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Qubad M, Dupont G, Hahn M, Martin SS, Puntmann V, Nagel E, Reif A, Bittner RA. When, Why and How to Re-challenge Clozapine in Schizophrenia Following Myocarditis. CNS Drugs 2024; 38:671-696. [PMID: 38951464 PMCID: PMC11316720 DOI: 10.1007/s40263-024-01100-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 07/03/2024]
Abstract
Clozapine-induced myocarditis (CIM) is among the most important adverse events limiting the use of clozapine as the most effective treatment for schizophrenia. CIM necessitates the immediate termination of clozapine, often resulting in its permanent discontinuation with considerable detrimental effects on patients' psychopathology and long-term outcome. Consequently, a clozapine re-challenge after CIM is increasingly regarded as a viable alternative, with published reports indicating a success rate of approximately 60%. However, published cases of re-challenges after CIM remain limited. Here, we provide a narrative review of the current state of research regarding the epidemiology, pathophysiology, risk factors, diagnosis and clinical management of CIM as well as a synthesis of current recommendations for re-challenging patients after CIM. This includes a step-by-step guide for this crucial procedure based on the current evidence regarding the pathophysiology and risk factors for CIM. Slow dose titration regimes and addressing risk factors including concomitant valproate and olanzapine are crucial both to prevent CIM and to ensure a safe and successful re-challenge. Furthermore, we discuss the utility of C-reactive protein, troponin, N-terminal-pro hormone and brain natriuretic peptide, therapeutic drug-monitoring and cardiac magnetic resonance imaging for CIM screening and diagnosis as well as for post-CIM re-challenges.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
| | - Gabriele Dupont
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Martina Hahn
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- Department of Mental Health, Varisano Hospital Frankfurt Hoechst, Frankfurt, Germany
| | - Simon S Martin
- Department of Radiology, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Valentina Puntmann
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Eike Nagel
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Robert A Bittner
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
- Ernst Strüngmann Institute for Neuroscience (ESI) in Cooperation with Max Planck Society, Frankfurt, Germany.
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Zhu Z, Wu R, Luo M, Zeng L, Zhang D, Hu N, Hu Y, Li Y. Two-Dimensional Deep Learning Frameworks for Drug-Induced Cardiotoxicity Detection. ACS Sens 2024; 9:3316-3326. [PMID: 38842187 DOI: 10.1021/acssensors.4c00654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
The identification of drug-induced cardiotoxicity remains a pressing challenge with far-reaching clinical and economic ramifications, often leading to patient harm and resource-intensive drug recalls. Current methodologies, including in vivo and in vitro models, have severe limitations in accurate identification of cardiotoxic substances. Pioneering a paradigm shift from these conventional techniques, our study presents two deep learning-based frameworks, STFT-CNN and SST-CNN, to assess cardiotoxicity with markedly improved accuracy and reliability. Leveraging the power of induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) as a more human-relevant cell model, we record mechanical beating signals through impedance measurements. These temporal signals were converted into enriched two-dimensional representations through advanced transformation techniques, specifically short-time Fourier transform (STFT) and synchro-squeezing transform (SST). These transformed data are fed into the proposed frameworks for comprehensive analysis, including drug type classification, concentration classification, cardiotoxicity classification, and new drug identification. Compared to traditional models like recurrent neural network (RNN) and 1-dimensional convolutional neural network (1D-CNN), SST-CNN delivered an impressive test accuracy of 98.55% in drug type classification and 99% in distinguishing cardiotoxic and noncardiotoxic drugs. Its feasibility is further highlighted with a stellar 98.5% average accuracy for classification of various concentrations, and the superiority of our proposed frameworks underscores their promise in revolutionizing drug safety assessments. With a potential for scalability, they represent a major leap in drug safety assessments, offering a pathway to more robust, efficient, and human-relevant cardiotoxicity evaluations.
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Affiliation(s)
- Zhijing Zhu
- Key Laboratory of Novel Targets and Drug Study for Neural Repair of Zhejiang Province, School of Medicine, Hangzhou City University, Hangzhou 310015, China
| | - Ruochen Wu
- University of Illinois at Urbana-Champaign, Urbana, Illinois 61801, United States
| | - Ma Luo
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou 311121, China
| | - Linghui Zeng
- Key Laboratory of Novel Targets and Drug Study for Neural Repair of Zhejiang Province, School of Medicine, Hangzhou City University, Hangzhou 310015, China
| | - Diming Zhang
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou 311121, China
| | - Ning Hu
- Department of Chemistry, Zhejiang-Israel Joint Laboratory of Self-Assembling Functional Materials, ZJU-Hangzhou Global Scientific and Technological Innovation Center, Zhejiang University, Hangzhou 310058, China
- General Surgery Department, Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310052, China
| | - Ye Hu
- Nanjing Institute for Food and Drug Control, Nanjing, Jiangsu 211198, China
| | - Ying Li
- College of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, China
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De Las Cuevas C, Sanz EJ, Gross JA, Correll CU, Verdoux H, Lally J, de Filippis R, Schulte PFJ, Molden E, Arrojo-Romero M, Bostrom AD, Schoretsanitis G, Fernandez-Egea E, de Leon J. Revealing the reporting disparity: VigiBase highlights underreporting of clozapine in other Western European countries compared to the UK. Schizophr Res 2024; 268:175-188. [PMID: 38065799 DOI: 10.1016/j.schres.2023.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 06/15/2024]
Abstract
BACKGROUND Pharmacovigilance studies indicate clozapine history is marked by adverse drug reactions (ADRs). OBJECTIVE In a 2021 article, the United Kingdom (UK) had >90 % of European clozapine-related fatal outcomes in VigiBase, the World Health Organization's pharmacovigilance database. Two possibly opposing hypotheses could explain this disparity: 1) fewer reported fatal outcomes in other Western European countries mainly reflect underreporting to VigiBase, and 2) the higher number of UK reports reflects higher real relative mortality. METHODS VigiBase reports from clozapine's introduction to December 31, 2022, were studied for ADRs and the top 10 causes of fatal outcomes. The UK was compared with 11 other top reporting Western countries (Germany, Denmark, France, Finland, Ireland, Italy, Netherlands, Norway, Spain, Sweden and Switzerland). Nine countries (except Ireland and Switzerland) were compared after controlling for population and clozapine prescriptions. RESULTS The UK accounted for 29 % of worldwide clozapine-related fatal outcomes, Germany 2 % and <1 % in each of the other countries. The nonspecific label "death" was the top cause in the world (46 %) and in the UK (33 %). "Pneumonia" was second in the world (8 %), the UK (12 %), Ireland (8 %) and Finland (14 %). Assuming that our corrections for population and clozapine use are correct, other countries underreported only 1-10 % of the UK clozapine fatal outcome number. CONCLUSIONS Different Western European countries consistently underreport to VigiBase compared to the UK, but have different reporting/publishing styles for clozapine-related ADRs/fatal outcomes. Three Scandinavian registries suggest lives are saved as clozapine use increases, but this cannot be studied in pharmacovigilance databases.
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Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain; Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, 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
| | | | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany; The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA.
| | - Hélène Verdoux
- Université Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, Bordeaux, France.
| | - John Lally
- Department of Psychiatry, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.; Department of Psychiatry, St Vincent's Hospital Fairview, Dublin, Ireland; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK.
| | - Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Peter F J Schulte
- Mental Health Services Noord-Holland-Noord, Alkmaar, the Netherlands; Dutch Clozapine Collaboration Group, Castricum, the Netherlands.
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway; Department of Pharmacy, University of Oslo, Oslo, Norway.
| | - Manuel Arrojo-Romero
- Department of Psychiatry, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain.
| | - Adrian D Bostrom
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences/Psychiatry, Umeå University, Umeå, Sweden.
| | - Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA; Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland
| | - Emilio Fernandez-Egea
- Department of Psychiatry, University of Cambridge, Cambridge, UK,; Cambridgeshire and Peterborough NHS Foundation Trust, Fulbourn Hospital, Fulbourn, Cambridge, UK.
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain.
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de Filippis R, De Las Cuevas C, Sanz EJ, Schoretsanitis G, Correll CU, de Leon J. Clozapine-associated pericarditis and pancreatitis in children and adolescents: A systematic literature review and pharmacovigilance study using the VigiBase database. Schizophr Res 2024; 268:118-130. [PMID: 37981478 DOI: 10.1016/j.schres.2023.10.027] [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: 07/31/2023] [Revised: 10/25/2023] [Accepted: 10/25/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND The literature has paid very little attention to pericarditis, pericardial effusion and pancreatitis during clozapine treatment in children and adolescents. METHODS Cases of clozapine-associated pericarditis and pancreatitis in children were studied using searches in: 1) PubMed (June 16, 2023), and 2) the World Health Organization's pharmacovigilance database (June 1, 2022), VigiBase. VigiBase uses a logarithmic measure of disproportionality called the information component (IC). RESULTS The PubMed search yielded 3 clozapine-associated pericarditis cases, 1 pancreatitis case and 1 with both. VigiBase provided a significant clozapine-associated pericarditis IC = 3.6 with an IC025 = 2.9 (only 3 cases were expected while 22 were observed). VigiBase provided a significant clozapine-associated pancreatitis IC = 2.2 with an IC025 = 1.4 (only 3 cases were expected while 16 were observed). In VigiBase clozapine-associated pericarditis and pericardial effusion in youth looked similar and on a continuum with myocarditis, as myocarditis, pericarditis and pancreatitis appeared to occur mainly during clozapine titration. Combining PubMed and VigiBase we identified: 1) 29 cases of at least possible clozapine-associated pericarditis/pericardial effusion (6 probable and 23 possible) including 7 cases with and 22 without myocarditis, and 2) 17 cases of clozapine-associated pancreatitis (1 definite and 16 possible). Two of the pancreatitis cases occurred during overdoses. No fatal outcomes were found in any clozapine-associated pericarditis and pancreatitis cases. CONCLUSIONS Despite the lack of attention in the literature to clozapine-associated pericarditis and pancreatitis, results demonstrate that they can happen in youth, particularly during titration. Pericarditis and pancreatitis appear to be forms of clozapine-associated inflammation during dose titration.
