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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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Arora S, Suhas S, Gowda GS, Reddi VSK, John JP. DRESS syndrome, seizures, and myocarditis on low dose clozapine - A case report. Schizophr Res 2024:S0920-9964(24)00044-6. [PMID: 38413285 DOI: 10.1016/j.schres.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/27/2024] [Accepted: 02/10/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Simran Arora
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Hosur Road, Bangalore, Karnataka 560029, India
| | - Satish Suhas
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Hosur Road, Bangalore, Karnataka 560029, India.
| | - Guru S Gowda
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Hosur Road, Bangalore, Karnataka 560029, India
| | - Venkata Senthil Kumar Reddi
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Hosur Road, Bangalore, Karnataka 560029, India
| | - John P John
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Hosur Road, Bangalore, Karnataka 560029, India.
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Ding J, Liu J, Zhang Y, Xing H, Zhang Y, Li L, Zhang S, Wang H, Yang L, Cui X. A retrospective study of clozapine and norclozapine concentration in patients with schizophrenia: Data from the Therapeutic Drug Monitoring Service, 2019-2022. Asian J Psychiatr 2024; 91:103865. [PMID: 38113699 DOI: 10.1016/j.ajp.2023.103865] [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: 07/18/2023] [Revised: 12/05/2023] [Accepted: 12/09/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVE The aim of this research was to assess the therapeutic drug monitoring (TDM) of clozapine (CLO) and norclozapine (NCLO). METHODS TDM results of CLO and NCLO in patients obtained from the Xi'an Mental Health Center were retrospectively analyzed. RESULTS TDM of CLO and NCLO was typically conducted only once in the majority of patients, particularly those receiving outpatient care. The CLO plasma concentrations were higher in inpatients and female patients. The interquartile (25th-75th) CLO concentrations ranged from 129.83 to 397.53 ng/mL, nearly 68.63% of the samples had subtherapeutic concentrations (<350 ng/mL). Receiver operating characteristic curve analysis showed that inpatients achieved the therapeutic level concentration of 350-600 ng/mL when their daily CLO dose was > 125 mg. CONCLUSIONS It was surprising to find such a large number of patients with CLO levels below the therapeutic range, there is still a window of improvement for optimizing pharmacological treatments in clinical practice.
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Affiliation(s)
- Jing Ding
- Xi'an Mental Health Center, 710100 Xi'an, PR China; Xi'an Key Laboratory of Pharmacy (Mental Health), Xi'an Mental Health Center, 710100 Xi'an, PR China; Pharmacy Laboratory, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Jianfeng Liu
- Department of Psychiatry, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Yan Zhang
- Xi'an Mental Health Center, 710100 Xi'an, PR China; Xi'an Key Laboratory of Pharmacy (Mental Health), Xi'an Mental Health Center, 710100 Xi'an, PR China; Pharmacy Laboratory, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Huan Xing
- Xi'an Mental Health Center, 710100 Xi'an, PR China; Xi'an Key Laboratory of Pharmacy (Mental Health), Xi'an Mental Health Center, 710100 Xi'an, PR China; Pharmacy Laboratory, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Yang Zhang
- Xi'an Mental Health Center, 710100 Xi'an, PR China; Xi'an Key Laboratory of Pharmacy (Mental Health), Xi'an Mental Health Center, 710100 Xi'an, PR China; Pharmacy Laboratory, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Luyao Li
- Xi'an Mental Health Center, 710100 Xi'an, PR China; Xi'an Key Laboratory of Pharmacy (Mental Health), Xi'an Mental Health Center, 710100 Xi'an, PR China; Pharmacy Laboratory, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Suo Zhang
- Xi'an Mental Health Center, 710100 Xi'an, PR China; Xi'an Key Laboratory of Pharmacy (Mental Health), Xi'an Mental Health Center, 710100 Xi'an, PR China; Pharmacy Laboratory, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Huiyuan Wang
- Department of Psychiatry, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Liu Yang
- Department of Research and Education, Xi'an Mental Health Center, 710100 Xi'an, PR China.
| | - Xiaohua Cui
- Xi'an Mental Health Center, 710100 Xi'an, PR China; Xi'an Key Laboratory of Pharmacy (Mental Health), Xi'an Mental Health Center, 710100 Xi'an, PR China; Pharmacy Laboratory, Xi'an Mental Health Center, 710100 Xi'an, PR China.
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Leung JG. Ethnopsychopharmacology: Clinical and scientific writing pearls. Ment Health Clin 2023; 13:276-288. [PMID: 38058595 PMCID: PMC10696167 DOI: 10.9740/mhc.2023.12.276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/26/2023] [Indexed: 12/08/2023] Open
Abstract
The concept of ethnopsychopharmacology aims to predict or explain the pharmacologic response to psychiatric medications based on the influence of biologic and nonbiologic factors. Interactions involving these factors are complex and influence patient outcomes in health care. Pharmacists and other clinicians working in patient care environments, research, or medical education should engage in lifelong learning to enhance ethnopsychopharmacologic knowledge gaps, which ultimately may improve and individualize care across diverse populations. Through two cases, this paper provides pearls on how biogeographical ancestry and cytochrome P450 status may influence pharmacotherapy selection, dosing, or response. A third scenario highlights a publication, like many other published works, with deficiencies in how data on ancestry, race, and ethnicity are collected or reported. Current recommendations on the use of inclusive language in scientific writing are reviewed, with attention to specific examples.
