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Javed N, Anto AM, Nasr R, Uday KA. Clozapine-Induced Granulomatous Interstitial Nephritis: A Case Report. Cureus 2023; 15:e46971. [PMID: 38021890 PMCID: PMC10640836 DOI: 10.7759/cureus.46971] [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] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Granulomatous interstitial nephritis is a rare form of tubulointerstitial nephritis and has been uncommonly observed with clozapine usage. Additionally, the progression of the disease to manifest as renal failure requiring dialysis is also uncommon. We describe a case of a 56-year-old female who presented with syncope and was diagnosed with granulomatous interstitial nephritis on biopsy. While hemodialysis may play a role in the management of the disease, steroids provide a definitive treatment. Large-scale studies are needed to evaluate the role of clozapine in causing interstitial nephritis and the characteristics of these features to establish a therapeutic goal.
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Affiliation(s)
- Nismat Javed
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Anandu M Anto
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Rabih Nasr
- Nephrology, BronxCare Health System, Bronx, USA
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Kalpana A Uday
- Nephrology, BronxCare Health System, Bronx, USA
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
- Nephrology, Grand Concourse Dialysis Unit, Bronx, USA
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RODRIGUES P, FERREIRA I, TAVARES S, GUIOMAR V, CHAVES V, ALMEIDA J. Clozapine-induced acute interstitial nephritis. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2022. [DOI: 10.23736/s0393-3660.19.04258-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Yartsev A, Peisah C. Caffeine-clozapine interaction associated with severe toxicity and multiorgan system failure: a case report. BMC Psychiatry 2021; 21:192. [PMID: 33849480 PMCID: PMC8043221 DOI: 10.1186/s12888-021-03199-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/05/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Caffeine is a known inhibitor of Clozapine metabolism mediated by inhibition of CYP1A2. Hitherto, the effects of caffeine on Clozapine levels have always been modest, as have the clinical manifestations of toxicity resulting from their interaction. We present a case of severe toxicity associated with the co-consumption of caffeine and Clozapine culminating in life-threatening complications requiring management in Intensive Care. CASE PRESENTATION A 34 year old male with a history of chronic schizophrenia, who had been managed stably on 400 mg Clozapine for the previous 5 years, changed his dietary behaviour and began consuming caffeine-containing energy drinks over the course of 3 weeks. The total daily dose of caffeine was estimated as 600 mg/day (four cans of Red Bull). He subsequently presented to the Emergency Department with life-threatening Clozapine toxicity, resulting in a decreased level of consciousness, severe metabolic acidosis, acute respiratory failure, raised inflammatory markers and acute renal failure attributed to interstitial nephritis. Maximum recorded Clozapine level was 1796 ng/ml. CONCLUSIONS This case describes the interaction between a common caffeine-containing beverage and a commonly prescribed antipsychotic medication, associated with severe adverse effects. We call for clinical and scientific attention to the possible interaction between these substances and draw attention to the implications for prescribing practices and patient counselling.
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Affiliation(s)
- Alex Yartsev
- Westmead Hospital Intensive Care Unit, Sydney, Australia.
| | - Carmelle Peisah
- grid.413252.30000 0001 0180 6477Westmead Hospital Intensive Care Unit, Sydney, Australia ,grid.1005.40000 0004 4902 0432University New South Wales, Sydney, Australia
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Clozapine-Associated Kidney Injury Complicated by Lithium Toxicity: A Case Report and Literature Review. J Clin Psychopharmacol 2019; 39:273-275. [PMID: 30939593 DOI: 10.1097/jcp.0000000000001042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Clozapine-induced interstitial nephritis in a patient with schizoaffective disorder in the forensic setting: a case report and review of the literature. Ir J Psychol Med 2019; 39:106-111. [PMID: 31223104 DOI: 10.1017/ipm.2019.24] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We present a rare case of Acute Interstitial Nephritis (AIN) that occurred following a re-trial of clozapine in a 56-year-old lady with schizoaffective disorder. On initial trial of clozapine, this patient felt generally unwell with respiratory symptoms. Her inflammatory markers were raised and her renal function showed a mild, transient deterioration which normalised on the day of cessation of clozapine. Two years later, clozapine was re-trialled due the refractory nature of her psychiatric symptoms. She subsequently developed renal failure and AIN was confirmed by renal biopsy. Renal function improved after cessation of clozapine; however, she never fully regained normal renal function.
