responsive and -resistant schizophrenia: A pilot cross-sectional study. J Psychiatr Res 2024; 178:228-235. [PMID: 39163661 DOI: 10.1016/j.jpsychires.2024.08.012] [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: 04/26/2024] [Revised: 06/25/2024] [Accepted: 08/06/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Cognitive dysfunction is a core feature of schizophrenia. Although treatment-resistant schizophrenia (TRS) exhibits wide-ranging neuropsychological deficits, factors defining cognitive prognosis in TRS are unclear. We aimed to clarify the association between cognitive dysfunction and factors, such as plasma concentrations of clozapine (CLZ), N-desmethylclozapine (NDMC), and homovanillic acid (HVA), due to differences in antipsychotic responses in patients with schizophrenia. METHODS This pilot cross-sectional study included 60 Japanese patients (35 with TRS and 25 with non-CLZ antipsychotic responders (AR)). Cognitive function was evaluated using the Brief Assessment of Cognition Short Form (BAC-SF). Plasma concentrations of HVA, CLZ, and NDMC were analyzed by high-performance liquid chromatography. RESULTS The cognitive performance of patients with AR was better than that of patients with TRS in all tasks. No significant cognitive differences were detected between the CLZ responders and non-responders. The severity of negative and extrapyramidal symptoms was found to be potentially negatively associated with BAC-SF composite and several subtest scores. In patients with TRS, chlorpromazine equivalents and the CLZ/NDMC ratio were identified as factors negatively associated with Digit Sequencing and the Symbol Coding subtest scores of the BAC-SF, respectively. CONCLUSIONS Our study suggests that patients with TRS experience worse cognitive dysfunction than those with AR, and CLZ responsiveness in TRS may be not associated with cognitive dysfunction. Additionally, higher chlorpromazine equivalents and the CLZ/NDMC ratio may be associated with severity of cognitive dysfunction in patients with TRS. Further studies are required to clarify the relationship between treatment response and cognitive dysfunction in schizophrenia.
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Affiliation(s)
- Yuhei Suzuki
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kenya Watanabe
- Department of Pharmacy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Keiko Kanno-Nozaki
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Sho Horikoshi
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan; Department of Psychiatry, Horikoshi Psychosomatic Clinic, Fukushima, Japan
| | - Mizue Ichinose
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan; Department of Neuropsychiatry, Hoshigaoka Hospital, Koriyama, Japan
| | - Yoichiro Hirata
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan; Department of Psychiatry, Itakura Hospital, Fukushima, Japan
| | - Yuri Kobayashi
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Satoshi Takeuchi
- Department of Neuropsychiatry, Hoshigaoka Hospital, Koriyama, Japan
| | - Kouichi Osonoe
- Department of Psychiatry, Takeda General Hospital, Aizuwakamatsu, Japan
| | - Shuzo Hoshino
- Department of Psychiatry, Takeda General Hospital, Aizuwakamatsu, Japan
| | - Itaru Miura
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan.
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Mach A, Wnorowska A, Siwek M, Wojnar M, Radziwoń-Zaleska M. Clinical and pharmacological factors influencing serum clozapine and norclozapine levels. Front Pharmacol 2024; 15:1356813. [PMID: 38601469 PMCID: PMC11004283 DOI: 10.3389/fphar.2024.1356813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/15/2024] [Indexed: 04/12/2024] Open
Abstract
Background Clozapine (CLO) is a very effective antipsychotic, whose use is associated with dose-dependent risk of complications. Due to high interindividual variability in CLO metabolism, there is a need to identify factors affecting the blood concentrations of CLO and its active metabolite, norclozapine (NCLO). Methods A total of 446 blood samples (collected from 233 women and 213 men, aged from 18 to 77 years) were included in this study and analyzed for CLO and NCLO concentrations. The patients were treated at a psychiatric hospital in Warsaw in the years 2016-2021. Serum CLO and NCLO concentrations were determined with high-performance liquid chromatography coupled to UV. Results The following factors were shown to increase serum CLO and NCLO levels: higher CLO dose (p < 0.001), female sex (p < 0.001), nonsmoker status (p < 0.001), the use of more than two additional psychotropic drugs (only in the case of CLO; p = 0.046), concomitant use of beta-blockers (for CLO p = 0.049; for NCLO p < 0.001), and older age (for CLO p < 0.001; for NCLO p = 0.011). Despite the use of CLO at daily doses within the recommended range (200-450 mg), the evaluated serum CLO and NCLO levels were within the therapeutic ranges in only 37% and 75% of cases, respectively, with 5.6% of cases exceeding the CLO toxicity threshold. Discussion The use of CLO at recommended doses does not guarantee achieving therapeutic concentrations of CLO or NCLO. Women and nonsmokers were at the highest risk of having toxic CLO levels.