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Laitman RS, Keshavan M, Mandel AC. The EASE model for optimum use of clozapine: A clinician perspective. Schizophr Res 2023; 261:203-205. [PMID: 37797361 DOI: 10.1016/j.schres.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/06/2023] [Accepted: 09/16/2023] [Indexed: 10/07/2023]
Affiliation(s)
- Robert S Laitman
- Bronx Westchester Medical Group, Suite 201, 83 South Bedford Road, Mount Kisco, New York 10549, United States of America.
| | - Matcheri Keshavan
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States of America
| | - Ann C Mandel
- Bronx Westchester Medical Group, Suite 201, 83 South Bedford Road, Mount Kisco, New York 10549, United States of America
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Suhas S, Malo PK, Kumar V, Issac TG, Chithra NK, Bhaskarapillai B, Reddy YCJ, Rao NP. Treatment strategies for serotonin reuptake inhibitor-resistant obsessive-compulsive disorder: A network meta-analysis of randomised controlled trials. World J Biol Psychiatry 2023; 24:162-177. [PMID: 35615998 DOI: 10.1080/15622975.2022.2082525] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Treatment-resistant obsessive-compulsive disorder is a chronic debilitating illness. We conducted a network meta-analysis [NMA] to compare the efficacy of all interventions in SRI-resistant OCD from published Randomised controlled trials [RCT]. METHODS We performed an NMA of RCTs in SRI resistant OCD from all modalities of treatments; pharmacological, psychological, neuromodulation, neurosurgery including deep brain stimulation. The design-by-treatment interaction inconsistency model within the frequentist framework was adopted with a change in Yale-Brown Obsessive-Compulsive Scale score as the primary outcome. We conducted sensitivity analyses excluding studies examining neurosurgical interventions, deep brain stimulation, studies in the paediatric population, and studies from a single geographical region. We also conducted analyses of interventions categorised into treatment groups. RESULTS 55 RCTs examining 19 treatments or placebo involving 2011 participants were included in the NMA. Ondansetron [Standardised mean difference -2.01 (95% CI: -3.19, -0.83)], deep TMS [- 1.95 (-3.25, -0.65)], therapist administered Cognitive Behavioural Therapy [CBT-TA] [-1.46 (-2.93, 0.01)] and aripiprazole [-1.36 (-2.56, -0.17)] were ranked as the best four treatments on using the Surface Under the Cumulative Ranking [SUCRA] percentage values (85.4%, 83.2%, 80.3%, 67.9% respectively). While all four interventions had large effect sizes, CBT[TA] narrowly missed statistical significance in our analysis. In sensitivity analyses, deep TMS was ranked as the best treatment strategy for SRI-resistant OCD. The small number of subjects in individual studies, higher confidence interval limits, and wider prediction interval for most agents warrant a cautious interpretation. CONCLUSIONS Considering the principal analysis and sensitivity analyses together, deep TMS, ondansetron, CBT[TA], and aripiprazole may be considered a first-line intervention for SRI-resistant OCD in adults. OTHER This work was not funded. The NMA has been registered with PROSPERO, [Registration number: CRD42020173589].
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Affiliation(s)
- Satish Suhas
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Palash Kumar Malo
- Department of Biostatistics, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Vijay Kumar
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Thomas Gregor Issac
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Nellai K Chithra
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Binukumar Bhaskarapillai
- Department of Biostatistics, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Y C Janardhan Reddy
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Naren P Rao
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
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Chichra A, Varughese NR, Innamuri R. De Novo Seizures, Obsessive Compulsive Symptoms and Neutropenias in Patients on Clozapine: A Retrospective Cohort Study. Indian J Psychol Med 2023; 45:33-37. [PMID: 36778619 PMCID: PMC9896117 DOI: 10.1177/02537176221140496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Clozapine has well-documented inter-ethnic variations in pharmacokinetics. There is a paucity of data about clozapine use and associated adverse events such as seizures, obsessive compulsive symptoms, neutropenia, and agranulocytosis, from India. METHODS This retrospective cohort study followed up 228 patients initiated on clozapine in a tertiary care referral center in India for an average of 10 years. We calculated incidence rates of new-onset seizures, new-onset obsessive compulsive symptoms, agranulocytosis, and neutropenia. We collected data on doses of clozapine used and serum assays and calculated concentration-to-dose (C/D) ratios. We also collected relevant clinical details about clozapine-induced seizures. RESULTS In the sample, 16.8% had new-onset seizures, 12.3% had new-onset OC symptoms, 2.7% had neutropenia, and 0.9% had agranulocytosis. The mean C/D ratio was 2.09 (SD = 1.8). Almost half (46.3%) of available serum assays were in the supra-therapeutic range. Seizures were associated with a higher clozapine dose at one year (OR = 1.003; 95%CI = 1.000-1.006; P value = 0.045) and the presence of positive psychotic symptoms at one year (OR = 4.214; 95%CI = 1.894-9.373; P < 0.001). CONCLUSION Compared to existing literature, Indians have a higher rate of clozapine- related seizures and need lower doses to reach therapeutic serum levels.
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Affiliation(s)
- Abhinav Chichra
- Dept. of Psychiatry Unit Two, Mental Health Centre, Christian Medical College, Vellore-Bagayam campus, Vellore, Tamil Nadu, India
| | - Niji Rachel Varughese
- Dept. of Psychiatry Unit Two, Mental Health Centre, Christian Medical College, Vellore-Bagayam campus, Vellore, Tamil Nadu, India
| | - Raviteja Innamuri
- Dept. of Psychiatry Unit Two, Mental Health Centre, Christian Medical College, Vellore-Bagayam campus, Vellore, Tamil Nadu, India
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Russo M, Ignjatovic-Ristic D, Cohen D, Arenliu A, Bajraktarov S, Dzubur Kulenovic A, Injac Stevovic L, Maric N, Novotni A, Jovanovic N. Clozapine prescription rates in Southeast Europe: A cross-sectional study. Front Psychiatry 2023; 14:1123246. [PMID: 37113539 PMCID: PMC10126685 DOI: 10.3389/fpsyt.2023.1123246] [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: 12/13/2022] [Accepted: 01/25/2023] [Indexed: 04/29/2023] Open
Abstract
Introduction International reports indicate that clozapine is under prescribed. Yet, this has not been explored in Southeast European (SEE) countries. This cross-sectional study investigates clozapine prescription rates in a sample of 401 outpatients with psychosis from Bosnia and Herzegovina, Kosovo by United Nations resolution, North Macedonia, Montenegro and Serbia. Methods Descriptive analysis was used to explore clozapine prescription rates; daily antipsychotic dosage was calculated and converted into olanzapine equivalents. Patients receiving clozapine were compared to those not receiving clozapine; next those that were on clozapine monotherapy were compared to those who were on clozapine polytherapy regime. Results It was showed that clozapine was prescribed to 37.7% of patients (with cross-country variation: from 25% in North Macedonia to 43.8% in Montenegro), with average dose of 130.7 mg/daily. The majority of patients on clozapine (70.5%) were prescribed at least one more antipsychotic (the most frequent combination was with haloperidol). Discussion Our findings suggested that clozapine prescription rate in SEE outpatients is higher than in Western Europe. The average dose is significantly below the optimal therapeutic dosage recommended by clinical guidelines, and clozapine polytherapy is common. This might indicate that clozapine is prescribed mainly for its sedative effect rather than antipsychotic. We hope that this finding will be taken up by relevant stakeholders to address this non-evidence-based practice.