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Davis EAK, Kelly DL. Clozapine-associated renal failure: A case report and literature review. Ment Health Clin 2019; 9:124-127. [PMID: 31123659 PMCID: PMC6513053 DOI: 10.9740/mhc.2019.05.124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
One of clozapine's unrecognized potential side effects is renal insufficiency and nephritis. Although most clinicians are aware of the possibility of clozapine-induced myocarditis, less is known about other inflammatory disorders due to clozapine treatment. This patient was started on lithium and clozapine within 4 days of each other although lithium was discontinued after 7 days due to tremor. Routine labs showed an increase in serum creatinine, which was initially attributed to the recent lithium. However, the patient's kidney function continued to worsen, requiring discontinuation of clozapine despite a robust response to a low dose. Several years later, the patient's kidney function improved but has not returned to baseline. This literature review and case report illustrates the similarities in diagnostic presentation of clozapine-associated renal insufficiency as well as potential risk factors. More research should be conducted into the role concomitant sodium valproate and/or lithium play in the risk of clozapine-associated renal insufficiency.
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Hepatitis, Interstitial Nephritis, and Pancreatitis in Association With Clozapine Treatment: A Systematic Review of Case Series and Reports. J Clin Psychopharmacol 2018; 38:520-527. [PMID: 30059436 DOI: 10.1097/jcp.0000000000000922] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE/BACKGROUND Clozapine is the criterion standard in treatment-resistant schizophrenia. We sought to review data on several inflammatory effects associated with clozapine, specifically interstitial nephritis, hepatitis, and pancreatitis. METHODS/PROCEDURES We conducted a systematic review to identify studies, published up until December 2017, describing clozapine-induced hepatitis, nephritis, and pancreatitis. The primary objective was to characterize the clinical characteristics associated with each of the specific inflammatory reactions to clozapine. FINDINGS/RESULTS We identified 42 cases of inflammatory reactions associated with clozapine treatment- 20 :cases of clozapine-induced hepatitis, 11 cases of nephritis, and 11 of pancreatitis. The mean (SD) age was 38.8 (11.9) years. The mean (SD) dose of clozapine used was 252.4 (133.7) mg. Time to onset of pancreatitis (17.9 [11.2] days; range 4-35 days) was shorter than that for hepatitis (34.2 [20.1] days; range, 12-90 days) and nephritis (27.9 [27.0]; range, 8-90 days) but was not statistically significant (F = 2.267, P = 0.117). The mean (SD) time to recovery was shorter for cases of pancreatitis (15.7 [18.4] days) compared with cases of hepatitis (25.9 [16.5] days) and nephritis (24.5 [18.9] days). Three cases with hepatitis died. Seven of the cases had a clozapine rechallenge (hepatitis [n = 3], nephritis [n = 1], pancreatitis [n = 3]), with 5 having a recurrence at a mean (SD) onset of 3.5 (2.5) days (range, 1-7 days); 2 hepatitis cases were successfully rechallenged. IMPLICATIONS/CONCLUSIONS Clozapine-induced hepatitis, nephritis, and pancreatitis are uncommon adverse events, reflected in the paucity of case studies in the literature. Early recognition of the signs and symptoms of clozapine-associated hepatitis, nephritis, and pancreatitis is important, as when identified, clozapine should be urgently discontinued. Clozapine is associated with evidence of benign inflammatory processes; the extent to which hepatitis, and other inflammatory reactions, may be on a continuum with these more benign and self-limiting reactions is unclear, and this can only be resolved by prospectively following cohorts of clozapine-treated patients.