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Affiliation(s)
- Anna Mach
- Department of Psychiatry, Medical University of Warsaw, Warsaw, Poland
| | - Anna Wnorowska
- Department of Psychiatry, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Siwek
- Department of Affective Disorders, Jagiellonian University Medical College, Cracow, Poland
| | - Marcin Wojnar
- Department of Psychiatry, Medical University of Warsaw, Warsaw, Poland
- Department of Psychiatry, Addiction Center, University of Michigan, Ann Arbor, MI, United States
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3
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Miroshnichenko II, Baymeeva NV, Platova AI, Kaleda VG. [Therapeutic drug monitoring of antipsychotic drugs in routine psychiatric practice]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:145-152. [PMID: 37315254 DOI: 10.17116/jnevro2023123051145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To evaluate the relationship between daily doses of antipsychotic drugs, their serum concentrations, and characteristics of patients treated for schizophrenia or schizophreniform disorder in day-to-day clinical practice. MATERIAL AND METHODS A total of 187 patients were included in the study, 77 (41.1%) patients were on monotherapy, and 110 (58.9%) patients received two or more antipsychotics. Patients age was 27.8±8.1 years, and their body weight was 79.8±15.6 kg. The sample was represented mainly by young men (93.0%). The proportion of smokers was 37.4%. The appropriate HPLC-MS/MS method was used for the simultaneous analysis of 8 antipsychotics and its active metabolites. Serum concentrations of the drugs aripiprazole (ARI), chlorpromazine (CPZ), haloperidol (HAL), zuclopenthixol (ZUC), clozapine (CLO), risperidone (RIS), quetiapine (QUE), olanzapine (OLA), norclozapine (N-desmethylclozapine, NOR), 9-hydroxyrisperidone (9-OH-RIS), dehydroaripiprazole (DGA) were measured. The serum concentration/dose ratio (C/D) was employed as the primary outcome measure, as doses were not kept constant during the study. The active antipsychotic fraction (drug+active metabolite, active moiety - AM) was also evaluated for RIS and ARI. In addition, the metabolite/parent ratio (MPR) was evaluated for RIS and ARI. RESULTS A total of 265 biological samples were obtained, 421 and 203 measurements of the concentration of drugs and their metabolites were carried out, respectively. Overall, 48% of antipsychotics levels were in the expected therapeutic ranges, 30% were below therapeutic ranges, and 22% were above them. A total of 55 patients underwent dose adjustments or drug changes due to ineffectiveness or side-effects. It has been found that smoking reduces the level of C/D for CLO (p<0.01, Mann-Whitney test). We have established that comedication with CLO significantly increases the C/D ratio of QUE (p<0.05, Mann-Whitney test). We have not revealed any influence of weight and age of the subjects on the C/D. The dose-concentration regression relationships are formalized for all AP. CONCLUSION Therapeutical drug monitoring (TDM) is an essential tool to personalize antipsychotic therapy. Careful analysis of TDM data can contribute significantly to the study of the impact of individual patient characteristics on systemic exposure to these drugs.
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Affiliation(s)
| | | | - A I Platova
- Mental Health Research Center, Moscow, Russia
| | - V G Kaleda
- Mental Health Research Center, Moscow, Russia
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4
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Maroney M. Management of cognitive and negative symptoms in schizophrenia. Ment Health Clin 2022; 12:282-299. [DOI: 10.9740/mhc.2022.10.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022] Open
Abstract
Abstract
Currently available antipsychotics provide only modest benefit in managing the cognitive and negative symptoms of schizophrenia even though these symptoms are often the most impairing in patients' daily lives. Certain antipsychotics may have slight benefits over others, and several nonpharmacologic and pharmacologic adjunctive treatments have been evaluated in recent clinical trials. Recently published meta-analyses and clinical studies of such treatments are reviewed. Potential strategies to manage cognitive and negative symptoms, including deprescribing of medications that may exacerbate these symptoms, are described using theoretical case examples.
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Affiliation(s)
- Megan Maroney
- 1 (Corresponding author) Clinical Associate Professor, Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey; Clinical Psychiatric Pharmacist, Monmouth Medical Center, Long Branch, New Jersey,
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5
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Paul SM, Yohn SE, Popiolek M, Miller AC, Felder CC. Muscarinic Acetylcholine Receptor Agonists as Novel Treatments for Schizophrenia. Am J Psychiatry 2022; 179:611-627. [PMID: 35758639 DOI: 10.1176/appi.ajp.21101083] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Schizophrenia remains a challenging disease to treat effectively with current antipsychotic medications due to their limited efficacy across the entire spectrum of core symptoms as well as their often burdensome side-effect profiles and poor tolerability. An unmet need remains for novel, mechanistically unique, and better tolerated therapeutic agents for treating schizophrenia, especially those that treat not only positive symptoms but also the negative and cognitive symptoms of the disease. Almost 25 years ago, the muscarinic acetylcholine receptor (mAChR) agonist xanomeline was reported to reduce psychotic symptoms and improve cognition in patients with Alzheimer's disease. The antipsychotic and procognitive properties of xanomeline were subsequently confirmed in a small study of acutely psychotic patients with chronic schizophrenia. These unexpected clinical findings have prompted considerable efforts across academia and industry to target mAChRs as a new approach to potentially treat schizophrenia and other psychotic disorders. The authors discuss recent advances in mAChR biology and pharmacology and the current understanding of the relative roles of the various mAChR subtypes, their downstream cellular effectors, and key neural circuits mediating the reduction in the core symptoms of schizophrenia in patients treated with xanomeline. They also provide an update on the status of novel mAChR agonists currently in development for potential treatment of schizophrenia and other neuropsychiatric disorders.