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Affiliation(s)
- Manuela Russo
- Unit for Social and Community Psychiatry, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
- Centre for Implementation Science, Health Services and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
- *Correspondence: Manuela Russo,
| | | | - Dan Cohen
- MHO North-Holland North, Heerhugowaard, Netherlands
| | - Aliriza Arenliu
- Department of Psychology, University of Pristina, Pristina, Kosovo by United Nations Resolution
| | | | | | | | - Nadja Maric
- Faculty of Medicine, Institute of Mental Health, University of Belgrade, Belgrade, Serbia
| | - Antoni Novotni
- University Clinic of Psychiatry, Skopje, North Macedonia
| | - Nikolina Jovanovic
- Unit for Social and Community Psychiatry, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
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Grover S, Kathiravan S. Clozapine research from India: A systematic review. Asian J Psychiatr 2023; 79:103353. [PMID: 36493690 DOI: 10.1016/j.ajp.2022.103353] [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: 10/02/2022] [Revised: 11/09/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although clozapine is much researched in western literature, a review on Indian research on clozapine published in 2010 reported limited data and need for further research in this area. AIM We aimed to conduct a systematic review of research on clozapine from India from 2010 to mid-2022 and also compare the same with research output before 2010. METHODOLOGY A systematic various search engines, i.e., PUBMED, Medknow, Hinari and Google Scholar was done using the key words clozapine and India. Published articles with clozapine in the title and having an author from India, published during 2010 to July 2022 were included. RESULTS Initial Internet and hand searches yielded 280 articles, out of which 126 articles were excluded due to various reasons and 154 articles, were included for the review. This included 84 case reports, 49 original articles, 11 review articles and 10 letters to the editor as comments. We found an increase in the number of publications during the period of 2010-2022 compared to 1997-2009 in all types of publications. Over the years a significant proportion of the articles focused on various side effects of clozapine, factors associated with response and non-response to clozapine and evaluation of outcomes other than efficacy/effectiveness. However, all the studies were limited to a single centre with no multicentric studies on clozapine. CONCLUSION Over the last 12 years or so, there is increase in the number of publications on clozapine. However, there is lack of multicentric studies.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Sanjana Kathiravan
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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10
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Arumugham SS, Praharaj SK, Shreekantiah U, Sreeraj VS, Roy C, Shenoy S, Purohith AN, Chithra U, Bagali KB, Venkataramaiah S, Nanjundaiah GKK, Thennarasu K, Kumar CN, Goyal N, Das B, Mehta UM, Muralidharan K, Venkatasubramanian G, Sinha P, Thirthalli J. Clinical efficacy and neurobiological correlates of electroconvulsive therapy in patients with clozapine-resistant/intolerant schizophrenia: study protocol of multi-site parallel arm double-blind randomized sham-controlled study. Wellcome Open Res 2022; 7:212. [PMID: 37953926 PMCID: PMC10636350 DOI: 10.12688/wellcomeopenres.18028.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 11/14/2023] Open
Abstract
Background: A substantial proportion of patients with treatment resistant schizophrenia do not respond well or partially to clozapine, with a subset that does not tolerate an adequate trial of clozapine. Electroconvulsive therapy (ECT) is regarded as one of the augmenting options, but there is a lack of high-quality evidence for this practice. This protocol describes a double-blind randomised sham-controlled modified-ECT trial to evaluate its efficacy in patients with clozapine resistant/intolerant schizophrenia. The study also involves multimodal investigations to identify the response predictors and the mechanistic basis of modified ECT in this population. Methods: One hundred consenting schizophrenia patients with resistance/intolerance to clozapine referred by clinicians for ECT would be randomly assigned to receive true ECT or sham ECT at three study centers. Sham ECT would mimic all the procedures of modified ECT including anaesthesia and muscle relaxation, except the electrical stimulation. After a blinded course, non-responders to sham ECT would be offered open-label true ECT. Clinical assessments, neurocognitive assessments and multimodal investigations (magnetic resonance imaging [MRI], electroencephalography, heart rate variability, investigative transcranial magnetic stimulation-transcranial direct current stimulation, gene polymorphism) would be conducted at baseline and repeated after the end of the trial, as well as open-label ECT course. The trial would evaluate the improvement in positive symptoms (scale for assessment of positive symptoms) of schizophrenia as the primary outcome measure with prediction of this change by resting-state functional-MRI based brain-connectivity as the second primary objective. Registration: Clinical Trial Registry of India (Reg no: CTRI/2021/05/033775) on 24 th May 2021.