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Ho YC, Lin HL. Continuation with clozapine after eosinophilia: a case report. Ann Gen Psychiatry 2017; 16:46. [PMID: 29259655 PMCID: PMC5731207 DOI: 10.1186/s12991-017-0169-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/06/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Clozapine-induced eosinophilia had been reported in several studies about blood dyscrasias in clozapine-treated patient. The largest study with 2404 patients in Italy found the incidence of 2.2% by criteria of more than 0.4 × 109/l. Associated cases of pancreatitis, hepatitis, colitis, nephritis, and myocarditis were reported. Interestingly, incidence of myocarditis is high in Australia, but low in the rest of the world. In the following, we will present a case of clozapine-induced eosinophilia which spontaneous resolution was noted under continuation of clozapine. CASE PRESENTATION "Mr. L" was a 54-year-old single, jobless man. He had treatment-resistant chronic schizophrenia with onset at age 28. He had received electroconvulsive therapy twice prior to this admission. After admission, a trial of clozapine was started with an initial dose of 100 mg/day, and gradually titrated to 200 mg/day. He experienced notable improvement after 2 weeks with decreased auditory hallucinations and no more self-harm behaviors, but he also developed eosinophilia. A medical workup was performed and showed no signs of end-organ inflammation. We continued clozapine use and closely monitored complete blood count with a differential test to track his eosinophil count by the recommendation of the hematology service. His eosinophil count decreased then and remained within normal limits 3 weeks later. The dosage of clozapine was gradually raised as high as 400 mg/day. His psychotic symptoms got partial remission and continued to show no signs of end-organ inflammation at the time of discharge. CONCLUSIONS The pathophysiology of clozapine-induced eosinophilia is still unknown, but resolution of eosinophilia despite ongoing clozapine treatment suggests the possibility of an acute allergic reaction. Signs or symptoms of organ inflammation are important for management of eosinophilia. In this case report, we demonstrated that if eosinophilia occurred without signs or symptoms of organ inflammation, it may be justified to continue clozapine use under careful monitoring.
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Affiliation(s)
- Yen-Cheng Ho
- Department of Psychiatry, Chang-Gung Memorial Hospital at Linkuo, Taoyuan City, Taiwan.,Chang-Gung University School of Medicine, Taoyuan City, Taiwan
| | - Huang-Li Lin
- Department of Psychiatry, Chang-Gung Memorial Hospital at Linkuo, Taoyuan City, Taiwan.,Chang-Gung University School of Medicine, Taoyuan City, Taiwan
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Hauben M, Aronson JK, Ferner RE. Evidence of Misclassification of Drug–Event Associations Classified as Gold Standard ‘Negative Controls’ by the Observational Medical Outcomes Partnership (OMOP). Drug Saf 2016; 39:421-32. [DOI: 10.1007/s40264-016-0392-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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10
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Nikolić-Kokić A, Mijušković A, Tatalović N, Nestorov J, Miler M, Oreščanin-Dušić Z, Nikolić M, Milošević V, Blagojević D, Spasić M, Miljević Č. Effects of antipsychotic drug administration on antioxidative defense enzymes in male rat kidney. JOURNAL OF TOXICOLOGY AND ENVIRONMENTAL HEALTH. PART A 2016; 79:905-911. [PMID: 27644343 DOI: 10.1080/15287394.2016.1201706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 06/11/2016] [Indexed: 06/06/2023]
Abstract
The use of atypical antipsychotic drugs (APD) was reported to be associated with adverse effects on the kidneys. Thus, the aim of this study was to examine whether APD exerted their adverse effects by interfering with the renal antioxidant defense system. Male 3-mo-old Wistar rats were treated for 28 d with ziprasidone (ZIP), clozapine (CLO), or sertindole (SER) using a daily dose recommended for antipsychotic drug therapy. The expression and activities of antioxidant enzymes superoxide dismutase (SOD) type 1 and type 2, catalase (CAT), glutathione reductase (GR), and glutathione S-transferases (GSTs) activity were measured in the kidneys. Changes in the kidneys were also evaluated histologically. Ziprasidone, CLO, and SER reduced renal SOD type 1 and type 2 activities. Decreased CAT activity was observed only in SER-treated rats. An inhibition in GR activity and increased activity of GST was found only after treatment with CLO. Histological analysis showed dilatation of proximal tubules in kidneys with all three drugs. In conclusion, data indicate that redox disturbances may contribute to renal morphologic alterations in proximal tubules in rats treated with all APD.