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Affiliation(s)
- Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy.
| | - Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain; Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, 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
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland; Department of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York, USA
| | - Christoph U Correll
- Department of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York, USA; Department of Psychiatry and Molecular Medicine, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany.
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain.
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Bellissima BL, Burns KE, Helsby NA, Kingston EL, Garavan F, Tingle MD. Clozapine metabolism and cardiotoxicity: A prospective longitudinal study. Int J Cardiol 2024; 403:131788. [PMID: 38244893 DOI: 10.1016/j.ijcard.2024.131788] [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: 08/26/2023] [Revised: 12/19/2023] [Accepted: 01/14/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Clozapine-induced myocarditis and cardiomyopathy are difficult to detect clinically and may be fatal if not detected early. The current/routine biomarkers for clozapine-induced myocarditis are non-specific indicators of inflammation (C-reactive protein) or cardiomyocyte damage (troponins I and T) that lack sensitivity, and for which changes often arise too late to be clinically useful. METHODS The Clozapine Safety Study was a prospective, longitudinal, observational study to determine what, if any, the plasma concentrations of clozapine, N-desmethylclozapine, and clozapine-N-oxide in patients contribute to cardiotoxicity. Samples were collected and analysed using liquid chromatography mass spectrometry over a 41-month period from patients in the Auckland District Health Board. RESULTS Sixty-seven patients were included. Six patients were diagnosed with myocarditis; none were diagnosed with cardiomyopathy in the study period. In patients not undergoing dose titration, clozapine biotransformation may shift to the N-oxide pathway rather than the N-desmethyl pathway with increasing dose. During dose titration, the timeframe in which myocarditis occurs, the rate of increase in the plasma concentration of clozapine-N-oxide, as well as the ratio of N-oxidation relative to N-desmethylation, were significantly higher in patients diagnosed with myocarditis. CONCLUSIONS The assessment of clozapine-N-oxide formation, and N-oxidation relative to N-desmethylation ratios during treatment, may help identify a biomarker to aid the early detection of patients at risk of developing clozapine-induced cardiotoxicity.
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Affiliation(s)
- Brandi L Bellissima
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Kathryn E Burns
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Nuala A Helsby
- Department of Molecular Medicine and Pathology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Ellen L Kingston
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Fintan Garavan
- Department of Forensic Pathology, Auckland District Health Board, LabPLUS, Auckland City Hospital, Gate 4, Grafton Road, PO Box 110031, Auckland, New Zealand.
| | - Malcom D Tingle
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
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de Leon J. Can Slow Personalized Titration Using C-Reactive Protein Monitoring Decrease the High Rates and Mortality of Clozapine-Associated Myocarditis Seen in Some Countries? A Call for Research. J Clin Psychopharmacol 2024; 44:212-219. [PMID: 38595145 DOI: 10.1097/jcp.0000000000001843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
PURPOSE/BACKGROUND The hypothesis that slower personalized titration may prevent clozapine-associated myocarditis and decrease the disproportion incidence of 3% found in Australia was not described in a recent Australian article in this journal. METHODS Six countries in addition to Australia have published information suggesting a similar incidence of clozapine-associated myocarditis. On September 19, 2023, PubMed searches were updated for articles from the United States, Korea, Japan, Canada, New Zealand, and Turkey. FINDINGS/RESULTS An incidence of 3.5% (4/76) was found in a US hospital, but US experts were the first to propose that clozapine-associated myocarditis may be a hypersensitivity reaction associated with rapid titration and possibly preventable. Koreans and Japanese are of Asian ancestry and need lower minimum therapeutic doses for clozapine than patients of European ancestry. A 0.1% (2/1408) incidence of myocarditis during clozapine titration was found in a Korean hospital, but pneumonia incidence was 3.7% (52/1408). In 7 Japanese hospitals, 34% (37/110) of cases of clozapine-associated inflammation were found during faster titrations (based on the official Japanese titration) versus 13% (17/131) during slower titrations (based on the international titration guideline for average Asian patients). Recent limited studies from Canada, New Zealand, and Turkey suggest that slower personalized titration considering ancestry may help prevent clozapine-associated myocarditis. IMPLICATIONS/CONCLUSIONS Other countries have very limited published data on clozapine-associated myocarditis. Based on a recent Australian case series and these non-Australian studies, the author proposes that Australia (and other countries) should use slow personalized titration for clozapine based on ancestry and c-reactive protein monitoring.
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Tirupati S, Arachchi MK. High rates of myocarditis with clozapine in the Hunter region of Australia. Schizophr Res 2024; 264:543-548. [PMID: 38330687 DOI: 10.1016/j.schres.2024.01.030] [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: 07/31/2023] [Revised: 01/09/2024] [Accepted: 01/22/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVE To study the causes of clozapine treatment discontinuation and measure clozapine-induced myocarditis (CIM) rates in an Australian region, to compare the observed rates of CMI with reports from Australia and the world, and discuss factors related to CIM incidence rates in the region. METHODS The study is a retrospective clinical audit of 327 patients prescribed clozapine. All patients were monitored by the mandatory CIM monitoring protocol for the first six weeks of treatment. The validity of a diagnosis of CIM was assessed using six criteria. Socio-demographic and clinical factors and clozapine prescription practices were analysed for their association with CIM. The study could not examine co-existing medical illness, co-prescribed psychotropic medication, genetics, and environmental factors. RESULTS CIM occurred in 9.8 % of the cohort after a mean treatment duration of 19.5 days. The diagnosis of CIM was considered valid in all cases. Gender, age at the start of treatment, ethnicity, cumulative clozapine dose, dose titration, and clozapine/norclozapine ratio were unrelated to CIM. CONCLUSION The CIM rate in the Hunter region was higher than in the rest of Australia and the world and increased after adopting the monitoring protocol. Over-diagnosis, patient's age and gender, ethnicity, cumulative clozapine dose, dosing titration, and clozapine metabolism rate were unrelated to the high occurrence rates. The possible role of comorbid illnesses, co-prescribed psychiatric medications, genetic, and environmental factors in the etiology of CIM requires further study. The reasons underlying the high rates of CIM in the Hunter region need further exploration.
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Affiliation(s)
- Srinivasan Tirupati
- Psychiatric Rehabilitation Service, Hunter New England Mental Health, Morisset, NSW 2264, Australia; School of Medicine and Public Health, Faculty of Health, The University of Newcastle, Callaghan, NSW 2308, Australia.
| | - Mahinda K Arachchi
- Psychiatric Rehabilitation Service, Hunter New England Mental Health, Morisset, NSW 2264, Australia
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Brennan D, Lal S, Hugo F, Waters F, Shymko G. Clozapine-related tachycardia: A conundrum to identify and treat. Australas Psychiatry 2024; 32:84-88. [PMID: 38165132 DOI: 10.1177/10398562231224156] [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] [Indexed: 01/03/2024]
Abstract
OBJECTIVE This study examined the rates and persistence of clozapine-induced tachycardia and heart-rate differences in patients treated with β-blockers in the largest sample of patients with a psychotic disorder to date. METHOD An audit of medical files for 101 patients who attended a clozapine community clinic and analysis of monthly measurements of resting heart rates. RESULTS 51% met the clinical criteria for tachycardia. Heart rates were stable over time. β-blockers were associated with small but significant reductions in heart rates. CONCLUSION The cardiovascular risks of clozapine are often overlooked. β-blockers are useful in lowering heart rates but they may be insufficient to reduce cardiac risk.
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Affiliation(s)
- Dermot Brennan
- Armadale Health Service, East Metropolitan Health Service, Armadale, WA, Australia
| | - Sweta Lal
- Armadale Health Service, East Metropolitan Health Service, Armadale, WA, Australia
- Peel and Rockingham Kwinana (PaRK) Mental Health Service, South Metropolitan Health Service, Rockingham, WA, Australia
| | - Frans Hugo
- Armadale Health Service, East Metropolitan Health Service, Armadale, WA, Australia
| | - Flavie Waters
- School of Psychological Sciences, The University of Western Australia, Perth, WA, Australia
- Black Swan Health, Headspace Youth Early Psychosis Program, Perth, WA, Australia
- North Metropolitan Health Service, Clinical Research Centre, Mount Claremont, WA, Australia
| | - Gordon Shymko
- Peel and Rockingham Kwinana (PaRK) Mental Health Service, South Metropolitan Health Service, Rockingham, WA, Australia
- Black Swan Health, Headspace Youth Early Psychosis Program, Perth, WA, Australia
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Kingston E, Tingle M, Bellissima BL, Helsby N, Burns K. CYP-catalysed cycling of clozapine and clozapine- N-oxide promotes the generation of reactive oxygen species in vitro. Xenobiotica 2024; 54:26-37. [PMID: 38108307 DOI: 10.1080/00498254.2023.2294473] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023]
Abstract
Clozapine is an effective atypical antipsychotic indicated for treatment-resistant schizophrenia, but is under-prescribed due to the risk of severe adverse drug reactions such as myocarditis.A mechanistic understanding of clozapine cardiotoxicity remains elusive.This study aimed to investigate the contribution of selected CYP isoforms to cycling between clozapine and its major circulating metabolites, N-desmethylclozapine and clozapine-N-oxide, with the potential for reactive species production.CYP supersome™-based in vitro techniques were utilised to quantify specific enzyme activity associated with clozapine, clozapine-N-oxide and N-desmethylclozapine metabolism.The formation of reactive species within each incubation were quantified, and known intermediates detected.CYP3A4 predominately catalysed clozapine-N-oxide formation from clozapine and was associated with concentration-dependent reactive species production, whereas isoforms favouring the N-desmethylclozapine pathway (CYP2C19 and CYP1A2) did not produce reactive species.Extrahepatic isoforms CYP2J2 and CYP1B1 were also associated with the formation of clozapine-N-oxide and N-desmethylclozapine but did not favour one metabolic pathway over another.Unique to this investigation is that various CYP isoforms catalyse clozapine-N-oxide reduction to clozapine.This process was associated with the concentration-dependent formation of reactive species with CYP3A4, CYP1B1 and CYP1A1 that did not correlate with known reactive intermediates, implicating metabolite cycling and reactive oxygen species in the mechanism of clozapine-induced toxicity.