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Affiliation(s)
- Shyam Sundar Arumugham
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Samir K. Praharaj
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | | | - Vanteemar S. Sreeraj
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Chandramouli Roy
- Central Institute of Psychiatry, Ranchi, Jharkhand, 834006, India
| | - Sonia Shenoy
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Abhiram Narasimhan Purohith
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Uppinkudru Chithra
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Kiran Basawaraj Bagali
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Sudhir Venkataramaiah
- Department of Neuroanaesthsia and Neuro Critical Care, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, 560029, India
| | - Gopala Krishna Kadarapura Nanjundaiah
- Department of Neuroanaesthsia and Neuro Critical Care, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, 560029, India
| | - Kandavel Thennarasu
- Department of Biostatistics, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, 560029, India
| | - Channaveerachari Naveen Kumar
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Nishant Goyal
- Central Institute of Psychiatry, Ranchi, Jharkhand, 834006, India
| | - Basudeb Das
- Central Institute of Psychiatry, Ranchi, Jharkhand, 834006, India
| | - Urvakhsh Meherwan Mehta
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Kesavan Muralidharan
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Ganesan Venkatasubramanian
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Preeti Sinha
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Jagadisha Thirthalli
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
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De Las Cuevas C, Sanz EJ, Ruan CJ, de Leon J. Clozapine-associated myocarditis in the World Health Organization's pharmacovigilance database: Focus on reports from various countries. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2022; 15:238-250. [PMID: 36513400 DOI: 10.1016/j.rpsmen.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/10/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The incidence of clozapine-associated myocarditis varies by country. These variations were explored in VigiBase, the World Health Organization's global database which has >25 million spontaneously reported adverse drug reaction (ADR) reports from 145 national drug agencies. METHODS On January 15, 2021, a search of VigiBase since inception focused on myocarditis in clozapine patients. The 3572 individual reports were studied using the standard VigiBase logarithmic measure of disproportionality called information component (IC). The IC measures the disproportionality between the expected and the reported rates. After duplicates were eliminated there were 3274 different patients with myocarditis studied in logistic regression models. RESULTS The first case was published in 1980 but since 1993 the VigiBase clozapine-myocarditis IC has been significant; moreover, currently it is very strong (IC=6.0, IC005-IC995=5.9-6.1) and statistically significantly different from other antipsychotics. Of the 3274 different patients with myocarditis, 43.4% were non-serious cases, 51.8% were serious but non-fatal, and 4.8% were fatal. More than half (1621/3274) of the reports came from Australia, of which 69.2% were non-serious, 27.7% serious but non-fatal, and 3.1% fatal. Asian countries contributed only 41 cases. CONCLUSIONS In pharmacovigilance studies, confounding factors may explain statistical associations, but the strength and robustness of these results are compatible with the hypothesis that myocarditis is definitively associated with early clozapine treatment (84% [1309/1560] and 5% [82/1560] in the first and second months). Myocarditis reports from Australia are over-represented to a major degree. Asian countries may be underreporting myocarditis to their drug agencies.
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Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, Instituto Universitario de Neurociencias (IUNE), University of La Laguna, Canary Islands, Spain
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain; Hospital Universitario de Canarias, Tenerife, Spain
| | - 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; Department of Psychiatry, The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders & Beijing Institute for Brain Disorders Center of Schizophrenia, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Jose de Leon
- Mental Health Research Center, 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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12
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Arumugham SS, Praharaj SK, Shreekantiah U, Sreeraj VS, Roy C, Shenoy S, Purohith AN, Chithra U, Bagali KB, Venkataramaiah S, Nanjundaiah GKK, Thennarasu K, Kumar CN, Goyal N, Das B, Mehta UM, Muralidharan K, Venkatasubramanian G, Sinha P, Thirthalli J. Clinical efficacy and neurobiological correlates of electroconvulsive therapy in patients with clozapine-resistant/intolerant schizophrenia: study protocol of multi-site parallel arm double-blind randomized sham-controlled study. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.18028.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: A substantial proportion of patients with treatment resistant schizophrenia do not respond well or partially to clozapine, with a subset that does not tolerate an adequate trial of clozapine. Electroconvulsive therapy (ECT) is regarded as one of the augmenting options, but there is a lack of high-quality evidence for this practice. This protocol describes a double-blind randomised sham-controlled modified-ECT trial to evaluate its efficacy in patients with clozapine resistant/intolerant schizophrenia. The study also involves multimodal investigations to identify the response predictors and the mechanistic basis of modified ECT in this population. Methods: One hundred consenting schizophrenia patients with resistance/intolerance to clozapine referred by clinicians for ECT would be randomly assigned to receive true ECT or sham ECT at three study centers. Sham ECT would mimic all the procedures of modified ECT including anaesthesia and muscle relaxation, except the electrical stimulation. After a blinded course, non-responders to sham ECT would be offered open-label true ECT. Clinical assessments, neurocognitive assessments and multimodal investigations (magnetic resonance imaging [MRI], electroencephalography, heart rate variability, investigative transcranial magnetic stimulation-transcranial direct current stimulation, gene polymorphism) would be conducted at baseline and repeated after the end of the trial, as well as open-label ECT course. The trial would evaluate the improvement in positive symptoms (scale for assessment of positive symptoms) of schizophrenia as the primary outcome measure with prediction of this change by resting-state functional-MRI based brain-connectivity as the second primary objective. Registration: Clinical Trial Registry of India (Reg no: CTRI/2021/05/033775) on 24th May 2021.
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13
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Suhas S, Mehta UM. A redux of schizophrenia research in 2021. Schizophr Res 2022; 243:458-461. [PMID: 35300898 PMCID: PMC8919807 DOI: 10.1016/j.schres.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/06/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Satish Suhas
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560029, India
| | - Urvakhsh Meherwan Mehta
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560029, India.
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14
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Hassab Errasoul A, Alarabi MA. Factors predicting serum clozapine levels in Middle Eastern patients: an observational study. BMC Psychiatry 2022; 22:269. [PMID: 35428222 PMCID: PMC9011948 DOI: 10.1186/s12888-022-03910-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/01/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Despite its superiority over other drugs for psychosis, clozapine remains underused and is associated with many clinical challenges, including difficulties in predicting therapeutic serum levels (350-600 ng/mL). We found no large or recent study that investigated the determinants of serum clozapine levels in Middle Eastern patients. Therefore, we investigated the association between clozapine dose and serum level, and the clinical predictors of the clozapine serum level, in Middle Eastern patients. METHODS This cross-sectional study included 94 patients of Middle Eastern ethnicity who attended the Clozapine Clinic in King Saud University Medical City in Riyadh, Saudi Arabia. We used a single measure of the serum clozapine level, which was collected 12 h after the last oral dose of clozapine under steady-state conditions. RESULTS The average clozapine dose and serum level were 400 mg/daily and 705 ng/mL, respectively. The majority of patients (59.8%) had serum levels higher than 600 ng/mL. Clozapine dose and serum level were positively correlated (rs [94] = 0.32, p = 0.002). We generated a predictive model of the serum clozapine level, which revealed that the daily dose, smoking status, use of fluvoxamine or lamotrigine, and body mass index (BMI) predicted 43.6% of the variance in the serum level (p < 0.001). Using this model, we calculated that patients with a BMI of 25 kg/m2 would require a clozapine dose between 50 to 275 mg/daily if they were non-smokers, and a dose of 200 to 450 mg/daily if they were smokers, in order to reach a serum clozapine level between 350 to 600 ng/mL. Patients with higher BMI and those receiving fluvoxamine would require lower doses. CONCLUSIONS This was a naturalistic study of the clozapine dose-level relationship and the clinical predictors of the serum clozapine level in a sample of Middle Eastern patients. The ratios of clozapine level to dose in our patients more closely resembled those reported in Asian samples than in European samples. These findings do not reduce the value of individualised therapeutic drug monitoring, but may assist clinicians when prescribing clozapine to Middle Eastern patients. Further psychopharmacological studies are needed on this demographic population.