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6
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Sarpal DK, Blazer A, Wilson JD, Calabro FJ, Foran W, Kahn CE, Luna B, Chengappa KNR. Relationship between plasma clozapine/N-desmethylclozapine and changes in basal forebrain-dorsolateral prefrontal cortex coupling in treatment-resistant schizophrenia. Schizophr Res 2022; 243:170-177. [PMID: 35381515 PMCID: PMC9189030 DOI: 10.1016/j.schres.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 03/07/2022] [Accepted: 03/27/2022] [Indexed: 10/18/2022]
Abstract
Clozapine (CLZ) demonstrates a unique clinical efficacy relative to other antipsychotic drugs. Previous work has linked the plasma ratio of CLZ and its major metabolite, N-desmethylclozapine (NDMC), to an inverse relationship with cognition via putative action on the cholinergic system. However, neuroimaging correlates of CLZ/NDMC remain unknown. Here, we examined changes in basal forebrain functional connectivity with the dorsolateral prefrontal cortex, and secondly, cognition in relation to the CLZ/NDMC ratio. A cohort of nineteen chronically ill participants with treatment-resistant schizophrenia (TRS) undergoing 12 weeks of CLZ treatment were included. Measures of cognition and plasma CLZ/NDMC ratios were obtained in addition to resting-state functional neuroimaging scans, captured at baseline and after 12 weeks of CLZ treatment. We observed a significant correlation between basal forebrain-DLPFC connectivity and CLZ/NDMC ratios across CLZ treatment (p = 0.02). Consistent with previous findings, we also demonstrate a positive relationship between CLZ/NDMC ratio and working memory (p = 0.03). These findings may reflect the action of CLZ and NDMC on the muscarinic cholinergic system, highlighting a possible neural correlate of cognition across treatment.
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Affiliation(s)
- Deepak K. Sarpal
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Annie Blazer
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - James D. Wilson
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Finnegan J. Calabro
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - William Foran
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charles E. Kahn
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Beatriz Luna
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA,Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA,Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - KN Roy Chengappa
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
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7
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Pharmacometabolomics-guided clozapine therapy in treatment resistant schizophrenia: Preliminary exploration of future too near. Asian J Psychiatr 2022; 67:102939. [PMID: 34844176 DOI: 10.1016/j.ajp.2021.102939] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 02/08/2023]
Abstract
AIM To study the association of clozapine pharmacometabolomics and clozapine response in Asian patients with treatment-resistant schizophrenia (TRS). METHOD A cross-sectional study was performed on 50 consecutive TRS patients following up in psychiatry department of the tertiary care hospital. Demographic details, response assessment, were collected on the case record form. A blood sample was also collected for trough concentration assessment of drug and its metabolites. Clozapine (CLZ) the parent drug and its two major metabolites - Clozapine N oxide (CNO) and N-Desmethyl clozapine (N-DSMC) levels were assessed using a high-performance liquid chromatography method. Clozapine responders and nonresponders patients were classified based upon Andreasen criteria. RESULTS The average trough concentration of CNO, N-DSMC, and CLZ were 123 ± 76.04, 171.93 ± 93.24, 229.27 ± 124.25 ng/ml, respectively. The two patient subgroups did not differ for CLZ, CNO, and N-DSMC concentrations statistically. However, clozapine nonresponse was associated with a higher CLZ/N-DSMC ratio (p = 0.03) and clozapine dose (p = 0.01). The receiver operator characteristic curve showed that the cut-off CLZ/N-DSMC ratio of 1.54 with a sensitivity of 85% and a positive predictive value of 84% for identifying nonresponders. CONCLUSION CLZ/N-DSMC ratio and clozapine dose were identified as significant variables for future dose optimization algorithms. Pharmacometabolomics-guided clozapine therapy has the potential to revolutionize TRS management.
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8
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Patil AN, Kasudhan KS, Naveen M, Batra GK, Chakrabarti S, Avasthi A, Grover S. Precise pharmacogenetic pharmacometabolomic (PPP) guided clozapine therapy in treatment resistant schizophrenia: Insights from one ethnicity experiment. Schizophr Res 2021; 237:26-28. [PMID: 34481201 DOI: 10.1016/j.schres.2021.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 08/22/2021] [Accepted: 08/22/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Amol N Patil
- Department of Clinical Pharmacology, PGIMER, Chandigarh, India
| | | | - M Naveen
- Department of Clinical Pharmacology, PGIMER, Chandigarh, India
| | | | | | - Ajit Avasthi
- Department of Psychiatry, PGIMER, Chandigarh, India
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9
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Foster DJ, Bryant ZK, Conn PJ. Targeting muscarinic receptors to treat schizophrenia. Behav Brain Res 2021; 405:113201. [PMID: 33647377 PMCID: PMC8006961 DOI: 10.1016/j.bbr.2021.113201] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/02/2021] [Accepted: 02/18/2021] [Indexed: 11/23/2022]
Abstract
Schizophrenia is a severe neuropsychiatric disorder characterized by a diverse range of symptoms that can have profound impacts on the lives of patients. Currently available antipsychotics target dopamine receptors, and while they are useful for ameliorating the positive symptoms of the disorder, this approach often does not significantly improve negative and cognitive symptoms. Excitingly, preclinical and clinical research suggests that targeting specific muscarinic acetylcholine receptor subtypes could provide more comprehensive symptomatic relief with the potential to ameliorate numerous symptom domains. Mechanistic studies reveal that M1, M4, and M5 receptor subtypes can modulate the specific brain circuits and physiology that are disrupted in schizophrenia and are thought to underlie positive, negative, and cognitive symptoms. Novel therapeutic strategies for targeting these receptors are now advancing in clinical and preclinical development and expand upon the promise of these new treatment strategies to potentially provide more comprehensive relief than currently available antipsychotics.