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Affiliation(s)
- Ellen Kingston
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Auckland, New Zealand
| | - Malcolm Tingle
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Auckland, New Zealand
| | - Brandi L Bellissima
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Auckland, New Zealand
| | - Nuala Helsby
- Department of Molecular Medicine and Pathology, The University of Auckland, Auckland, New Zealand
| | - Kathryn Burns
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Auckland, New Zealand
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Vaziri N, Marques D, Greenway SC, Bousman CA. The cellular mechanism of antipsychotic-induced myocarditis: A systematic review. Schizophr Res 2023; 261:206-215. [PMID: 37797362 DOI: 10.1016/j.schres.2023.09.039] [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: 01/22/2023] [Revised: 04/23/2023] [Accepted: 09/24/2023] [Indexed: 10/07/2023]
Abstract
Antipsychotic drug-induced myocarditis is a serious and potentially fatal adverse drug reaction characterized by inflammation of the heart muscle (myocardium) that typically develops within the first month after commencing an antipsychotic drug. Although the precise mechanism of this severe adverse drug reaction is unknown, multiple theories have been proposed with varying levels of support from cellular or animal studies. We conducted a systematic review, in accordance with PRISMA guidelines, of published preclinical and clinical studies investigating the cellular mechanism by which antipsychotic drugs induce myocarditis. A literature search including all studies available before December 10, 2022, yielded 15 studies that met our inclusion criteria. Antipsychotics examined in the included studies included clozapine (n = 13), ziprasidone (n = 1), amisulpride (n = 1), haloperidol (n = 1), levomepromazine (n = 1), olanzapine (n = 1), and sertindole (n = 1). The evidence suggests several overlapping mechanistic cascades involving: (1) increased levels of catecholamines, (2) increased proinflammatory cytokines, (3) increased reactive oxygen species (ROS), (4) reduced antioxidant levels and activity, and (5) mitochondrial damage. Notable limitations such as, a focus on clozapine, sample heterogeneity, and use of supratherapeutic doses will need to be addressed in future studies. Discovery of the mechanism by which antipsychotic drugs induce myocarditis will allow the development of clinically-useful biomarkers to identify those patients at increased risk prior to drug exposure. The development or repurposing of therapeutics to prevent or treat drug-induced myocarditis will also be possible and this will enable increased and safe use of antipsychotics for those patients in need.
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Affiliation(s)
- Nazanin Vaziri
- Department of Medical Genetics, University of Calgary, Calgary, AB, Canada
| | - Diogo Marques
- Department of Medical Genetics, University of Calgary, Calgary, AB, Canada
| | - Steven C Greenway
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Biochemistry & Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Chad A Bousman
- Department of Medical Genetics, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Psychiatry, University of Calgary, Calgary, AB, Canada; Department of Physiology & Pharmacology, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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11
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Chandru P, Gunja N. Toxicity and Adverse Effects in Clozapine-Related Presentations to a Medical Toxicology Service in Western Sydney. J Med Toxicol 2023; 19:374-380. [PMID: 37624540 PMCID: PMC10522536 DOI: 10.1007/s13181-023-00963-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Clozapine is an anti-psychotic agent, reserved for treatment-resistant schizophrenia, with demonstrated efficacy in an otherwise therapeutically challenging patient population. We aimed to review the full spectrum casemix of clozapine presentations to our tertiary toxicology service. METHODS In this retrospective study, we reviewed consecutive clozapine related toxicity presentations to a tertiary medical toxicology inpatient and consultation service-including deliberate self-poisoning (DSP), adverse drug reaction (ADR), recreational use, and therapeutic misadventure over a 10-year period from 2011 to 2021. Data were extracted for demographics, ingested dose, exposure characteristics, and patient outcome. RESULTS We identified 83 patients with clozapine-related presentations over the 10-year period. Twenty-two patients were excluded. Of the remaining 61 patients, 28 patients presented with DSP, 20 patients with accidental overdose, and 13 patients with an ADR; no patients presented with recreational use. It was noted that ADRs were largely idiosyncratic reactions and not always related to dose adjustments. In the context of therapeutic misadventure and DSP, we noted that a lower mean dose achieved a higher poison severity score (PSS) in clozapine-naive patients when compared to those patients on regular clozapine. CONCLUSIONS The presentation of clozapine-related toxicity differs depending on the modality of ingestion, whether DSP, accidental, or as a result of ADR. Patients naive to clozapine therapy tend to experience higher PSS with lower doses ingested either in a deliberate self-poisoning or accidental ingestion context. This is likely due to tolerance to the sedative properties of clozapine. No patients manifested clinical toxicity greater than 8 hours after ingestion, with an observation period of 6 hours accurately identifying toxicity in most patients.
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Affiliation(s)
- Pramod Chandru
- Department of Clinical Pharmacology & Toxicology, Western Sydney Health, Sydney, Australia.
| | - Naren Gunja
- Department of Clinical Pharmacology & Toxicology, Western Sydney Health, Sydney, Australia
- Discipline of Emergency Medicine, Sydney Medical School, University of Sydney, New South Wales, Australia
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12
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Clapham E, Reutfors J, Linder M, Brandt L, Sundström J, Bodén R. The association between exposure to clozapine, olanzapine, and quetiapine and the outcomes perimyocarditis and heart failure: A population-based cohort study. Psychiatry Res 2023; 326:115336. [PMID: 37451082 DOI: 10.1016/j.psychres.2023.115336] [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: 04/26/2023] [Revised: 06/28/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
The risk of cardiac adverse events following clozapine use is debated and is unknown for the chemically related and widely used antipsychotics olanzapine and quetiapine. National Swedish registers were used to identify all patients 16-75 years old with antipsychotic dispensations between 2005 and 2018. The short-term outcome was a diagnosis of perimyocarditis (pericarditis and/or myocarditis) within two months of first dispensation, and the long-term outcome was heart failure (including cardiomyopathy) within three years. Cox regressions with time varying exposure were used to estimate hazard rates (HR) and their 95% confidence intervals (CI). A total of 201,045 individuals were included in the cohort. The risk of developing perimyocarditis during clozapine treatment tripled compared to no antipsychotic treatment (HR 3.4, CI 1.6-7.3), although the absolute rate remained comparably low. The long-term risk of heart failure during clozapine treatment was also elevated (HR 1.3, CI 1.1-1.7). Treatment with either or both olanzapine or quetiapine was not associated with an increased relative risk of perimyocarditis, or heart failure compared to no antipsychotic treatment. Clozapine use is therefore associated with a substantially elevated short-term risk of perimyocarditis and an increased risk of heart failure within three years.
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Affiliation(s)
- Eric Clapham
- Department of Medical Sciences, Psychiatry, Uppsala University, Sweden; Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden.