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Affiliation(s)
- Ahmed Hassab Errasoul
- grid.56302.320000 0004 1773 5396Department of Psychiatry, College of Medicine, King Saud University, PO Box 7805, Riyadh, 11472 Kingdom of Saudi Arabia
| | - Mohammed A. Alarabi
- grid.56302.320000 0004 1773 5396Department of Psychiatry, College of Medicine, King Saud University, PO Box 7805, Riyadh, 11472 Kingdom of Saudi Arabia
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15
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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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16
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de Leon J, Schoretsanitis G, Smith RL, Molden E, Solismaa A, Seppälä N, Kopeček M, Švancer P, Olmos I, Ricciardi C, Iglesias-Garcia C, Iglesias-Alonso A, Spina E, Ruan CJ, Wang CY, Wang G, Tang YL, Lin SK, Lane HY, Kim YS, Kim SH, Rajkumar AP, González-Esquivel DF, Jung-Cook H, Baptista T, Rohde C, Nielsen J, Verdoux H, Quiles C, Sanz EJ, Las Cuevas CD, Cohen D, Schulte PFJ, Ertuğrul A, Yağcıoğlu AEA, Chopra N, McCollum B, Shelton C, Cotes RO, Kaithi AR, Kane JM, Farooq S, Ng CH, Bilbily J, Hiemke C, López-Jaramillo C, McGrane I, Lana F, Eap CB, Arrojo-Romero M, Rădulescu FŞ, Seifritz E, Every-Palmer S, Bousman CA, Bebawi E, Bhattacharya R, Kelly DL, Otsuka Y, Lazary J, Torres R, Yecora A, Motuca M, Chan SKW, Zolezzi M, Ouanes S, Berardis DD, Grover S, Procyshyn RM, Adebayo RA, Kirilochev OO, Soloviev A, Fountoulakis KN, Wilkowska A, Cubała WJ, Ayub M, Silva A, Bonelli RM, Villagrán-Moreno JM, Crespo-Facorro B, Temmingh H, Decloedt E, Pedro MR, Takeuchi H, Tsukahara M, Gründer G, Sagud M, Celofiga A, Ristic DI, Ortiz BB, Elkis H, Pacheco Palha AJ, LLerena A, Fernandez-Egea E, Siskind D, Weizman A, Masmoudi R, Saffian SM, Leung JG, Buckley PF, Marder SR, Citrome L, Freudenreich O, Correll CU, Müller DJ. An International Adult Guideline for Making Clozapine Titration Safer by Using Six Ancestry-Based Personalized Dosing Titrations, CRP, and Clozapine Levels. PHARMACOPSYCHIATRY 2021; 55:73-86. [PMID: 34911124 DOI: 10.1055/a-1625-6388] [Citation(s) in RCA: 104] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This international guideline proposes improving clozapine package inserts worldwide by using ancestry-based dosing and titration. Adverse drug reaction (ADR) databases suggest that clozapine is the third most toxic drug in the United States (US), and it produces four times higher worldwide pneumonia mortality than that by agranulocytosis or myocarditis. For trough steady-state clozapine serum concentrations, the therapeutic reference range is narrow, from 350 to 600 ng/mL with the potential for toxicity and ADRs as concentrations increase. Clozapine is mainly metabolized by CYP1A2 (female non-smokers, the lowest dose; male smokers, the highest dose). Poor metabolizer status through phenotypic conversion is associated with co-prescription of inhibitors (including oral contraceptives and valproate), obesity, or inflammation with C-reactive protein (CRP) elevations. The Asian population (Pakistan to Japan) or the Americas' original inhabitants have lower CYP1A2 activity and require lower clozapine doses to reach concentrations of 350 ng/mL. In the US, daily doses of 300-600 mg/day are recommended. Slow personalized titration may prevent early ADRs (including syncope, myocarditis, and pneumonia). This guideline defines six personalized titration schedules for inpatients: 1) ancestry from Asia or the original people from the Americas with lower metabolism (obesity or valproate) needing minimum therapeutic dosages of 75-150 mg/day, 2) ancestry from Asia or the original people from the Americas with average metabolism needing 175-300 mg/day, 3) European/Western Asian ancestry with lower metabolism (obesity or valproate) needing 100-200 mg/day, 4) European/Western Asian ancestry with average metabolism needing 250-400 mg/day, 5) in the US with ancestries other than from Asia or the original people from the Americas with lower clozapine metabolism (obesity or valproate) needing 150-300 mg/day, and 6) in the US with ancestries other than from Asia or the original people from the Americas with average clozapine metabolism needing 300-600 mg/day. Baseline and weekly CRP monitoring for at least four weeks is required to identify any inflammation, including inflammation secondary to clozapine rapid titration.