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Affiliation(s)
- Daniel J Foster
- Department of Pharmacology, Vanderbilt University, Nashville, TN, 37232, United States; Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, TN, 37232, United States
| | - Zoey K Bryant
- Department of Pharmacology, Vanderbilt University, Nashville, TN, 37232, United States; Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, TN, 37232, United States
| | - P Jeffrey Conn
- Department of Pharmacology, Vanderbilt University, Nashville, TN, 37232, United States; Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, TN, 37232, United States.
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10
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Abstract
BACKGROUND Although clozapine is the gold standard for treatment-resistant schizophrenia, more than 30% of patients remain unresponsive to clozapine monotherapy and may benefit from augmentation strategies. Fluvoxamine augmentation of clozapine may be beneficial in treatment resistance because of pharmacokinetic interactions, allowing for lower clozapine dosages with higher clozapine serum levels and an increased clozapine-to-norclozapine ratio, which can modify adverse effects. An augmentation strategy using higher fluvoxamine doses may also improve persistent negative, anxiety, and obsessive-compulsive symptoms through fluvoxamine's serotonergic activity. METHODS Through chart review, we identified 4 cases of patients with treatment-resistant psychosis who underwent high-dose fluvoxamine augmentation of clozapine to target residual negative symptoms, refractory psychosis, anxiety, and obsessive-compulsive symptoms. FINDINGS This augmentation strategy continued in 2 patients after discharge who showed clinical improvement without significant adverse effects. Two patients experienced adverse effects that led to the fluvoxamine discontinuation. Despite the fact that fluvoxamine augmentation led to symptom improvement in only 2 patients, all patients achieved high serum clozapine levels. Hematologic parameters were monitored in all patients, and no abnormalities were observed. No severe adverse effects of clozapine were experienced. CONCLUSIONS Although high variability of responses and adverse effects were observed during fluvoxamine augmentation to clozapine, this strategy was successful in increasing clozapine serum levels. Through fluvoxamine's serotonergic effects, this strategy may confer benefit to residual negative, obsessive, and anxiety symptoms. Limitations of this case series include the retrospective nature, absence of controls, diversity of diagnoses, multiple interventions in each patient, and lack of masked raters.
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11
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Abstract
BACKGROUND Given the wide implications of cognitive impairment for prognosis and outcome in schizophrenia, the research on pharmacological approaches aimed at addressing dysfunctional cognition has been extensive; nevertheless, there are no currently available licensed drugs, and the evidence in this field is still unimpressive. Vortioxetine is a multimodal antidepressant, which has been proposed as a suitable treatment option for cognitive symptoms in depression. METHODS Twenty schizophrenia outpatients (mean age ± SD, 40.7 ±10.6 years) on stable clozapine treatment, assessed by neuropsychological (Wisconsin Card Sorting Test, Verbal Fluency, and Stroop task) and psychodiagnostic instruments (Positive and Negative Syndrome Scale [PANSS] and Calgary Depression Scale for Schizophrenia), received vortioxetine at the single daily dose of 10 mg/d until week 12; the dose was increased at 20 mg/d afterward, and this dosage was maintained unchanged until week 24. A physical examination, electrocardiogram with QTc measurement, and laboratory tests were also performed. RESULTS Vortioxetine supplementation significantly improved Stroop test (P = 0.013) at week 12 and Stroop test (P = 0.031) and Semantic Fluency (P = 0.002) at end point. Moreover, a significantly reduction of PANSS domains "positive" (P = 0.019) at week 12 and of PANSS domains positive (P = 0.019) and total score (P = 0.041) and of depressive symptoms (Calgary Depression Scale for Schizophrenia, P = 0.032) at end point. There was no significant change in clinical, metabolic, and safety parameters, and no subject spontaneously reported adverse effects. CONCLUSIONS Despite the limitations (open design, lack of a control group, small sample size, and short intervention period), our findings suggest for the first time that vortioxetine augmentation of clozapine may be a promising therapeutic strategy for addressing cognitive deficits in patients with schizophrenia.
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12
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Costa-Dookhan KA, Rajji TK, Tran VN, Bowden S, Mueller DJ, Remington GJ, Agarwal SM, Hahn MK. Associations between plasma clozapine/N-desmethylclozapine ratio, insulin resistance and cognitive performance in patients with co-morbid obesity and ultra-treatment resistant schizophrenia. Sci Rep 2021; 11:2004. [PMID: 33479273 PMCID: PMC7820218 DOI: 10.1038/s41598-021-81493-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/09/2020] [Indexed: 11/09/2022] Open
Abstract
Clozapine (CLZ), the sole antipsychotic with superior efficacy for ultra-treatment resistant schizophrenia (TRS), is limited by adverse effects, including metabolic dysregulation. Clozapine's main metabolite, N-desmethylclozapine (NDMC), has potent 5-HT2C antagonist properties which may explain this metabolic dysfunction, thus the CLZ:NDMC ratio is of particular interest. High insulin resistance states could be associated with CYP1A2 induction and lower CLZ:NDMC ratios. Additionally, lower CLZ:NDMC ratios have been associated with better cognitive, but worse metabolic functioning. This study investigated associations between metabolic and cognitive parameters with the CLZ/NDMC ratio. Primary outcomes included relationships between the CLZ:NDMC ratio to the homeostatic model assessment for insulin resistance (HOMA-IR) and Brief Assessment of Cognition in Schizophrenia (BACS) composite z-scores. Secondary outcomes assessed relationships between CLZ:NDMC ratios to fasting insulin, BMI, weight, fasting glucose, and BACS digit sequencing z-scores. 38 patients who were overweight or obese with schizophrenia or schizoaffective disorder completed fasting bloodwork, anthropometric, psychopathological, and cognitive assessments. Multivariate regressions found a statistically significant inverse association between the CLZ/NDMC ratio and HOMA-IR (B = - 1.028, SE B = .473, β = - 0.348 p = 0.037), which may have been driven by fasting insulin levels (B = - 27.124, SE B = 12.081, β = - 0.351 p = 0.031). The CLZ/NDMC ratio may predict insulin resistance/metabolic comorbidity among patients with TRS receiving clozapine.