| | - Johan Reutfors
- Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden
| | - Marie Linder
- Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden
| | - Lena Brandt
- Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Sweden; The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Robert Bodén
- Department of Medical Sciences, Psychiatry, Uppsala University, Sweden
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13
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Qubad M, Bittner RA. Second to none: rationale, timing, and clinical management of clozapine use in schizophrenia. Ther Adv Psychopharmacol 2023; 13:20451253231158152. [PMID: 36994117 PMCID: PMC10041648 DOI: 10.1177/20451253231158152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/24/2023] [Indexed: 03/31/2023] Open
Abstract
Despite its enduring relevance as the single most effective and important evidence-based treatment for schizophrenia, underutilization of clozapine remains considerable. To a substantial degree, this is attributable to a reluctance of psychiatrists to offer clozapine due to its relatively large side-effect burden and the complexity of its use. This underscores the necessity for continued education regarding both the vital nature and the intricacies of clozapine treatment. This narrative review summarizes all clinically relevant areas of evidence, which support clozapine's wide-ranging superior efficacy - for treatment-resistant schizophrenia (TRS) and beyond - and make its safe use eminently feasible. Converging evidence indicates that TRS constitutes a distinct albeit heterogeneous subgroup of schizophrenias primarily responsive to clozapine. Most importantly, the predominantly early onset of treatment resistance and the considerable decline in response rates associated with its delayed initiation make clozapine an essential treatment option throughout the course of illness, beginning with the first psychotic episode. To maximize patients' benefits, systematic early recognition efforts based on stringent use of TRS criteria, a timely offer of clozapine, thorough side-effect screening and management as well as consistent use of therapeutic drug monitoring and established augmentation strategies for suboptimal responders are crucial. To minimize permanent all-cause discontinuation, re-challenges after neutropenia or myocarditis should be considered. Owing to clozapine's unique efficacy, comorbid conditions including substance use and most somatic disorders should not dissuade but rather encourage clinicians to consider clozapine. Moreover, treatment decisions need to be informed by the late onset of clozapine's full effects, which for reduced suicidality and mortality rates may not even be readily apparent. Overall, the singular extent of its efficacy combined with the high level of patient satisfaction continues to distinguish clozapine from all other available antipsychotics.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Robert A. Bittner
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe University, Heinrich-Hoffmann-Str. 10, D-60528 Frankfurt am Main, Germany
- Ernst Strüngmann Institute (ESI) for Neuroscience in Cooperation with Max Planck Society, Frankfurt am Main, Germany
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14
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de Leon J. Reflections on the Lack of Consideration of Ethnic Ancestry to Stratify Clozapine Dosing. Psychiatry Investig 2023; 20:183-195. [PMID: 36850057 PMCID: PMC10064212 DOI: 10.30773/pi.2022.0293] [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: 10/08/2022] [Revised: 12/17/2022] [Accepted: 12/26/2022] [Indexed: 03/01/2023] Open
Abstract
This review article argues against trusting standard clozapine references, including the US package insert, because they do not include advances in the sciences of pharmacokinetics and pharmacovigilance and ignore the effects of ethnic ancestry on therapeutic dosing. The minimum therapeutic dose leading to the minimum therapeutic concentration of 350 ng/mL in serum/plasma can be used to compare individuals/groups with treatment-resistant schizophrenia. The US clozapine package insert recommends targeting doses of 300-450 mg/day and, subsequently, increments of up to 100 mg with a maximum dose of 900 mg/day. Ethnic ancestry is defined by DNA ancestry group. Asians (people with ancestry ranging from Pakistan to Japan) and Indigenous Americans are similar in clozapine dosing; their average clozapine minimum therapeutic dose ranged from 166 mg/day (female non-smokers) to 270 mg/day (male smokers). For those with European ancestry, average clozapine minimum therapeutic doses ranged from 236 mg/day (female non-smokers) to 368 mg/day (male smokers). Based on limited studies, Black (African sub-Saharan ancestry) patients may be treated with typical US doses (300-600 mg/day), assuming no poor metabolism (PM) status. Ancestry's impact on clozapine lethality in four countries is discussed (two countries with highly homogenous populations, Denmark and Japan, and two countries with increasingly heterogenous populations due to immigration, Australia and the UK). An international guideline with 104 authors from 50 countries/regions was recently published, providing 6 personalized clozapine titration schedules for adult inpatients (3 ancestry groups and PM/non-PM schedules) and recommending c-reactive protein monitoring at baseline and weekly for 4 weeks.
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Affiliation(s)
- Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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15
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Effect of antipsychotic use by patients with schizophrenia on deceleration capacity and its relation to the corrected QT interval. Gen Hosp Psychiatry 2023; 81:15-21. [PMID: 36716654 DOI: 10.1016/j.genhosppsych.2023.01.005] [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: 10/07/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Schizophrenia patients treated with antipsychotics are at higher risk of sudden cardiac death. Decreased deceleration capacity (DC) of the heart rate is an accurate predictor of cardiac mortality. We evaluated the risk of sudden cardiac death due to antipsychotic use by assessing DC and examining the association between DC and the corrected QT interval (QTc) in schizophrenia patients. METHODS We measured the DC and QTc of 138 schizophrenia patients. We then compared the DC of 86 age- and sex-matched healthy controls with that of 86 schizophrenia patients. We investigated the correlation of DC of approximately 138 schizophrenia patients with prescribed doses of antipsychotics using linear regression analysis. We compared the DC of schizophrenia patients with and without prolonged QT intervals. RESULTS We found DC significantly differed between schizophrenia patients on antipsychotic medication and healthy controls. Additionally, DC was negatively correlated with antipsychotic use, especially chlorpromazine, zotepine, olanzapine and clozapine, in a dose-dependent manner. There was no significant association between DC and the QTc. CONCLUSION Assessing DC could facilitate monitoring and identification of increased risk of cardiac mortality in patients with schizophrenia that take antipsychotics. Assessing both DC and the QTc may enhance the accuracy of predicting sudden cardiac death.
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16
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Daniel P, Rajaree KM, Rudy L, Jafor S, Prasad S, Avanthika C, Jhaveri S. Myocarditis in patients on long-term antipsychotics -mechanism, management and recent updates. Heliyon 2023; 9:e13930. [PMID: 36923851 PMCID: PMC10008991 DOI: 10.1016/j.heliyon.2023.e13930] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 12/17/2022] [Accepted: 02/15/2023] [Indexed: 02/25/2023] Open
Abstract
Objective Clozapine is the first atypical antipsychotic drug and was frequently cited as the most effective antipsychotic for treatment-resistant schizophrenia, but it is associated with a concert of significant cardiotoxic side effects. Clozapine-induced Myocarditis (CIM) is diagnosed based on the combination of clinical symptoms, laboratory investigations, radiological findings, and sometimes biopsy. The literature on CIM management and clinical consensus on the best course of action is mixed. Methodology An all-language literature search on Medline, Cochrane, Embase, and Google Scholar until April 2022. The following search strings and Medical Subject Heading (MeSH) terms were used: "CIM," "clozapine," "cardiotoxicity," and "myocarditis." We explored the literature on CIM for its pathophysiology, diagnosis, monitoring, and management. Results The clinical features of CIM may be highly variable, ranging from asymptomatic disease to fulminant heart failure, and cessation of medication was the mainstay treatment of CIM, followed by supportive therapy. Other antipsychotics have also been linked with cardiotoxic side effects. Conclusion Despite being the most effective antipsychotic, clozapine is associated with a cardiotoxic side effect. Current literature suggests that these antipsychotic-related cardiotoxic events impact the treatment selection for schizophrenia and other psychotic disorders, and they must be kept in mind while designing new treatment protocols in the future.
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Affiliation(s)
| | | | - Luna Rudy
- Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sadeque Jafor
- Al Mostaqbal Hospital, Jeddah, Kingdom of Saudi Arabia
| | - Sakshi Prasad
- Faculty of Medicine, National Pirogov Memorial Medical University, 21018, Vinnytsya, Ukraine
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17
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Yang W, Ouyang Q, Zhu Z, Wu Y, Fan M, Liao Y, Guo X, Xu Z, Zhang X, Zhang Y, Hu N, Zhang D. A biosensing system employing nonlinear dynamic analysis-assisted neural network for drug-induced cardiotoxicity assessment. Biosens Bioelectron 2023; 222:114923. [PMID: 36455375 DOI: 10.1016/j.bios.2022.114923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/16/2022] [Indexed: 11/18/2022]
Abstract
Preclinical investigation of drug-induced cardiotoxicity is of importance for drug development. To evaluate such cardiotoxicity, in vitro high-throughput interdigitated electrode-based recording of cardiomyocytes mechanical beating is widely used. To automatically analyze the features from the beating signals for drug-induced cardiotoxicity assessment, artificial neural network analysis is conventionally employed and signals are segmented into cycles and feature points are located in the cycles. However, signal segmentation and location of feature points for different signal shapes require design of specific algorithms. Consequently, this may lower the efficiency of research and the applications of such algorithms in signals with different morphologies are limited. Here, we present a biosensing system that employs nonlinear dynamic analysis-assisted neural network (NDANN) to avoid the signal segmentation process and directly extract features from beating signal time series. By processing beating time series with fixed time duration to avoid the signal segmentation process, this NDANN-based biosensing system can identify drug-induced cardiotoxicity with accuracy over 0.99. The individual drugs were classified with high accuracies over 0.94 and drug-induced cardiotoxicity levels were accurately predicted. We also evaluated the generalization performance of the NDANN-based biosensing system in assessing drug-induced cardiotoxicity through an independent dataset. This system achieved accuracy of 0.85-0.95 for different drug concentrations in identification of drug-induced cardiotoxicity. This result demonstrates that our NDANN-based biosensing system has the capacity of screening newly developed drugs, which is crucial in practical applications. This NDANN-based biosensing system can work as a new screening platform for drug-induced cardiotoxicity and improve the efficiency of bio-signal processing.
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Affiliation(s)
- Wenjian Yang
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China
| | - Qiangqiang Ouyang
- First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510006, China
| | - Zhijing Zhu
- Key Laboratory of Novel Target and Drug Study for Neural Repair of Zhejiang Province, School of Medicine, School of Computer & Computing Science, Zhejiang University City College, Hangzhou, 310015, China; School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, 310058, China
| | - Yue Wu
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China.
| | - Minzhi Fan
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China
| | - Yuheng Liao
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China
| | - Xinyu Guo
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China
| | - Zhongyuan Xu
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China
| | - Xiaoyu Zhang
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China
| | - Yunshan Zhang
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China
| | - Ning Hu
- ZJU-Hangzhou Global Scientific and Technological Innovation Center, Hangzhou, 311200, China; Stoddart Institute of Molecular Science, Department of Chemistry, Zhejiang University, Hangzhou, 310058, China
| | - Diming Zhang
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China.
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18
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Oyarzun A, Parsons S, Bassed R. Myocarditis in the forensic setting. Cardiovasc Pathol 2023; 62:107476. [PMID: 36122893 DOI: 10.1016/j.carpath.2022.107476] [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: 06/03/2022] [Revised: 08/16/2022] [Accepted: 09/11/2022] [Indexed: 12/24/2022] Open
Abstract
Diagnosis of myocarditis as the cause of death in the forensic setting at post-mortem is currently determined by a forensic pathologist. There is no systematic method for diagnosis and thus the determination is subject to inter-observer variability and is often non-reproducible. The primary aim of this study was to investigate the differences in the amount of inflammation between cases where myocarditis was deemed the cause of death, compared to cases where myocardial inflammation was incidentally present at autopsy, but not determined to be the cause of death. Participants were sourced from the Victorian Institute of Forensic Medicine (VIFM) database, from full autopsies conducted on reportable death in Victoria, Australia between the years 2011 and 2021. Cases of fatal myocarditis were significantly more likely to experience infection-like symptoms prior to death, and to be in hospital at the time of death. Histopathological examination revealed fatal cases had a significantly higher inflammatory index compared to the incidental group. Lethal cases were also significantly more likely to have myocyte necrosis, and a diffuse pattern of inflammation. There are significant differences between cases where myocardial inflammation has been determined to be the cause of death and cases where inflammation in the myocardium was an incidental finding. These results could be used in the forensic autopsy to help pathologists determine if inflammation should be considered fatal or incidental.