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Affiliation(s)
- Aleksandra Nikolić-Kokić
- a Department of Physiology , Institute for Biological Research "Siniša Stanković," University of Belgrade , Belgrade , Serbia
| | - Ana Mijušković
- a Department of Physiology , Institute for Biological Research "Siniša Stanković," University of Belgrade , Belgrade , Serbia
| | - Nikola Tatalović
- a Department of Physiology , Institute for Biological Research "Siniša Stanković," University of Belgrade , Belgrade , Serbia
| | - Jelena Nestorov
- b Department of Biochemistry , Institute for Biological Research "Siniša Stanković," University of Belgrade , Belgrade , Serbia
| | - Marko Miler
- c Department of Cytology , Institute for Biological Research "Siniša Stanković," University of Belgrade , Belgrade , Serbia
| | - Zorana Oreščanin-Dušić
- a Department of Physiology , Institute for Biological Research "Siniša Stanković," University of Belgrade , Belgrade , Serbia
| | - Milan Nikolić
- d Department of Biochemistry, Faculty of Chemistry , University of Belgrade , Belgrade , Serbia
| | - Verica Milošević
- c Department of Cytology , Institute for Biological Research "Siniša Stanković," University of Belgrade , Belgrade , Serbia
| | - Duško Blagojević
- a Department of Physiology , Institute for Biological Research "Siniša Stanković," University of Belgrade , Belgrade , Serbia
| | - Mihajlo Spasić
- a Department of Physiology , Institute for Biological Research "Siniša Stanković," University of Belgrade , Belgrade , Serbia
| | - Čedo Miljević
- e Institute of Mental Health, School of Medicine , University of Belgrade , Belgrade , Serbia
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Lundblad W, Azzam PN, Gopalan P, Ross CA. Medical management of patients on clozapine: A guide for internists. J Hosp Med 2015; 10:537-43. [PMID: 25809850 DOI: 10.1002/jhm.2345] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 02/05/2015] [Accepted: 02/13/2015] [Indexed: 11/07/2022]
Abstract
Clozapine was approved by the US Food and Drug Administration in 1989 for the management of treatment-resistant schizophrenia, and has since proven to reduce symptom burden and suicide risk, increase quality of life, and reduce substance use in individuals with psychotic disorders. Nevertheless, clozapine's psychiatric benefits have been matched by its adverse effect profile. Because they are likely to encounter medical complications of clozapine during admissions or consultations for other services, hospitalists are compelled to maintain an appreciation for these iatrogenic conditions. The authors outline common (eg, constipation, sialorrhea, weight gain) and serious (eg, agranulocytosis, seizures, myocarditis) medical complications of clozapine treatment, with internist-targeted recommendations for management, including indications for clozapine discontinuation.
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Affiliation(s)
- Wynne Lundblad
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pierre N Azzam
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Priya Gopalan
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Parekh R, Fattah Z, Sahota D, Colaco B. Clozapine induced tubulointerstitial nephritis in a patient with paranoid schizophrenia. BMJ Case Rep 2014; 2014:bcr2013203502. [PMID: 24849641 PMCID: PMC4039933 DOI: 10.1136/bcr-2013-203502] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2014] [Indexed: 11/03/2022] Open
Abstract
We describe the development of tubulointerstitial nephritis after starting clozapine therapy in a patient with treatment-resistant schizophrenia. A 54-year-old mixed-race patient with a longstanding history of paranoid schizophrenia was started on the antipsychotic clozapine. Two months after starting clozapine he developed fevers, cough and acute renal failure which initially responded to 7 days of prednisolone but recurred after completing the steroid course. Renal biopsy confirmed acute tubulointerstitial nephritis and he was started on a course of steroids with renal recovery in 72 h. Clozapine was later stopped. This case highlights a serious and potential life-threatening complication of an important antipsychotic used in treatment-resistant schizophrenia.
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Affiliation(s)
| | | | | | - Bernie Colaco
- Department of Rheumatology, Central Middlesex Hospital, London, UK
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An NY, Lee J, Noh JS. A case of clozapine induced acute renal failure. Psychiatry Investig 2013; 10:92-4. [PMID: 23483092 PMCID: PMC3590438 DOI: 10.4306/pi.2013.10.1.92] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Revised: 07/26/2012] [Accepted: 08/01/2012] [Indexed: 12/22/2022] Open
Abstract
There have been a few case reports that clozapine, an atypical antipsychotic, caused acute renal failure of interstitial type. Here we report a case of a 38-year-old Korean male patient with treatment-resistant bipolar I disorder who developed acute renal failure after the initiation of treatment with clozapine. We describe the clinical and laboratory findings of the case and discuss the measures for early detection of this life threating condition. Within our knowledge, this is the first report of clozapine-induced acute renal failure in South Korea.