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Affiliation(s)
- Kenya A Costa-Dookhan
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada
| | - Tarek K Rajji
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Veronica N Tran
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
| | - Sylvie Bowden
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Daniel J Mueller
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Gary J Remington
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Sri Mahavir Agarwal
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Banting and Best Diabetes Center, University of Toronto, Toronto, Canada
| | - Margaret K Hahn
- Institute of Medical Science, University of Toronto, Toronto, Canada. .,Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada. .,Department of Psychiatry, University of Toronto, Toronto, Canada. .,Banting and Best Diabetes Center, University of Toronto, Toronto, Canada. .,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada.
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13
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Yoshida K, Takeuchi H. Dose-dependent effects of antipsychotics on efficacy and adverse effects in schizophrenia. Behav Brain Res 2021; 402:113098. [PMID: 33417992 DOI: 10.1016/j.bbr.2020.113098] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/02/2020] [Accepted: 12/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Antipsychotics are a cornerstone of pharmacological treatment of schizophrenia. Improved understanding of the dose-response relationship of antipsychotics in terms of efficacy, adverse effects, and mortality can help to optimize the pharmacological treatment of schizophrenia. METHODS This narrative literature review summarizes current evidence on the relationship of antipsychotic dose with efficacy, adverse effects, and mortality in patients with schizophrenia. RESULTS The efficacy of antipsychotics generally appeared to be highly dose-dependent in the acute phase of schizophrenia, with each antipsychotic having a specific dose-response curve. The presence or absence of dose-dependency and its extent varied according to the type of adverse effect. Parkinsonism, hyperprolactinemia, weight gain, and neurocognitive impairment appeared to be dose-related. The following adverse effects might be at least somewhat dose-dependent: akathisia, tardive dyskinesia, osteoporosis, sexual dysfunction, diabetes mellitus, myocardial infarction, stroke, thromboembolism, QT interval prolongation, anticholinergic adverse effects, somnolence, pneumonia, hip fracture, and neuroleptic malignant syndrome. In contrast, the relationships of antipsychotic dose with dyslipidemia, hypotension, seizure, sialorrhea, and neutropenia and agranulocytosis remained unclear due to mixed findings and/or limited data. Although a higher lifetime cumulative antipsychotic dose might contribute to higher mortality, it is still difficult to conclude whether mortality increases in a dose-dependent manner. CONCLUSION These findings could help clinicians to optimize antipsychotic treatment in patients with schizophrenia by balancing risks and benefits in clinical practice. However, further investigations with larger sample sizes and more robust study designs that focus on each antipsychotic agent are needed.
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Affiliation(s)
- Kazunari Yoshida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Pharmacogenetics Research Clinic, Centre for Addiction and Mental Health, Toronto, ON, Canada; Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.
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Krivoy A, Whiskey E, Webb-Wilson H, Joyce D, Tracy DK, Gaughran F, MacCabe JH, Shergill SS. Outcomes in treatment-resistant schizophrenia: symptoms, function and clozapine plasma concentrations. Ther Adv Psychopharmacol 2021; 11:20451253211037179. [PMID: 34676067 PMCID: PMC8524694 DOI: 10.1177/20451253211037179] [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: 06/13/2021] [Accepted: 07/16/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clozapine is the only medication licenced for treating patients with treatment-refractory schizophrenia. However, there are no evidence-based guidelines as to the optimal plasma level of clozapine to aim for, and their association with clinical and functional outcome. OBJECTIVE We assessed the relationship between clinical and functional outcome measures and blood concentrations of clozapine among patients with treatment-refractory psychosis. METHODS Data were reviewed in 82 patients with treatment-refractory psychosis admitted to a specialised tertiary-level service and treated with clozapine. Analysis focussed on the relationship between clozapine and norclozapine plasma concentrations and the patient's clinical symptoms and functional status. RESULTS Clinical symptom improvement was positively correlated with norclozapine plasma concentrations and inversely correlated with clozapine to norclozapine plasma concentrations ratio. Clozapine concentrations showed a bimodal association with clinical improvement (peaks around 350 and 660 ng/ml). Clinical symptom improvement correlated with functional outcomes, although there was no significant correlation between the latter and clozapine or norclozapine plasma concentrations. CONCLUSION Clozapine treatment was associated with optimal clinical improvement at two different peak plasma concentrations around 350 and 650 ng/ml. Clinical improvement was associated with functional outcome; however, functionality was not directly associated with clozapine concentrations. A subset of patients may require higher clozapine plasma concentrations to achieve clinical improvement.