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Affiliation(s)
- Adele Oyarzun
- Adjunct Associate Professor Sarah Parsons, Prof Richard Bassed, Melbourbe, VIC, Australia.
| | - Sarah Parsons
- Victorian Institute of Forensic Medicine, Department of Forensic Medicine, Monash University, Melbourbe, VIC, Australia
| | - Richard Bassed
- Victorian Institute of Forensic Medicine, Department of Forensic Medicine, Monash University, Melbourbe, VIC, Australia
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19
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Oyarzun A, Parsons S, Bassed R. Myocarditis in the forensic setting - a review of the literature. Cardiovasc Pathol 2023; 62:107475. [PMID: 36116635 DOI: 10.1016/j.carpath.2022.107475] [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: 06/03/2022] [Revised: 08/16/2022] [Accepted: 09/11/2022] [Indexed: 12/13/2022] Open
Abstract
Diagnosis of myocarditis as the cause of death at post-mortem is currently determined by a forensic pathologist. There is no systematic method for diagnosis and thus the determination is subject to inter-observer variability and is non-reproducible. Postmortem studies often rely on the clinical method of diagnosis, which is inaccurate. Furthermore, there is no current standardized method of distinguishing between myocarditis as cause of death, and myocardial inflammation as an incidental finding post-mortem. Only a few studies have investigated a method of quantifying this difference using variables such as number of inflammatory cells and presence of myocyte necrosis, however, there are several limitations hindering the reproducibility of this research. This review investigates the current practices and limitations associated with the diagnosis of myocarditis as cause of death in the autopsy setting.
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Affiliation(s)
- Adele Oyarzun
- Victorian Institute of Forensic Medicine, Department of Forensic Medicine, Monash University, Melbourne, Australia
| | - Sarah Parsons
- Victorian Institute of Forensic Medicine, Department of Forensic Medicine, Monash University, Melbourne, Australia.
| | - Richard Bassed
- Victorian Institute of Forensic Medicine, Department of Forensic Medicine, Monash University, Melbourne, Australia
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20
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Rabkin SW, Tang JKK. Clozapine-induced Myocarditis: Pathophysiologic Mechanisms and Implications for Therapeutic Approaches. Curr Mol Pharmacol 2023; 16:60-70. [PMID: 35152873 DOI: 10.2174/1874467215666220211094910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/19/2021] [Accepted: 11/29/2021] [Indexed: 11/22/2022]
Abstract
Clozapine, a superior treatment for treatment-resistant schizophrenia can cause potentially life-threatening myocarditis and dilated cardiomyopathy. While the occurrence of this condition is well known, its molecular mechanisms are unclear and may be multifactorial. Putative mechanisms warrant an in-depth review not only from the perspective of toxicity but also for understanding the molecular mechanisms of the adverse cardiac effects of clozapine and the development of novel therapeutic approaches. Clozapine-induced cardiac toxicity encompasses a diverse set of pathways, including (i) immune modulation and proinflammatory processes encompassing an IgEmediated (type I hypersensitivity) response and perhaps a cytokine release syndrome (ii) catecholaminergic activation (iii) induction of free radicals and oxidative stress (iv) activation of cardiomyocyte cell death pathways, including apoptosis, ischemia through impairment in coronary blood flow via changes in endothelial production of NO and vasoconstriction induced by norepinephrine as well as other factors released from cardiac mast cells. (v) In addition, an extensive examination of the effects of clozapine on non-cardiac cellular proteins demonstrates that clozapine can impair enzymes involved in cellular metabolism, such as pyruvate kinase, mitochondrial malate dehydrogenase, and other proteins, including α-enolase, triosephosphate isomerase and cofilin, which might explain clozapine-induced reductions in myocardial energy generation for cell viability as well as contractile function. Pharmacologic antagonism of these cellular protein effects may lead to the development of strategies to antagonize the cardiac damage induced by clozapine.
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Affiliation(s)
- Simon W Rabkin
- Division of Cardiology, University of British Columbia, Vancouver, B.C., Canada
| | - Jacky K K Tang
- Division of Cardiology, University of British Columbia, Vancouver, B.C., Canada
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21
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Atkins M, McGuire P, Balgobin B, Desouza N, Taylor D. Haematological point of care testing for clozapine monitoring. J Psychiatr Res 2023; 157:66-71. [PMID: 36442408 DOI: 10.1016/j.jpsychires.2022.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/17/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Clozapine treatment requires regular full blood counts (FBC) because of the risk of agranulocytosis. Traditionally, FBCs use venous blood samples but the need for frequent venepuncture adversely affects adherence. We investigated the utility of a point of care testing (POCT) finger prick method for clozapine patients. METHOD Patients being treated with clozapine, who were having a venous blood sample taken for haematological monitoring, also provided a fingerprick capillary blood sample. The PixCell HemoScreen® POCT analyser was used to test both the capillary and venous samples, and the venous sample was also tested using a standard laboratory method. RESULTS We completed FBCs on 226 patients. We found strong correlations between the results from the standard laboratory venous method and the POCT capillary and venous assays for WBC (R = 0.96 & R = 0.99), neutrophils (R = 0.96 & R = 0.97) and eosinophils (R = 0.94 & R = 0.94). Compared with the standard laboratory venous blood method, mean biases for capillary blood POCT method were -0.56 × 109/L for WBC, -0.39 × 109/L for neutrophils, and -0.01 × 109/L for eosinophils. Mean biases for venous blood POCT method were -0.004 × 109/L for WBC, -0.28 × 109/L for neutrophils, and 0.01 × 109/L for eosinophils. Of the 226 patients tested, 10 (4.4%) had levels below clozapine monitoring thresholds (WBC <3.5 × 109/L and Neutrophils <1.5 × 109/L) by capillary blood, and 4 (1.8%) by venous blood by POCT. The standard laboratory method showed 3 of these to be sub-threshold. All cases of neutropenia were identified by capillary and venous POCT. CONCLUSION The PixCell HemoScreen® POCT analyser provided results that were comparable with those from a standard venous blood laboratory method for WBC, neutrophil and eosinophil counts. The availability of an accurate capillary monitoring method may result in increased clozapine uptake and better clozapine adherence.
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Affiliation(s)
- Matthew Atkins
- South London and Maudsley NHS Foundation Trust, Pharmacy Department Maudsley Hospital, Denmark Hill, London, SE5 8AZ, UK; Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK.
| | - Philip McGuire
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK
| | - Bhirundra Balgobin
- South London and Maudsley NHS Foundation Trust, Clozapine Clinic Maudsley Hospital, Denmark Hill, London, SE5 8AZ, UK
| | - Neville Desouza
- South London and Maudsley NHS Foundation Trust, Pharmacy Department Maudsley Hospital, Denmark Hill, London, SE5 8AZ, UK
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, Pharmacy Department Maudsley Hospital, Denmark Hill, London, SE5 8AZ, UK; Institute of Pharmaceutical Science, King's College, Stamford Street, London, SE1 9NH, UK
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22
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De Las Cuevas C, Arrojo-Romero M, Ruan CJ, Schoretsanitis G, Sanz EJ, de Leon J. Clozapine-induced myocarditis in children and adolescents: a pharmacovigilance study using VigiBase and a systematic literature review. Expert Opin Drug Metab Toxicol 2022; 18:715-727. [PMID: 36526610 DOI: 10.1080/17425255.2022.2160318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Clozapine-induced myocarditis in children (age ≤18 yo) was studied from a PubMed search (18 July 2022) (9 cases) and from the World Health Organization's pharmacovigilance database, called Vigibase, of adverse drug reaction (ADR) reports (72 non-duplicated cases). VigiBase uses a logarithmic measure of disproportionality called the information component (IC). A logistic regression model of presence/absence (40/32) of seriousness in VigiBase was developed. AREAS COVERED VigiBase provided a significant myocarditis IC = 4.2 with an IC025 = 3.8; only 4 clozapine-induced myocarditis cases were expected, while 72 were observed. The PubMed search identified 9 cases, while VigiBase identified 72 cases (of which 67 did not overlap with published cases). These 76 combined cases included 35 doubtful (most with missing information on the day of diagnosis), 19 possible and 22 probable, according to the ADR scale. After adjusting for confounders, quetiapine increased the risk of seriousness with an odds ratio (OR) of 17.6 (95% confidence interval CI, 1.56 to 198.6), while Australian origin decreased it with an OR = 0.13 (CI, 0.04 to 0.47). EXPERT OPINION These 41 cases of at least possible clozapine-induced myocarditis indicated that this ADR can definitively occur in children, particularly in the first 30 days of up-titration. Children's and adult cases appeared similar.