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Affiliation(s)
- Na Young An
- Department of Psychiatry & Behavioral Sciences, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jeewon Lee
- Department of Psychiatry & Behavioral Sciences, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jai Sung Noh
- Department of Psychiatry & Behavioral Sciences, Ajou University School of Medicine, Suwon, Republic of Korea
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Kanofsky JD, Woesner ME, Harris AZ, Kelleher JP, Gittens K, Jerschow E. Antibiotic treatment may exacerbate clozapine induced renal failure. Intern Med J 2012; 42:1272. [DOI: 10.1111/j.1445-5994.2012.02906.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 07/09/2012] [Indexed: 11/30/2022]
Affiliation(s)
- J. D. Kanofsky
- Bronx Psychiatric Center; Bronx USA
- Department of Psychiatry, Montefiore Medical Center; Albert Einstein College of Medicine; Bronx USA
| | - M. E. Woesner
- Bronx Psychiatric Center; Bronx USA
- Department of Psychiatry, Montefiore Medical Center; Albert Einstein College of Medicine; Bronx USA
| | - A. Z. Harris
- Department of Psychiatry; Weill Cornell Medical College; New York USA
| | - J. P. Kelleher
- New York Medical College; St Vincent's Hospital Westchester; Harrison New York USA
| | | | - E. Jerschow
- Department of Allergy and Immunology, Montefiore Medical Center; Albert Einstein College of Medicine; Bronx USA
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Bowen DJ, Lucas NL, Braude S. Persistent febrile illness with multisystem organ failure associated with clozapine. Intern Med J 2012; 42:104-6. [PMID: 22389904 DOI: 10.1111/j.1445-5994.2011.02607.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kanofsky JD, Woesner ME, Harris AZ, Kelleher JP, Gittens K, Jerschow E. A case of acute renal failure in a patient recently treated with clozapine and a review of previously reported cases. Prim Care Companion CNS Disord 2011; 13:PCC.10br01091. [PMID: 21977363 PMCID: PMC3184555 DOI: 10.4088/pcc.10br01091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Accepted: 12/21/2010] [Indexed: 01/22/2023] Open
Abstract
Clozapine has been reported to cause acute renal failure due to acute interstitial nephritis. We discuss a case of clozapine-induced acute renal failure and compare it to 7 other cases reported in the literature. We review the signs and symptoms of the hypersensitivity response, such as fever and eosinophilia, caused by clozapine and make recommendations for early detection. Early detection and prompt discontinuation of clozapine can prevent renal damage, as can the avoidance of other nephrotoxic drugs like antibiotics.
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Clozapine-induced interstitial nephritis - a rare but important complication: a case report. J Med Case Rep 2009; 3:8574. [PMID: 20126316 PMCID: PMC2815648 DOI: 10.4076/1752-1947-3-8574] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2008] [Accepted: 02/09/2009] [Indexed: 11/25/2022] Open
Abstract
Introduction Given the limited range of effective drug treatments for patients with schizophrenia, increasing numbers of patients, often termed 'treatment-resistant' are prescribed clozapine. While the induction of neutropenia or agranulocytosis by clozapine is well appreciated, other rare potentially fatal adverse reactions may also occur including acute interstitial nephritis as reported in this case. Case presentation A 57-year-old Caucasian woman with treatment-resistant chronic schizophrenia developed acute renal failure following initiation of treatment with clozapine. The adverse reaction occurred after only four doses of the drug had been administered (titrated from 12.5 to 25 mg per day). After clozapine had been withdrawn, the patient's renal function returned to normal with no other changes to medication. The patient had been exposed to clozapine about 4 years previously when she had developed a similar reaction. Conclusion Renal reactions to clozapine are extremely rare but, if not recognized promptly, may prove fatal. Psychiatrists need to be aware of this possible complication when clozapine is initiated.