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Affiliation(s)
- Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA.,Department of Psychiatry, University of Kentucky, 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
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland.,The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA
| | - Robert L Smith
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway.,Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Anssi Solismaa
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Psychiatry, Tampere University Hospital, Tampere, Finland
| | | | - Miloslav Kopeček
- National Institute of Mental Health, Klecany, Czech Republic.,Department of Psychiatry, Charles University, Third Faculty of Medicine, Prague, Czech Republic
| | - Patrik Švancer
- National Institute of Mental Health, Klecany, Czech Republic.,Department of Psychiatry, Charles University, Third Faculty of Medicine, Prague, Czech Republic
| | - Ismael Olmos
- Clinical Pharmacology Unit and Pharmacy Department, Vilardebó Hospital, Administración de Servicios de Salud, Montevideo, Uruguay
| | - Carina Ricciardi
- Clinical Pharmacology Unit and Outpatient Clinic, Vilardebó Hospital, Administración de Servicios de Salud, Montevideo, Uruguay
| | - Celso Iglesias-Garcia
- Universidad de Oviedo. CIBERSAM. INEUROPA. ISPA-FIMBA, Oviedo, Spain.,Hospital Valle del Nalón, Langreo, Spain
| | | | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology, Beijing Anding Hospital, Capital Medical University, Beijing, China.,The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Chuan-Yue Wang
- The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China.,Department of Psychiatry, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Gang Wang
- The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Yi-Lang Tang
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.,Substance Abuse Treatment Program, Atlanta VA Medical Center, Decatur, Georgia, USA
| | - Shih-Ku Lin
- Department of Psychiatry, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsien-Yuan Lane
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan.,Department of Psychiatry and Brain Disease Research Center, China Medical University Hospital, Taichung, Taiwan.,Department of Psychology, College of Medical and Health Sciences, Asia University, Taichung, Taiwan
| | - Yong Sik Kim
- Department of Neuropsychiatry, Nowon Eulji Medical Center, Eulji University, School of Medicine, Seoul, Korea
| | - Se Hyun Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Anto P Rajkumar
- Department of Psychiatry, Christian Medical College, Vellore, India.,Institute of Mental Health, Jubilee Campus, University of Nottingham, Triumph Road, Nottingham, United Kingdom
| | | | - Helgi Jung-Cook
- Instituto Nacional de Neurología y Neurocirugía, México City, México.,Facultad de Química, Universidad Nacional Autónoma de México (UNAM), México City, México
| | - Trino Baptista
- Department of Physiology, Los Andes University Medical School, Mérida, Venezuela
| | - Christopher Rohde
- Department of Affective Disorders, Aarhus University Hospital - Psychiatry, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jimmi Nielsen
- Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France
| | - Clelia Quiles
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain.,Hospital Universitario de Canarias, Tenerife, Spain
| | - Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, and Instituto Universitario de Neurociencia (IUNE), University of La Laguna, Canary Islands, Spain
| | - Dan Cohen
- Dutch Clozapine Collaboration Group, Castricum, The Netherlands.,FACT-team in Heerhugowaard, Department of Severe Mental Illness, Mental Health Services North-Holland North, The Netherlands
| | - Peter F J Schulte
- Dutch Clozapine Collaboration Group, Castricum, The Netherlands.,Mental Health Team Alkmaar, Mental Health Services Noord-Holland-Noord, Alkmaar, The Netherlands
| | - Aygün Ertuğrul
- Department of Psychiatry, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - Nitin Chopra
- Addictions Division, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | | | - Charles Shelton
- Department of Psychiatry, University of Kentucky, Lexington, KY, USA.,Eastern State Hospital, Lexington, Kentucky, USA
| | - Robert O Cotes
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Hempstead, New York, USA
| | - Saeed Farooq
- School of Medicine, Keele University, Staffordshire, and Midlands Partnership NHS Foundation Trust, Staffordshire, United Kingdom
| | - Chee H Ng
- Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - John Bilbily
- Department of Psychiatry, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Germany
| | - Carlos López-Jaramillo
- Grupo de Investigación en Psiquiatría GIPSI, Departamento de Psiquiatría, Facultad de Medicina, Universidad de Antioquia, Medellin, Colombia.,Programa Trastornos del Ánimo, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Ian McGrane
- Department of Pharmacy Practice, University of Montana, Missoula, USA
| | - Fernando Lana
- Institute of Neuropsychiatry and Addictions (INAD), Parc de Salut Mar, Barcelona, Spain.,Department of Psychiatry, Autonomous University of Barcelona, Spain
| | - Chin B Eap
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Switzerland
| | - Manuel Arrojo-Romero
- Department of Psychiatry, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Flavian Ş Rădulescu
- Center for Drug Sciences, Faculty of Pharmacy, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland
| | - Susanna Every-Palmer
- Te Korowai Whāriki Central Regional Forensic Service, Capital and Coast District Health Board, Wellington, New Zealand.,Department of Psychological Medicine, University of Otago, Wellington, New Zealand
| | - Chad A Bousman
- Departments of Medical Genetics, Psychiatry, Physiology & Pharmacology, and Community Health Sciences University of Calgary, Alberta, Canada
| | - Emmanuel Bebawi
- Faculty of Medicine, University of Montreal, Montreal, Canada.,Department of Pharmacy, Hôpital du Sacré-Cœur de Montréal, Montreal, Canada
| | - Rahul Bhattacharya
- East London NHS Foundation Trust, London, United Kingdom.,Honorary Clinical Senior Lecturer, Barts and the London School of Medicine, Queen Mary University of London, United Kingdom
| | - Deanna L Kelly
- Department of Psychiatry, School of Medicine, Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Yuji Otsuka
- Department of Psychiatry, Asahi General Hospital, Chiba, Japan
| | - Judit Lazary
- National Institute of Mental Health, Neurology and Neurosurgery, Budapest, Hungary
| | - Rafael Torres
- Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Agustin Yecora
- Secretaría de Salud Mental y Adicciones, Ministerio de Salud de la Provincia de Jujuy, San Salvador de Jujuy, Argentina
| | - Mariano Motuca
- Instituto Vilapriño, Center for Studies, Assistance and Research in Neurosciences, Mendoza, Argentina
| | - Sherry K W Chan
- Department of Psychiatry, LSK Faculty of Medicine, The University of Hong Kong, Hong Kong SAR.,State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR
| | - Monica Zolezzi
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Sami Ouanes
- Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | | | - Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ric M Procyshyn
- British Columbia Mental Health and Substance Use Research Institute, Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | | | - Oleg O Kirilochev
- Department of Clinical Pharmacology, Astrakhan State Medical University, Astrakhan, Russian Federation
| | - Andrey Soloviev
- Department of Psychiatry and Clinical Psychology, Northern State Medical University, Arkhangelsk, Russia
| | - Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, Division of Neurosciences, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Alina Wilkowska
- Department of Psychiatry, Medical University of Gdańsk, Gdańsk, Poland
| | - Wiesław J Cubała
- Department of Psychiatry, Medical University of Gdańsk, Gdańsk, Poland