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Affiliation(s)
- 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.,Department of Psychiatry, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Manuel Arrojo-Romero
- Department of Psychiatry, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology, Beijing Key Laboratory of Mental Disorders, 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
| | - 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
| | - 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
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, US.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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23
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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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24
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Rout A, Suri S, Vorla M, Kalra DK. Myocarditis associated with COVID-19 and its vaccines - a systematic review. Prog Cardiovasc Dis 2022; 74:111-121. [PMID: 36279947 PMCID: PMC9596182 DOI: 10.1016/j.pcad.2022.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 10/16/2022] [Indexed: 11/07/2022]
Abstract
Since the beginning of the COVID-19 (Coronavirus Disease of 2019) pandemic, myocarditis has received much attention and controversy as one of the more worrisome cardiovascular complications. After the availability of highly effective COVID-19 mRNA vaccines in late 2020, myocarditis was also appreciated as an important vaccine-related adverse event. Though the overall frequency of clinically evident viral myocarditis is rare in the general population, young males show a higher predilection for COVID vaccine-induced myocarditis. The severity of COVID-19 viral myocarditis is variable, ranging from very mild to severe, while vaccine-induced myocarditis is usually mild, and rarely a severe or fatal disease. The diagnosis of either COVID-19 or vaccine-induced myocarditis is based on typical clinical features, laboratory investigations, and imaging, preferably with cardiac magnetic resonance. The management of COVID-19 myocarditis is supportive care for mild or moderate disease. For the rare patient who develops severe disease, advanced heart failure therapies such as mechanical circulatory support devices may have to be employed and can be lifesaving. Avoidance of strenuous exercise during the bout of myocarditis and its recovery phase is important. Despite the small but finite risk of vaccine-induced myocarditis, the benefits of protection against COVID-19 disease and its attendant complications far outweigh the risks.
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Affiliation(s)
- Amit Rout
- Division of Cardiology, University of Louisville, Louisville, KY, USA
| | - Sarabjeet Suri
- Division of Cardiology, University of Louisville, Louisville, KY, USA
| | - Mounica Vorla
- Division of Cardiology, University of Louisville, Louisville, KY, USA
| | - Dinesh K Kalra
- Division of Cardiology, University of Louisville, Louisville, KY, USA.
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25
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Thotamgari SR, Bath AS, Dhaliwal L, Kommineni SK, Aujla P, Brar V. Real world analysis of cardiac adverse events associated with clozapine: A pharmacovigilance analysis using food and drug administration adverse event reporting system. Gen Hosp Psychiatry 2022; 78:123-125. [PMID: 35396035 DOI: 10.1016/j.genhosppsych.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Sahith Reddy Thotamgari
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, United States of America
| | - Anandbir S Bath
- Department of Cardiology, University of Tennessee, Memphis, TN, United States of America
| | - Lovekirat Dhaliwal
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, United States of America
| | - Sai Karthik Kommineni
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, United States of America
| | - Perminder Aujla
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, United States of America
| | - Vijaywant Brar
- Department of Cardiology, Louisiana State University Health Sciences Center, Shreveport, LA, United States of America.
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26
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de Bartolomeis A, Vellucci L, Barone A, Manchia M, De Luca V, Iasevoli F, Correll CU. Clozapine's multiple cellular mechanisms: What do we know after more than fifty years? A systematic review and critical assessment of translational mechanisms relevant for innovative strategies in treatment-resistant schizophrenia. Pharmacol Ther 2022; 236:108236. [PMID: 35764175 DOI: 10.1016/j.pharmthera.2022.108236] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 12/21/2022]
Abstract
Almost fifty years after its first introduction into clinical care, clozapine remains the only evidence-based pharmacological option for treatment-resistant schizophrenia (TRS), which affects approximately 30% of patients with schizophrenia. Despite the long-time experience with clozapine, the specific mechanism of action (MOA) responsible for its superior efficacy among antipsychotics is still elusive, both at the receptor and intracellular signaling level. This systematic review is aimed at critically assessing the role and specific relevance of clozapine's multimodal actions, dissecting those mechanisms that under a translational perspective could shed light on molecular targets worth to be considered for further innovative antipsychotic development. In vivo and in vitro preclinical findings, supported by innovative techniques and methods, together with pharmacogenomic and in vivo functional studies, point to multiple and possibly overlapping MOAs. To better explore this crucial issue, the specific affinity for 5-HT2R, D1R, α2c, and muscarinic receptors, the relatively low occupancy at dopamine D2R, the interaction with receptor dimers, as well as the potential confounder effects resulting in biased ligand action, and lastly, the role of the moiety responsible for lipophilic and alkaline features of clozapine are highlighted. Finally, the role of transcription and protein changes at the synaptic level, and the possibility that clozapine can directly impact synaptic architecture are addressed. Although clozapine's exact MOAs that contribute to its unique efficacy and some of its severe adverse effects have not been fully understood, relevant information can be gleaned from recent mechanistic understandings that may help design much needed additional therapeutic strategies for TRS.
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Affiliation(s)
- Andrea de Bartolomeis
- Section of Psychiatry, Laboratory of Translational and Molecular Psychiatry and Unit of Treatment Resistant Psychosis, Department of Neuroscience, Reproductive Science and Dentistry, University Medical School of Naples "Federico II", Naples, Italy.
| | - Licia Vellucci
- Section of Psychiatry, Laboratory of Translational and Molecular Psychiatry and Unit of Treatment Resistant Psychosis, Department of Neuroscience, Reproductive Science and Dentistry, University Medical School of Naples "Federico II", Naples, Italy
| | - Annarita Barone
- Section of Psychiatry, Laboratory of Translational and Molecular Psychiatry and Unit of Treatment Resistant Psychosis, Department of Neuroscience, Reproductive Science and Dentistry, University Medical School of Naples "Federico II", Naples, Italy
| | - Mirko Manchia
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy; Department of Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Felice Iasevoli
- Section of Psychiatry, Laboratory of Translational and Molecular Psychiatry and Unit of Treatment Resistant Psychosis, Department of Neuroscience, Reproductive Science and Dentistry, University Medical School of Naples "Federico II", Naples, Italy
| | - Christoph U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; Charité Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany
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27
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Li L, Gao P, Tang X, Liu Z, Cao M, Luo R, Li X, Wang J, Lin X, Peng C, Li Z, Zhang J, Zhang X, Cao Z, Zou Y, Jin L. CB1R-stabilized NLRP3 inflammasome drives antipsychotics cardiotoxicity. Signal Transduct Target Ther 2022; 7:190. [PMID: 35739093 PMCID: PMC9225989 DOI: 10.1038/s41392-022-01018-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/25/2022] [Accepted: 05/06/2022] [Indexed: 12/21/2022] Open
Abstract
Long-term use of antipsychotics is a common cause of myocardial injury and even sudden cardiac deaths that often lead to drug withdrawn or discontinuation. Mechanisms underlying antipsychotics cardiotoxicity remain largely unknown. Herein we performed RNA sequencing and found that NLRP3 inflammasome-mediated pyroptosis contributed predominantly to multiple antipsychotics cardiotoxicity. Pyroptosis-based small-molecule compound screen identified cannabinoid receptor 1 (CB1R) as an upstream regulator of the NLRP3 inflammasome. Mechanistically, antipsychotics competitively bond to the CB1R and led to CB1R translocation to the cytoplasm, where CB1R directly interacted with NLRP3 inflammasome via amino acid residues 177-209, rendering stabilization of the inflammasome. Knockout of Cb1r significantly alleviated antipsychotic-induced cardiomyocyte pyroptosis and cardiotoxicity. Multi-organ-based investigation revealed no additional toxicity of newer CB1R antagonists. In authentic human cases, the expression of CB1R and NLRP3 inflammasome positively correlated with antipsychotics-induced cardiotoxicity. These results suggest that CB1R is a potent regulator of the NLRP3 inflammsome-mediated pyroptosis and small-molecule inhibitors targeting the CB1R/NLRP3 signaling represent attractive approaches to rescue cardiac side effects of antipsychotics.
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Affiliation(s)
- Liliang Li
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China. .,State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences & Human Phenome Institute, Fudan University, Shanghai, 200438, China.
| | - Pan Gao
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China
| | - Xinru Tang
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China
| | - Zheng Liu
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China
| | - Mengying Cao
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China
| | - Ruoyu Luo
- State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences & Human Phenome Institute, Fudan University, Shanghai, 200438, China
| | - Xiaoqing Li
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China
| | - Jing Wang
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China
| | - Xinyi Lin
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, China
| | - Chao Peng
- National Facility for Protein Science in Shanghai, Zhangjiang Lab, Shanghai Advanced Research Institute, Chinese Academy of Science, Shanghai, 201210, China
| | - Zhihong Li
- National Facility for Protein Science in Shanghai, Zhangjiang Lab, Shanghai Advanced Research Institute, Chinese Academy of Science, Shanghai, 201210, China
| | - Jianhua Zhang
- Academy of Forensic Science, Ministry of Justice, and Shanghai Key Laboratory of Forensic Medicine, Shanghai, 200063, China
| | - Xian Zhang
- Department of Cardiology, Kunshan Hospital of Integrated Traditional Chinese and Western Medicine, Kunshan, Jiangsu, 215301, China
| | - Zhonglian Cao
- School of Pharmacy, Fudan University, Shanghai, 201203, China
| | - Yunzeng Zou
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China.
| | - Li Jin
- State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences & Human Phenome Institute, Fudan University, Shanghai, 200438, China. .,Shanghai Medical College, Fudan University, Shanghai, 200032, China.