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Hunter R, Gaughan T, Queirazza F, McMillan D, Shankie S. Clozapine-induced interstitial nephritis - a rare but important complication: a case report. J Med Case Rep 2009. [DOI: 10.1186/1752-1947-0003-0000008574] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Shen H, Li R, Xiao H, Zhou Q, Cui Q, Chen J. Higher serum clozapine level is associated with increased antiphospholipid antibodies in schizophrenia patients. J Psychiatr Res 2009; 43:615-9. [PMID: 18976782 DOI: 10.1016/j.jpsychires.2008.09.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 09/12/2008] [Accepted: 09/15/2008] [Indexed: 01/28/2023]
Abstract
OBJECTIVES This study was to evaluate the relationship between clozapine and aPL in schizophrenia patients. METHODS 163 Participants were evaluated: 37 unmedicated schizophrenia patients, 50 clozapine-treated schizophrenia patients and 76 age- and sex-matched healthy controls. A fasting blood sample was taken for serum aPL and serum clozapine level. Serum aPL were measured by ELISA technique and HPLC method was used for the determination of serum clozapine level. RESULTS The unmedicated schizophrenia patients showed higher IgG aCL level [mean+/-SD: 1.51+/-0.81 and 1.25+/-0.13 U, respectively (t=2.77, df=111, p<0.01)] and IgM aCL level [mean+/-SD: 1.53+/-0.54. and 1.33+/-0.15 U, respectively (t=-2.98, df=111, p<0.01)] compared with the healthy controls. The comparison of the clozapine-treated schizophrenia patients and the healthy controls showed significant difference in IgG aCL level [mean+/-SD: 1.74+/-0.90 and 1.25+/-0.13 U, respectively (t=-4.77, df=124, p<0.01)] and IgM aCL level [mean+/-SD: 1.62+/-0.83 and 1.33+/-0.15 U, respectively (t=-4.35, df=124, p<0.01)]. In clozapine-treated schizophrenia patients, the results of Pearson correlation coefficients showed that there was a significant positive relationship between serum IgM aCL and serum clozapine level (r=0.461, p<0.01), and serum IgG aCL were significantly correlated with serum IgM aCL (r=0.279, p<0.05). Stepwise multiple regression analysis was performed with various characteristics, such as duration of medication, daily dose and serum clozapine level as candidate factors for serum aCL (IgG and IgM isotypes) in clozapine-treated schizophrenia patients. Only serum clozapine level was able to enter into the regression model of IgM aCL (Model R(2)=0.212, p<0.05). CONCLUSIONS A higher serum clozapine level is associated with an increased aPL in schizophrenia patients.
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Affiliation(s)
- Hong Shen
- Neuro-psychiatric Institute, Nanjing Brain Hospital Affiliated to Nanjing Medical University, 264 Guangzhou Road, Nanjing 210029, China
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20
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Coelho M, Ferreira J, Rosa M, Sampaio C. Treatment options for non-motor symptoms in late-stage Parkinson's disease. Expert Opin Pharmacother 2008; 9:523-35. [DOI: 10.1517/14656566.9.4.523] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Siddiqui BK, Asim S, Shamim A, Pillai N, Rajan S. Simultaneous allergic interstitial nephritis and cardiomyopathy in a patient on clozapine. NDT Plus 2008; 1:55-56. [PMID: 30792788 PMCID: PMC6375230 DOI: 10.1093/ndtplus/sfm003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Bilal K Siddiqui
- Department of Internal Medicine, Long Island Jewish Medical Center, New York, USA
| | - Syed Asim
- Department of Medicine, Danbury Hospital, Danbury, CT, USA
| | - Afroz Shamim
- Department of Psychiatry, Zucker Hillside Hospital, Glen Oaks, New York, USA
| | - Nisha Pillai
- Department of Internal Medicine, Long Island Jewish Medical Center, New York, USA
| | - Sujatha Rajan
- Department of Internal Medicine, Long Island Jewish Medical Center, New York, USA
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22
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Abstract
OBJECTIVE To review the published literature on serious adverse cardiac events associated with the atypical antipsychotic agent, clozapine, and to make recommendations for cardiac assessment of candidates for clozapine treatment and for monitoring of cardiac status after treatment is initiated. DATA SOURCES We searched the PubMed and MEDLINE databases for articles published from 1970 to 2004 that contain the keywords "clozapine and myocarditis," "clozapine and cardiomyopathy," "clozapine and cardiotoxicity," "clozapine and sudden death" or "clozapine and mortality." We also manually searched the bibliographies of these articles for related sources. STUDY SELECTION We reviewed the 30 case reports, case series, laboratory and clinical trials, data mining studies, and previous reviews identified by this search. DATA SYNTHESIS Recent evidence suggests that clozapine is associated with a low (0.015% to 0.188%) risk of potentially fatal myocarditis or cardiomyopathy. The drug is not known to be independently associated with pathologic prolongation of the QTc interval, but it may contribute to pathologic QTc prolongation in patients with other risk factors for this condition. CONCLUSIONS The low risk of a serious adverse cardiac event should be outweighed by a reduction in suicide risk for most patients taking clozapine. We provide recommendations for assessing and monitoring cardiac status in patients prior to and after initiation of treatment with clozapine.