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Affiliation(s)
- Amir Krivoy
- Geha Mental Health Center, Petach-Tikva, Israel
| | - Eromona Whiskey
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Henrietta Webb-Wilson
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Dan Joyce
- National Institute of Health Research Oxford Health Biomedical Research Center and Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Derek K Tracy
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Fiona Gaughran
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - James H MacCabe
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Sukhwinder S Shergill
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
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15
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Islam F, Maciukiewicz M, Freeman N, Huang E, Tiwari A, Mulsant BH, Pollock BG, Remington G, Kennedy JL, Müller DJ, Rajji TK. Contributions of cholinergic receptor muscarinic 1 and CYP1A2 gene variants on the effects of plasma ratio of clozapine/N-desmethylclozapine on working memory in schizophrenia. J Psychopharmacol 2021; 35:31-39. [PMID: 33143542 DOI: 10.1177/0269881120946288] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clozapine has heterogenous efficacy in enhancing working memory in schizophrenia. We have previously hypothesized that this is due to opposing effects of clozapine and its metabolite, N-desmethylclozapine, at the muscarinic M1 receptor and demonstrated that a lower clozapine/N-desmethylclozapine ratio is associated with better working memory than clozapine or N-desmethylclozapine levels alone. AIMS In this study, we expanded the above hypothesis to explore whether genetic variation in the cholinergic receptor muscarinic 1 gene, encoding the M1 receptor, affects the relationship between clozapine/N-desmethylclozapine and working memory. Further, we explored whether CYP1A2 gene variants affect the ratio of clozapine/N-desmethylclozapine and by this, working memory performance. METHODS We evaluated two functionally significant single nucleotide polymorphisms, rs1942499 and rs2075748, in cholinergic receptor muscarinic 1, with the haplotype T-A associated with lower transcriptional activity than the haplotype C-G. Further, we examined CYP1A2 *1F, with *1F/*1F conferring high inducibility in the presence of smoking. RESULTS In a sample of 30 patients with schizophrenia on clozapine monotherapy, clozapine/N-desmethylclozapine was correlated with working memory only in non-carriers of the haplotype T-A of the cholinergic receptor muscarinic 1 gene. Interaction of CYP1A2 genotype and smoking status significantly affected clozapine concentrations, but there were no significant effects of CYP1A2 genotype and smoking status on the relationship between clozapine/N-desmethylclozapine on working memory. CONCLUSIONS Our finding that the relationship between clozapine/N-desmethylclozapine and working memory is specific to patients with potentially higher transcription of M1 receptor (i.e. non-carriers of the haplotype T-A of cholinergic receptor muscarinic 1) supports a cholinergic mechanism underlying this relationship.
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Affiliation(s)
- Farhana Islam
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
| | - Malgorzata Maciukiewicz
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
| | - Natalie Freeman
- Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, Toronto, Canada
| | - Eric Huang
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
| | - Arun Tiwari
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
| | - Benoit H Mulsant
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Adult Neurodevelopment and Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Canada
| | - Bruce G Pollock
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Adult Neurodevelopment and Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Canada
| | - Gary Remington
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - James L Kennedy
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Daniel J Müller
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Tarek K Rajji
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
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16
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Park R, Kim S, Kim E. Relationship of Change in Plasma Clozapine/N-desmethylclozapine Ratio with Cognitive Performance in Patients with Schizophrenia. Psychiatry Investig 2020; 17:1158-1165. [PMID: 33198433 PMCID: PMC7711124 DOI: 10.30773/pi.2020.0306] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/05/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The clozapine/N-desmethylclozapine (NDMC) ratio is proposed to be used as a predictor of cognitive performance in clozapine-treated patients, as its principal metabolite, NDMC, has an opposite action with clozapine on the cholinergic system. The aim of this study is to determine whether clozapine has influence on cognitive performance in accordance with changes in the clozapine/NDMC in patients with schizophrenia. METHODS The data of fifteen patients with schizophrenia, who had initial and follow-up assessments after starting clozapine treatment, were retrospectively collected. The assessments included clinical scale, cognitive battery, and pharmacological data including plasma concentrations of clozapine and NDMC. The data were analyzed with Pearson correlation and stepwise multiple regression analyses. RESULTS ΔAttention/vigilance, Δsocial cognition, and Δcomposite score had a significant correlation with Δclozapine/NDMC ratio, while ΔWorking memory had correlation with Δclozapine concentration and ΔNDMC concentration, and Δsocial cognition had association with Δclozapine concentration. Multiple regression analysis showed that Δattention/vigilance had negative association with Δclozapine/NDMC ratio, Δworking memory had negative relation with Δclozapine concentration, and that Δsocial cognition had negative association with Δclozapine concentration. CONCLUSION This finding implicates that lowering the clozapine/NDMC ratio could enhance cognition in patients with schizophrenia treated with clozapine.
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Affiliation(s)
- Royun Park
- Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seoyoung Kim
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Euitae Kim
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Brain & Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea
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17
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Kır Y, Baskak B, Kuşman A, Sayar-Akaslan D, Özdemir F, Sedes-Baskak N, Süzen HS, Baran Z. The relationship between plasma levels of clozapine and N-desmethyclozapine as well as M1 receptor polymorphism with cognitive functioning and associated cortical activity in schizophrenia. Psychiatry Res Neuroimaging 2020; 303:111128. [PMID: 32593951 DOI: 10.1016/j.pscychresns.2020.111128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/06/2020] [Accepted: 06/12/2020] [Indexed: 11/19/2022]
Abstract
Studies that examined the effect of clozapine on cognitive functions in schizophrenia provided contradictory results. N-desmethylclozapine (NDMC) is the major metabolite of clozapine and have procognitive effects via agonistic activity in the M1 cholinergic receptors. The rs2067477 polymorphism in the M1 receptors may play role in cognitive profile in schizophrenia. We investigated the association of plasma clozapine (PClz), NDMC (PNdmc) levels and the rs2067477 polymorphism with cognitive functions and cortical activity measured by functional near infrared spectroscopy during the N-Back task in subjects with schizophrenia (N = 50) who are under antipsychotic monotherapy with clozapine. We found that PClz and PNdmc levels were negatively, PNdmc/PClz ratio was positively correlated with immediate recall score in the Rey Auditory Verbal Learning Test. PNdmc/PClz ratio was positively correlated with cortical activity during the N-back task. M1 wild-type group (CC: wild-type) produced higher cortical activity than M1 non wild-type group (CA: heterozygote / AA: mutant) in cortical regions associated with working memory (WM). These results suggest that individual differences in clozapine's effect on short term episodic memory may be associated with PClz and PNdmc. Higher activity in the M1 wild-type group may indicate inefficient use of cortical resources and/or excessive use of certain cognitive strategies during WM performance.