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28
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de Leon J. The history of clozapine in clinical practice: From its introduction to a guideline proposing personalized titrations. J Psychopharmacol 2022; 36:657-660. [PMID: 35634693 DOI: 10.1177/02698811221101059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria-Gasteiz, Spain
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29
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Narang A, Lacaze P, Ronaldson KJ, McNeil JJ, Jayaram M, Thomas N, Sellmer R, Crockford DN, Stowe R, Greenway SC, Pantelis C, Bousman CA. Whole-genome sequencing analysis of clozapine-induced myocarditis. THE PHARMACOGENOMICS JOURNAL 2022; 22:173-179. [PMID: 35461379 DOI: 10.1038/s41397-022-00271-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 06/14/2023]
Abstract
One of the concerns limiting the use of clozapine in schizophrenia treatment is the risk of rare but potentially fatal myocarditis. Our previous genome-wide association study and human leucocyte antigen analyses identified putative loci associated with clozapine-induced myocarditis. However, the contribution of DNA variation in cytochrome P450 genes, copy number variants and rare deleterious variants have not been investigated. We explored these unexplored classes of DNA variation using whole-genome sequencing data from 25 cases with clozapine-induced myocarditis and 25 demographically-matched clozapine-tolerant control subjects. We identified 15 genes based on rare variant gene-burden analysis (MLLT6, CADPS, TACC2, L3MBTL4, NPY, SLC25A21, PARVB, GPR179, ACAD9, NOL8, C5orf33, FAM127A, AFDN, SLC6A11, PXDN) nominally associated (p < 0.05) with clozapine-induced myocarditis. Of these genes, 13 were expressed in human myocardial tissue. Although independent replication of these findings is required, our study provides preliminary insights into the potential role of rare genetic variants in susceptibility to clozapine-induced myocarditis.
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Affiliation(s)
- Ankita Narang
- Department of Medical Genetics, University of Calgary, Calgary, AB, Canada
| | - Paul Lacaze
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Kathlyn J Ronaldson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - John J McNeil
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Mahesh Jayaram
- Adult Mental Health Rehabilitation Unit, North Western Mental Health, Melbourne Health, Western Health, Sunshine Hospital, St Albans, VIC, Australia
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Western Centre for Health & Education, St Albans, VIC, Australia
| | - Naveen Thomas
- Adult Mental Health Rehabilitation Unit, North Western Mental Health, Melbourne Health, Western Health, Sunshine Hospital, St Albans, VIC, Australia
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Western Centre for Health & Education, St Albans, VIC, Australia
| | - Rory Sellmer
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - David N Crockford
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Robert Stowe
- Departments of Psychiatry and Neurology (Medicine), Neuropsychiatry Program, and Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Steven C Greenway
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Biochemistry & Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christos Pantelis
- Adult Mental Health Rehabilitation Unit, North Western Mental Health, Melbourne Health, Western Health, Sunshine Hospital, St Albans, VIC, Australia
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Western Centre for Health & Education, St Albans, VIC, Australia
| | - Chad A Bousman
- Department of Medical Genetics, University of Calgary, Calgary, AB, Canada.
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada.
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Department of Physiology & Pharmacology, University of Calgary, Calgary, AB, Canada.
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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30
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Grover S, Sahoo S, Mehra A. Safe use of Clozapine in a patient with treatment resistant schizophrenia with co-morbid Dilated cardiomyopathy: A case report. Asian J Psychiatr 2022; 68:102971. [PMID: 34953217 DOI: 10.1016/j.ajp.2021.102971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 11/02/2022]
Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Swapnajeet Sahoo
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Aseem Mehra
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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31
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Systematic analysis of drug-associated myocarditis reported in the World Health Organization pharmacovigilance database. Nat Commun 2022; 13:25. [PMID: 35013204 PMCID: PMC8748719 DOI: 10.1038/s41467-021-27631-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 12/02/2021] [Indexed: 12/12/2022] Open
Abstract
While multiple pharmacological drugs have been associated with myocarditis, temporal trends and overall mortality have not been reported. Here we report the spectrum and main features of 5108 reports of drug-induced myocarditis, in a worldwide pharmacovigilance analysis, comprising more than 21 million individual-case-safety reports from 1967 to 2020. Significant association between myocarditis and a suspected drug is assessed using disproportionality analyses, which use Bayesian information component estimates. Overall, we identify 62 drugs associated with myocarditis, 41 of which are categorized into 5 main pharmacological classes: antipsychotics (n = 3108 reports), salicylates (n = 340), antineoplastic-cytotoxics (n = 190), antineoplastic-immunotherapies (n = 538), and vaccines (n = 790). Thirty-eight (61.3%) drugs were not previously reported associated with myocarditis. Antipsychotic was the first (1979) and most reported class (n = 3018). In 2019, the two most reported classes were antipsychotics (54.7%) and immunotherapies (29.5%). Time-to-onset between treatment start and myocarditis is 15 [interquartile range: 10; 23] days. Subsequent mortality is 10.3% and differs between drug classes with immunotherapies the highest, 32.5% and salicylates the lowest, 2.6%. These elements highlight the diversity of presentations of myocarditis depending on drug class, and show the emerging role of antineoplastic drugs in the field of drug-induced myocarditis.
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32
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Chest Pain in a Psychiatric Patient Due to Clozapine-Induced Myopericarditis. Case Rep Cardiol 2022; 2021:6067652. [PMID: 34976414 PMCID: PMC8720013 DOI: 10.1155/2021/6067652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/08/2021] [Indexed: 11/18/2022] Open
Abstract
Drug-induced myocarditis is a rare, but underrecognized complication of clozapine therapy for schizophrenia. We present a case of clozapine-induced myocarditis with recovery of cardiac function after drug cessation and summarize the literature to highlight the variable presentation of this condition.
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33
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Segev A, Iqbal E, McDonagh TA, Casetta C, Oloyede E, Piper S, Plymen CM, MacCabe JH. Clozapine-induced myocarditis: electronic health register analysis of incidence, timing, clinical markers and diagnostic accuracy. Br J Psychiatry 2021; 219:644-651. [PMID: 35048875 PMCID: PMC8636612 DOI: 10.1192/bjp.2021.58] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 04/07/2021] [Accepted: 04/13/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Clozapine is associated with increased risk of myocarditis. However, many common side-effects of clozapine overlap with the clinical manifestations of myocarditis. As a result, there is uncertainty about which signs, symptoms and investigations are important in distinguishing myocarditis from benign adverse effects of clozapine. Clarity on this issue is important, since missing a diagnosis of myocarditis or discontinuing clozapine unnecessarily may both have devastating consequences. AIMS To examine the clinical characteristics of clozapine-induced myocarditis and to identify which signs and symptoms distinguish true myocarditis from other clozapine adverse effects. METHOD A retrospective analysis of the record database for 247 621 patients was performed. A natural language processing algorithm identified the instances of patients in which myocarditis was suspected. The anonymised case notes for the patients of each suspected instance were then manually examined, and those whose instances were ambiguous were referred for an independent assessment by up to three cardiologists. Patients with suspected instances were classified as having confirmed myocarditis, myocarditis ruled out or undetermined. RESULTS Of 254 instances in 228 patients with suspected myocarditis, 11.4% (n = 29 instances) were confirmed as probable myocarditis. Troponin and C-reactive protein (CRP) had excellent diagnostic value (area under the curve 0.975 and 0.896, respectively), whereas tachycardia was of little diagnostic value. All confirmed instances occurred within 42 days of clozapine initiation. CONCLUSIONS Suspicion of myocarditis can lead to unnecessary discontinuation of clozapine. The 'critical period' for myocarditis emergence is the first 6 weeks, and clinical signs including tachycardia are of low specificity. Elevated CRP and troponin are the best markers for the need for further evaluation.
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Affiliation(s)
- Aviv Segev
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Shalvata Mental Health Centre, Israel; and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Ehtesham Iqbal
- The Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Theresa A. McDonagh
- Cardiology Department, King's College Hospital and King's College London, UK
| | - Cecilia Casetta
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; and National Psychosis Service, South London and Maudsley NHS Foundation Trust, UK
| | - Ebenezer Oloyede
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; and Pharmacy Department, South London and Maudsley NHS Foundation Trust, UK
| | - Susan Piper
- Cardiology Department, King's College Hospital and King's College London, UK
| | - Carla M. Plymen
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, UK
| | - James H. MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; and National Psychosis Service, South London and Maudsley NHS Foundation Trust, UK
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34
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Bellman V, Russell N, Depala K, Dellenbaugh A, Desai S, Vadukapuram R, Patel S, Srinivas S. Challenges in Treating Cancer Patients With Unstable Psychiatric Disorder. World J Oncol 2021; 12:137-148. [PMID: 34804276 PMCID: PMC8577605 DOI: 10.14740/wjon1402] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/17/2021] [Indexed: 11/14/2022] Open
Abstract
In this review, we first present a case of chronic myeloid leukemia with acute psychosis, and then we will discuss the incidence of cancer in patients with psychotic disorders, the manifestations of new-onset psychosis, and the prevalence of preexisting psychosis in cancer patients, coupled with their impact on the treatment, diagnosis, and prognosis of cancer. This was a case that presented with acute psychosis and was found to have an elevated white blood cell count upon admission to an inpatient psychiatric unit. He was diagnosed with chronic myeloid leukemia and successfully managed with imatinib/dasatinib therapy. Psychiatrically, he was stabilized on two long-acting injectable medications to help maintain adherence. We were able to eliminate his active psychotic symptoms and return him to normal functioning in affect and thinking, achieving sustained compliance with treatment. We identified multiple inconsistencies in screening for cancer of all types in these patients, masking of signs and symptoms that would typically clue physicians to the presence of cancers, underreporting of symptoms, and disparate access to healthcare resources in patients with mental disorders when compared to the general population. Treatment of cancer in these patients as compared to the general population has also been shown to be incongruent, which will be elaborated upon. Psychiatric interventions, as well as supportive measures, for treating patients who are facing challenges during active cancer treatment will be discussed.