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Affiliation(s)
- David B Merrill
- New York State Psychiatric Institute, Department of Psychiatry, Columbia University, New York, NY 10032, USA.
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23
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Fineschi V, Neri M, Riezzo I, Turillazzi E. Sudden cardiac death due to hypersensitivity myocarditis during clozapine treatment. Int J Legal Med 2004; 118:307-9. [PMID: 15235919 DOI: 10.1007/s00414-004-0464-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The case concerns the sudden death of a 29-year-old male during clozapine therapy started 2 weeks before. He had a history of treatment-resistant chronic schizophrenia. A complete immunohistochemical study was performed on heart specimens. Histologically, the heart presented diffuse eosinophilic infiltrates located around perivascular structures and focal myocyte necrosis with numerous interstitial eosinophils admixed with histiocytes. The diagnosis of acute myocarditis with an eosinophilic infiltrate was established as the cause of death. The autopsy findings and a detailed medical history supported the conclusion that clozapine-induced hypersensitivity myocarditis was the most likely cause of death.
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Affiliation(s)
- Vittorio Fineschi
- Institute of Legal Medicine, University of Foggia Ospedali Riuniti, Foggia, Italy.
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24
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Haack MJ, Bak MLFJ, Beurskens R, Maes M, Stolk LML, Delespaul PAEG. Toxic rise of clozapine plasma concentrations in relation to inflammation. Eur Neuropsychopharmacol 2003; 13:381-5. [PMID: 12957337 DOI: 10.1016/s0924-977x(03)00042-7] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Recently a small number of patients were observed in two psychiatric hospitals in the Netherlands with clozapine intoxications that complicate or mimic infections. These patients were on chronic medication and normally had stable clozapine blood plasma levels. This article presents four of these cases. Medline was searched for reports of similar cases. A hypothesis was formulated and tested by literature study. Immune modulatory and toxic effects of clozapine protein reactive metabolites or haptens, may play a role in the development of inflammation. Clozapine has a direct influence on different cytokines resembling an inflammatory reaction. Infection or inflammation could induce bioactivation of clozapine into its nitrenium ion that can exert a toxic reaction that induces apoptosis and gives rise to elevated cytokine levels. Clozapine can function as a hapten and induce an IgG, IgM or IgE mediated hypersensitivity reaction. The cytokines released during infection or inflammation downregulate the clozapine metabolism in the P450 system through CYP 1A2. Clozapine plasma levels should be monitored closely if an inflammatory or infectious process is suspected.
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Affiliation(s)
- Marie Jeanne Haack
- Department of Psychiatry and Neuropsychology, University of Maastricht, Maastricht, The Netherlands
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25
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Abstract
We report the case of an 85 year old woman, admitted to hospital with a two month history of a depressive illness. Within one week of commencing treatment with citalopram 20mg daily, she had developed a widespread rash, bilateral ankle oedema and a range of biochemical and haematological abnormalities, including marked elevations of plasma urea and creatinine and increased neutrophil and eosinophil counts. Following withdrawal of citalopram, her physical state returned to normal within two weeks. The episode is suggestive of acute interstitial nephritis triggered by citalopram, a phenomenon not previously reported in association with the selective serotonin reuptake inhibitors.
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26
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Abstract
BACKGROUND Clozapine is effective for resistant schizophrenia. After two sudden deaths in physically well young men soon after starting clozapine, we investigated the cardiovascular complications for this drug. METHODS From January, 1993, to March, 1999, 8000 patients started clozapine treatment in Australia, and were registered with a mandatory monitoring service. We identified cases of myocarditis and cardiomyopathy from voluntary reports to the Australian Adverse Drug Reaction Committee and sought details of the relevant diagnostic studies, necropsies that had been done in suspicious cases, or both. FINDINGS 23 cases (20 men, three women, mean age 36 years [SD 9]) were identified: 15 of myocarditis and eight of cardiomyopathy associated with clozapine treatment. Six patients died. All cases of myocarditis (five deaths) occurred within 3 weeks of starting clozapine. Cardiomyopathy (one death) was diagnosed up to 36 months after clozapine was started. Necropsy results showed mainly eosinophilic infiltrates with myocytolysis, consistent with an acute drug reaction. INTERPRETATION Clozapine therapy may be associated with potentially fatal myocarditis and cardiomyopathy in physically healthy young adults with schizophrenia.
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Affiliation(s)
- J G Kilian
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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