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Affiliation(s)
- Yağmur Kır
- Ankara University, Brain Research Center, Ankara, Turkey
| | - Bora Baskak
- Ankara University, Department of Psychiatry, Brain Research Center, Ankara, Turkey.
| | - Adnan Kuşman
- Ankara University, Department of Psychiatry, Brain Research Center, Ankara, Turkey
| | - Damla Sayar-Akaslan
- Ankara University, Department of Psychiatry, Brain Research Center, Ankara, Turkey
| | - Fezile Özdemir
- Ankara University, Institute of Forensic Sciences, Department of Forensic Toxicology, Ankara, Turkey
| | - Nilay Sedes-Baskak
- Yildirim Beyazit University, Yenimahalle Training and Research Hospital, Department of Psychiatry, Ankara, Turkey
| | | | - Zeynel Baran
- Hacettepe University, Department of Psychology, Ankara, Turkey
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18
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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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19
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Costa-Dookhan KA, Agarwal SM, Chintoh A, Tran VN, Stogios N, Ebdrup BH, Sockalingam S, Rajji TK, Remington GJ, Siskind D, Hahn MK. The clozapine to norclozapine ratio: a narrative review of the clinical utility to minimize metabolic risk and enhance clozapine efficacy. Expert Opin Drug Saf 2019; 19:43-57. [PMID: 31770500 DOI: 10.1080/14740338.2020.1698545] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Introduction: Clozapine remains the most effective antipsychotic for treatment-refractory schizophrenia. However, ~40% of the patients respond insufficiently to clozapine. Clozapine's effects, both beneficial and adverse, have been proposed to be partially attributable to its main metabolite, N-desmethylclozapine (NDMC). However, the relation of the clozapine to norclozapine ratio (CLZ:NDMC; optimally defined as ~2) to clinical response and metabolic outcomes is not clear.Areas covered: This narrative review comprehensively examines the clinical utility of the CLZ:NDMC ratio to reduce metabolic risk and increase treatment efficacy. The association of the CLZ:NDMC ratio with changes in psychopathology, cognitive functioning, and cardiometabolic burden will be explored, as well as adjunctive treatments and their effects.Expert opinion: The literature suggests a positive association between the CLZ:NDMC ratio and better cardiometabolic outcomes. Conversely, the CLZ:NDMC ratio appears inversely associated with better cognitive functioning but less consistently with other psychiatric domains. The CLZ:NDMC ratio may be useful for predicting and monitoring cardiometabolic adverse effects and optimizing potential cognitive benefits of clozapine. Future studies are required to replicate these findings, which if substantiated, would encourage examination of adjunctive treatments aiming to alter the CLZ:NDMC ratio to best meet the needs of the individual patient, thereby broadening clozapine's clinical utility.
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Affiliation(s)
- Kenya A Costa-Dookhan
- Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sri Mahavir Agarwal
- Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Araba Chintoh
- Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Veronica N Tran
- Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
| | - Nicolette Stogios
- Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Bjørn H Ebdrup
- Centre for Neuropsychiatric Schizophrenia Research, CNSR & Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sanjeev Sockalingam
- Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Tarek K Rajji
- Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Gary J Remington
- Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Dan Siskind
- School of Medicine, University of Queensland, Brisbane, Australia.,Schizophrenia Department, Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Margaret K Hahn
- Schizophrenia Department, Centre for Addiction and Mental Health, Toronto, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Banting and Best Diabetes Centre, University of Toronto, Toronto, Canada
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20
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A comparison of the effects of clozapine and its metabolite norclozapine on metabolic dysregulation in rodent models. Neuropharmacology 2019; 175:107717. [PMID: 31348941 DOI: 10.1016/j.neuropharm.2019.107717] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/13/2019] [Accepted: 07/22/2019] [Indexed: 01/11/2023]
Abstract
RATIONALE The second generation antipsychotic drug clozapine is a psychotherapeutic agent with superior efficacy for treatment-resistant schizophrenia. Clozapine is associated with a low likelihood of neurological side-effects, but a high propensity to induce weight gain and metabolic dysregulation. The primary metabolite of clozapine is norclozapine (N-Desmethylclozapine), which has psychoactive properties itself, but its effects on metabolic function remains unknown. The goal of the present study was to determine whether directly administered norclozapine could cause metabolic dysregulation, similar to clozapine. METHODS Adult female rats were treated with a range of doses of clozapine and norclozapine (0.5, 2, 8 & 20 mg/kg, i.p.) and then subjected to the intraperitoneal glucose tolerance test (IGTT), where glucose levels were recorded for 2 h following a glucose challenge. In parallel, rats were tested with two doses of clozapine and norclozapine (2 & 20 mg/kg, i.p.) in the hyperinsulinemic-euglycemic clamp (HIEC), to measure whole body insulin resistance. RESULTS In the IGTT, clozapine demonstrated dose-dependent effects on fasting glucose levels and total glucose area-under-the-curve following the glucose challenge, with the two highest doses strongly increasing glucose levels. Only the highest dose of norclozapine increased fasting glucose levels, and caused a non-significant increase in glucose levels following the challenge. By contrast, both doses of clozapine and norclozapine caused a potent and long-lasting decrease in the glucose infusion rate in the HIEC, indicating that both compounds cause whole body insulin resistance. ABSTRACT While not as potent as its parent compound, norclozapine clearly exerts acute metabolic effects, particularly on insulin resistance. This article is part of the issue entitled 'Special Issue on Antipsychotics'.