| | - Muhammad Ayub
- Department of Psychiatry, Queens University, Kingston, Canada
| | - Alzira Silva
- Psychiatry Department, Centro Hospitalar Universitário de S. João, Porto, Portugal., Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - José M Villagrán-Moreno
- Department of Neurosciences, Jerez University Hospital, Andalusian Health Service, University of Cadiz, Jerez, Spain
| | - Benedicto Crespo-Facorro
- Department of Psychiatry, School of Medicine, University Hospital Virgen del Rocio-IBIS, Sevilla, Spain., Spanish Network for Research in Mental Health (CIBERSAM), Sevilla, Spain
| | - Henk Temmingh
- Department of Psychiatry and Mental Health, University of Cape Town, Valkenberg Hospital, Western Cape, Cape Town, South Africa
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Tsukahara
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Gerhard Gründer
- Central Institute of Mental Health, Department of Molecular Neuroimaging, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Marina Sagud
- Department of Psychiatry, School of Medicine, University of Zagreb, Zagreb, Croatia.,Department for Psychiatry and Psychological Medicine, University Hospital Center Zagreb, Croatia
| | - Andreja Celofiga
- Department of Psychiatry, University Medical Centre Maribor, Maribor, Slovenia
| | | | - Bruno B Ortiz
- Group of Resistant Schizophrenia (GER), Schizophrenia Program (Proesq), Federal University of Sao Paulo, SP, Brazil
| | - Helio Elkis
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Sao Paulo, Brazil
| | - António J Pacheco Palha
- Department and Institute of Psychiatry and Mental Health, Oporto Faculty of Medicine, Oporto, Portugal.,Casa de Salidedo Som Jesus (Psychiatric Hospital), Oporto, Portugal
| | - Adrián LLerena
- INUBE Biosanitary Research Institute of Extremadura. Extremadura University Hospital and Medical School, Badajoz, Spain.,Spanish Network for Research in Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
| | - Emilio Fernandez-Egea
- Cambridge Psychosis Centre, Cambrigeshire and Peterborough NHS Foundation Trust & Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Dan Siskind
- Metro South Addiction and Mental Health Service, Brisbane, Australia.,Queensland Centre for Mental Health Research and School of Clinical Medicine, University of Queensland, Brisbane, Australia
| | - Abraham Weizman
- Research Unit, Geha Mental Health Center and Molecular Psychiatry Laboratory, Felsenstein Medical Research Center, Tel Aviv, Israel.,Department of Psychiatry Sackler Faculty of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Rim Masmoudi
- Psychiatry "A" Department, Hedi Chaker University Hospital, Sfax, Tunisia.,Faculty of Medicine, University of Sfax, Sfax, Tunisia
| | - Shamin Mohd Saffian
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | | | - Peter F Buckley
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephen R Marder
- Semel Institute for Neuroscience at UCLA, Los Angeles, CA, USA.,VA Desert Pacific Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, USA
| | - Leslie Citrome
- New York Medical College, Department of Psychiatry and Behavioral Sciences, Valhalla, NY, USA
| | - Oliver Freudenreich
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christoph U Correll
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Hempstead, New York, USA.,Charité Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany
| | - Daniel J Müller
- Addictions Division, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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17
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Chakrabarti S. Clozapine resistant schizophrenia: Newer avenues of management. World J Psychiatry 2021; 11:429-448. [PMID: 34513606 PMCID: PMC8394694 DOI: 10.5498/wjp.v11.i8.429] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/12/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
About 40%-70% of the patients with treatment-resistant schizophrenia have a poor response to adequate treatment with clozapine. The impact of clozapine-resistant schizophrenia (CRS) is even greater than that of treatment resistance in terms of severe and persistent symptoms, relapses and hospitalizations, poorer quality of life, and healthcare costs. Such serious consequences often compel clinicians to try different augmentation strategies to enhance the inadequate clozapine response in CRS. Unfortunately, a large body of evidence has shown that antipsychotics, antidepressants, mood stabilizers, electroconvulsive therapy, and cognitive-behavioural therapy are mostly ineffective in augmenting clozapine response. When beneficial effects of augmentation have been found, they are usually small and of doubtful clinical significance or based on low-quality evidence. Therefore, newer treatment approaches that go beyond the evidence are needed. The options proposed include developing a clinical consensus about the augmentation strategies that are most likely to be effective and using them sequentially in patients with CRS. Secondly, newer approaches such as augmentation with long-acting antipsychotic injections or multi-component psychosocial interventions could be considered. Lastly, perhaps the most effective way to deal with CRS would be to optimize clozapine treatment, which might prevent clozapine resistance from developing. Personalized dosing, adequate treatment durations, management of side effects and non-adherence, collaboration with patients and caregivers, and addressing clinician barriers to clozapine use are the principal ways of ensuring optimal clozapine treatment. At present, these three options could the best way to manage CRS until research provides more firm directions about the effective options for augmenting clozapine response.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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De Las Cuevas C, Sanz EJ, Ruan CJ, de Leon J. Clozapine-associated myocarditis in the World Health Organization's pharmacovigilance database: Focus on reports from various countries. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2021; 15:S1888-9891(21)00070-7. [PMID: 34298164 DOI: 10.1016/j.rpsm.2021.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The incidence of clozapine-associated myocarditis varies by country. These variations were explored in VigiBase, the World Health Organization's global database which has >25 million spontaneously reported adverse drug reaction (ADR) reports from 145 national drug agencies. METHODS On January 15, 2021, a search of VigiBase since inception focused on myocarditis in clozapine patients. The 3572 individual reports were studied using the standard VigiBase logarithmic measure of disproportionality called information component (IC). The IC measures the disproportionality between the expected and the reported rates. After duplicates were eliminated there were 3274 different patients with myocarditis studied in logistic regression models. RESULTS The first case was published in 1980 but since 1993 the VigiBase clozapine-myocarditis IC has been significant; moreover, currently it is very strong (IC=6.0, IC005-IC995=5.9-6.1) and statistically significantly different from other antipsychotics. Of the 3274 different patients with myocarditis, 43.4% were non-serious cases, 51.8% were serious but non-fatal, and 4.8% were fatal. More than half (1621/3274) of the reports came from Australia, of which 69.2% were non-serious, 27.7% serious but non-fatal, and 3.1% fatal. Asian countries contributed only 41 cases. CONCLUSIONS In pharmacovigilance studies, confounding factors may explain statistical associations, but the strength and robustness of these results are compatible with the hypothesis that myocarditis is definitively associated with early clozapine treatment (84% [1309/1560] and 5% [82/1560] in the first and second months). Myocarditis reports from Australia are over-represented to a major degree. Asian countries may be underreporting myocarditis to their drug agencies.