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21
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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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22
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23
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McArdle PA, De Mel V, DeMonte V, Winckel K, Gore-Jones V, Foley S, Korman N, Parker S, Dark F, Siskind D. An investigation into the relationship between clozapine treatment and cognitive performance in patients with treatment resistant schizophrenia. Schizophr Res 2019; 206:450-451. [PMID: 30527271 DOI: 10.1016/j.schres.2018.11.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 10/24/2018] [Accepted: 11/23/2018] [Indexed: 10/27/2022]
Affiliation(s)
- P A McArdle
- Rehabilitation Academic Clinical Unit, Metro South Mental Health and Addiction Services, Brisbane, Qld, Australia.
| | - V De Mel
- Rehabilitation Academic Clinical Unit, Metro South Mental Health and Addiction Services, Brisbane, Qld, Australia
| | - V DeMonte
- Rehabilitation Academic Clinical Unit, Metro South Mental Health and Addiction Services, Brisbane, Qld, Australia
| | - K Winckel
- Pharmacy Department, Princess Alexandra Hospital, Woolloongabba, Qld, Australia; School of Pharmacy, The University of Queensland, Woolloongabba, Qld, Australia
| | - V Gore-Jones
- Rehabilitation Academic Clinical Unit, Metro South Mental Health and Addiction Services, Brisbane, Qld, Australia
| | - S Foley
- Rehabilitation Academic Clinical Unit, Metro South Mental Health and Addiction Services, Brisbane, Qld, Australia
| | - N Korman
- Rehabilitation Academic Clinical Unit, Metro South Mental Health and Addiction Services, Brisbane, Qld, Australia
| | - S Parker
- Rehabilitation Academic Clinical Unit, Metro South Mental Health and Addiction Services, Brisbane, Qld, Australia; School of Public Health, The University of Queensland, Herston, QLD, Australia
| | - F Dark
- Rehabilitation Academic Clinical Unit, Metro South Mental Health and Addiction Services, Brisbane, Qld, Australia; School of Public Health, The University of Queensland, Herston, QLD, Australia
| | - D Siskind
- Rehabilitation Academic Clinical Unit, Metro South Mental Health and Addiction Services, Brisbane, Qld, Australia; School of Medicine, The University of Queensland, Brisbane, Qld, Australia
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Mauri MC, Paletta S, Di Pace C, Reggiori A, Cirnigliaro G, Valli I, Altamura AC. Clinical Pharmacokinetics of Atypical Antipsychotics: An Update. Clin Pharmacokinet 2018; 57:1493-1528. [DOI: 10.1007/s40262-018-0664-3] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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25
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Kikuchi YS, Kanbayashi T, Shimizu T. Relationship between Clozapine-Induced Electroencephalogram Abnormalities and Serum Concentration of Clozapine in Japanese Patients with Treatment-Resistant Schizophrenia. Psychiatry Investig 2018; 16:279-284. [PMID: 30947495 PMCID: PMC6504775 DOI: 10.30773/pi.2018.12.16] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 12/16/2018] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The objective of this study was to investigate the relationship between the serum concentration of clozapine (C-CLZ), Ndesmethylclozapine (N-CLZ) and the daily dose of CLZ (D-CLZ), and the relationships among CLZ and electroencephalogram (EEG) abnormalities. METHODS Twenty-eight patients were recruited to this study, but 8 patients were excluded because clozapine was discontinued before the post-treatment measurement of EEG or C-CLZ. Ultimately, 20 patients (6 men, 14 women) with an average age of 36 years were enrolled. The subjects were divided into EEG normal and abnormal groups. C-CLZ and N-CLZ were measured at 4, 12, 26, and 52 weeks after initiating CLZ administration. RESULTS All patients had normal baseline EEG signals, and 8 patients showed EEG abnormalities later. There were significant correlations between C-CLZ and D-CLZ, and between N-CLZ and D-CLZ. The C-CLZ/D-CLZ, N-CLZ/D-CLZ, and C-CLZ/N-CLZ ratio were not significantly different between the EEG normal and EEG abnormal groups. The EEG abnormal group had significant higher proportion of patients with high intra-individual variability in their C-CLZ/D-CLZ ratio. CONCLUSION There is no relationship between C-CLZ and EEG abnormalities. However, patients with high intra-individual variability in their C-CLZ/D-CLZ ratio had greater possibility of exhibiting EEG abnormalities.
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Affiliation(s)
- Yuka Sugawara Kikuchi
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Takashi Kanbayashi
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Tetsuo Shimizu
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
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