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Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, Instituto Universitario de Neurociencias (IUNE), University of La Laguna, Canary Islands, Spain
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain; Hospital Universitario de Canarias, Tenerife, Spain
| | - 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; Department of Psychiatry, The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders & Beijing Institute for Brain Disorders Center of Schizophrenia, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Jose de Leon
- Mental Health Research Center, 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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20
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Understanding the effect of various factors on clozapine serum levels in Indian population. Schizophr Res 2021; 231:178. [PMID: 33866263 DOI: 10.1016/j.schres.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/08/2021] [Indexed: 11/23/2022]
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21
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Suhas S, Kumar V, Damodharan D, Sharma P, Rao NP, Varambally S, Venkatasubramanian G, Murthy P, Gangadhar BN. Comment on: "Elevated Clozapine Concentrations in Clozapine-Treated Patients with Hypersalivation". Clin Pharmacokinet 2021; 60:1073-1075. [PMID: 33899164 DOI: 10.1007/s40262-021-01021-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Satish Suhas
- Schizophrenia and Metabolic Clinics, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore, 560029, India
| | - Vijay Kumar
- Schizophrenia and Metabolic Clinics, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore, 560029, India.
| | - Dinakaran Damodharan
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Priyamvada Sharma
- Department of Clinical Psychopharmacology and Neurotoxicology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Naren P Rao
- Schizophrenia and Metabolic Clinics, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore, 560029, India
| | - Shivarama Varambally
- Schizophrenia and Metabolic Clinics, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore, 560029, India
| | - Ganesan Venkatasubramanian
- Schizophrenia and Metabolic Clinics, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore, 560029, India
| | - Pratima Murthy
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Bangalore N Gangadhar
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
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22
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Schoretsanitis G, Kuzin M, Kane JM, Hiemke C, Paulzen M, Haen E. Authors' Reply to Suhas et al.: Comment on: "Elevated Clozapine Concentrations in Clozapine-Treated Patients with Hypersalivation". Clin Pharmacokinet 2021; 60:1077-1079. [PMID: 33899165 DOI: 10.1007/s40262-021-01022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Behavioral Health Pavilion, 7559 263rd Street, Glen Oaks, NY, 11004, USA.
- University Hospital of Psychiatry Zurich, Zurich, Switzerland.
| | - Maxim Kuzin
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland
| | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Behavioral Health Pavilion, 7559 263rd Street, Glen Oaks, NY, 11004, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy and Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Mainz, Germany
| | - Michael Paulzen
- Alexianer Hospital Aachen, Aachen, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany
- JARA-Translational Brain Medicine, Jülich, Germany
| | - Ekkehard Haen
- Department of Psychiatry and Psychotherapy, Clinical Pharmacology, University of Regensburg, Regensburg, Germany
- Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
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Suhas S, Kumar V, Venkatasubramanian G. Therapeutic drug monitoring of clozapine in Indian patients with schizophrenia - Authors response. Schizophr Res 2021; 229:25-26. [PMID: 33609987 DOI: 10.1016/j.schres.2021.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/11/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Satish Suhas
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, India.
| | - Vijay Kumar
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, India.
| | - Ganesan Venkatasubramanian
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, India.
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European Whites May Need Lower Minimum Therapeutic Clozapine Doses Than Those Customarily Proposed. J Clin Psychopharmacol 2021; 41:140-147. [PMID: 33587398 DOI: 10.1097/jcp.0000000000001341] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE/BACKGROUND A nomogram from a British naturalistic study proposed that the clozapine dosing needed to reach a serum concentration of 350 ng/mL ranged from 265 mg/d (female nonsmokers) to 525 mg/d (male smokers). Some European reviews have used these dosing recommendations, which seem greater than what we found in an Italian White sample ranging from 245 mg/d (female nonsmokers) to 299 mg/d (male smokers). Five other published samples of European Whites were added to the Italian sample to estimate clozapine doses recommended for reaching 350 ng/mL. METHODS/PROCEDURES Average clozapine metabolizers were obtained by eliminating outliers with confounding variables: (1) psychiatric inducers and inhibitors; (2) doses less than 100 mg/d; and (3) when possible, patients with inflammation, obesity, or using oral contraceptives. The study included 1363 average metabolizer European Whites: the Italian sample and 5 new samples. Mean averages that reached serum concentration levels of 350 ng/mL were calculated after stratification by sex and smoking status in each sample. Then, weighted mean averages were obtained by combining the 6 samples. FINDINGS/RESULTS The estimated weighted mean clozapine dosages ranged from 236 to 368 mg/d (236 mg/d in 218 female nonsmokers, 256 mg/d in 340 male nonsmokers, 357 mg/d in 269 female smokers, and 368 mg/d in 546 male smokers). IMPLICATIONS/CONCLUSIONS Our recommended dosages are less than those recommended in Europe. Future studies in European Whites need to replicate these recommended doses for average metabolizer patients after sex and smoking stratification and further explore clozapine dosing for those with relevant clinical confounders.
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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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