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Affiliation(s)
- Val Bellman
- Department of Psychiatry, University of Missouri Kansas City School of Medicine, 1000 E. 24th Street, Kansas City, MO 64108, USA
| | - Nina Russell
- University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | - Kartik Depala
- University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | | | - Saral Desai
- Department of Psychiatry, Brookdale University Hospital Medical Center, Brooklyn, NY, USA
| | - Ramu Vadukapuram
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Sushma Srinivas
- A.J. Institute of Medical Sciences and Research Centre, NH66, Kuntikan, Mangalore, Karnataka, India
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Li XQ, Tang XR, Li LL. Antipsychotics cardiotoxicity: What's known and what's next. World J Psychiatry 2021; 11:736-753. [PMID: 34733639 PMCID: PMC8546771 DOI: 10.5498/wjp.v11.i10.736] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/08/2021] [Accepted: 09/02/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic use of antipsychotic medications entails a dilemma between the benefit of alleviating psychotic symptoms and the risk of troubling, sometimes life-shortening adverse effects. Antipsychotic-induced cardiotoxicity is one of the most life-threatening adverse effects that raises widespread concerns. These cardiotoxic effects range from arrhythmia to heart failure in the clinic, with myocarditis/cardiomyopathy, ischemic injuries, and unexplained cardiac lesions as the pathological bases. Multiple mechanisms have been proposed to underlie antipsychotic cardiotoxicity. This review aims to summarize the clinical signs and pathological changes of antipsychotic cardiotoxicity and introduce recent progress in understanding the underlying mechanisms at both the subcellular organelle level and the molecular level. We also provide an up-to-date perspective on future clinical monitoring and therapeutic strategies for antipsychotic cardiotoxicity. We propose that third-generation antipsychotics or drug adjuvant therapy, such as cannabinoid receptor modulators that confer dual benefits — i.e., alleviating cardiotoxicity and improving metabolic disorders — deserve further clinical evaluation and marketing.
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Affiliation(s)
- Xiao-Qing Li
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China
| | - Xin-Ru Tang
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China
| | - Li-Liang Li
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China
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Clozapine-Induced Pericardial Effusion Presenting with Persistent Tachycardia. Case Rep Med 2021; 2021:5523562. [PMID: 34497649 PMCID: PMC8419507 DOI: 10.1155/2021/5523562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 11/18/2022] Open
Abstract
Clozapine is an atypical antipsychotic used in refractory schizophrenia and depression. Its use is often complicated by its vast side-effect profile including cardiovascular reactions, agranulocytosis, and seizures. Specifically, the cardiac complications of clozapine have been shown to predominantly cause myocarditis and pericarditis. In this case report, the case of a 58-year-old male being treated for treatment-resistant depression and schizophrenia who suffers from tachycardia is presented. He is treated empirically for orthostatic hypotension with IV fluids without much success. Further imaging and echocardiography demonstrated a pericardial effusion, a rare reaction (≤1 : 10000) that has only been documented in a handful of case reports. This anecdotal evidence highlights the significance of polyserositis/pericardial effusion in the context of clozapine-induced orthostatic hypotension resistant to rehydration. When starting a patient on clozapine, it is important to consider further workup and monitoring with laboratory baseline biomarkers and cardiac evaluation with symptomatic individuals. Upon immediate cessation of clozapine, the pericardial effusion should spontaneously resolve without complication and should not be rechallenged.
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Safety profile of clozapine: Analysis using national registry data in Japan. J Psychiatr Res 2021; 141:116-123. [PMID: 34192602 DOI: 10.1016/j.jpsychires.2021.06.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 02/05/2023]
Abstract
Clozapine is the only effective antipsychotic drug used for the treatment of treatment-resistant schizophrenia. Although it has been shown that the frequency of clozapine use is very low in Japan, our previous study revealed that the number of clozapine prescriptions has been increasing in recent years, and that risk factors leading to discontinuation of clozapine were also identified as age ≥40 years, poor tolerability to olanzapine, previous treatment with clozapine, and white blood cell count <6000/mm3. The main cause for discontinuation of clozapine is the occurrence of a wide range of adverse events, including neutropenia/leukopenia and fatal cardiac disorders. In this study, we analyzed the physical details and backgrounds of patients with adverse events that led to clozapine discontinuation using a national registry database of more than 8000 Japanese patients. The physical adverse events that led to discontinuation of clozapine were neutropenia/leukopenia, glucose intolerance, cardiac disorders, gastrointestinal disorders, neuroleptic malignant syndrome, pleurisy, pulmonary embolism, sedation/somnolence, and seizures. Neutropenia/leukopenia had the highest incidence (5.0%). Neutropenia/leukopenia and cardiac disorders tended to occur early in the treatment period, indicating the need for careful monitoring for these adverse events in the early stages of clozapine treatment. Gastrointestinal disorders occurred over a long period of time, suggesting the need for careful observation during the maintenance period. The data obtained in our study will lead to the optimal and safe use of clozapine treatment.
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D’Errico S, Russa RL, Maiese A, Santurro A, Scopetti M, Romano S, Zanon M, Frati P, Fineschi V. Atypical antipsychotics and oxidative cardiotoxicity: review of literature and future perspectives to prevent sudden cardiac death. J Geriatr Cardiol 2021; 18:663-685. [PMID: 34527032 PMCID: PMC8390928 DOI: 10.11909/j.issn.1671-5411.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Oxidative stress is considered the principal mediator of myocardial injury under pathological conditions. It is well known that reactive oxygen (ROS) or nitrogen species (RNS) are involved in myocardial injury and repair at the same time and that cellular damage is generally due to an unbalance between generation and elimination of the free radicals due to an inadequate mechanism of antioxidant defense or to an increase in ROS and RNS. Major adverse cardiovascular events are often associated with drugs with associated findings such as fibrosis or inflammation of the myocardium. Despite efforts in the preclinical phase of the development of drugs, cardiotoxicity still remains a great concern. Cardiac toxicity due to second-generation antipsychotics (clozapine, olanzapine, quetiapine) has been observed in preclinical studies and described in patients affected with mental disorders. A role of oxidative stress has been hypothesized but more evidence is needed to confirm a causal relationship. A better knowledge of cardiotoxicity mechanisms should address in the future to establish the right dose and length of treatment without impacting the physical health of the patients.
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Affiliation(s)
- Stefano D’Errico
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Raffaele La Russa
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
- IRCSS Neuromed Mediterranean Neurological Institute, Pozzilli, Italy
| | - Aniello Maiese
- IRCSS Neuromed Mediterranean Neurological Institute, Pozzilli, Italy
- Department of Surgical Pathology, Medical, Molecular and Critical Area, University of Pisa, Pisa, Italy
| | - Alessandro Santurro
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Matteo Scopetti
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Silvia Romano
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Martina Zanon
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Paola Frati
- IRCSS Neuromed Mediterranean Neurological Institute, Pozzilli, Italy
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Vittorio Fineschi
- IRCSS Neuromed Mediterranean Neurological Institute, Pozzilli, Italy
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
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Wang J, Li X, Liu Z, Lin X, Zhong F, Li S, Tang X, Zhang Y, Li L. Second-generation antipsychotics induce cardiotoxicity by disrupting spliceosome signaling: Implications from proteomic and transcriptomic analyses. Pharmacol Res 2021; 170:105714. [PMID: 34098070 DOI: 10.1016/j.phrs.2021.105714] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/18/2021] [Accepted: 06/02/2021] [Indexed: 02/07/2023]
Abstract
Second-generation antipsychotics (SGAs) are first-line drugs that are prescribed for mental disorders in clinic. Severe cardiotoxicity has been widely reported and thus limits their clinical application. This study aimed to identify the common mechanism underlying SGAs-induced cardiotoxicity using dual-omics analyses. Balb/C mice were intraperitoneally injected with two representative SGAs, olanzapine (2.5 mg/kg) and clozapine (25 mg/kg), at clinically comparable doses for 0, 7, 14 and 21 days. Our results showed that both SGAs induced cardiomyocyte degeneration, inflammation infiltration, and cardiac fibrosis, all of which worsened with time. Proteomic analysis revelaed that 22 differentially expressed (DE) proteins overlapped in olanzapine and clozapine-treated hearts. These proteins were significantly enriched in muscle contraction, amino acid metabolism and spliceosomal assembly by GO term analysis and spliceosome signaling was among the top enriched pathways by KEGG analysis. Among the 22 DE proteins, three spliceosome signal proteins were validated in a dynamic detection, and their expression significantly correlated with the extent of SGAs-induced cardiac fibrosis. Following the spliceosome signaling dysregulation, RNA sequencing revealed that alternative splicing events in the mouse hearts were markedly enhanced by SGAs treatments, and the production of vast transcript variants resulted in dysregulation of multiple pathways that are critical for cardiomyocytes adaptation and cardiac remodeling. Pladienolide B, a specific inhibitor of mRNA splicing, successfully corrected SGAs-induced alternative splicing and significantly attenuated the secretion of pro-inflammatory factors and cell deaths induced by SGAs exposure. Our study concluded that the spliceosome signaling was a common pathway driving SGAs cardiotoxicity. Pharmacological inhibition of the spliceosome signaling represents a novel therapeutic strategy against SGAs cardiotoxicity.
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Affiliation(s)
- Jing Wang
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China.
| | - Xiaoqing Li
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China.
| | - Zheng Liu
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China.
| | - Xinyi Lin
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China.
| | - Fan Zhong
- Department of Systems Biology for Medicine, Shanghai Medical College, Fudan University, Shanghai 200032, China; Institutes of Biomedical Sciences, Fudan University, Shanghai 200032, China.
| | - Shuhao Li
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China.
| | - Xinru Tang
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China.
| | - Yang Zhang
- Institutes of Biomedical Sciences, Fudan University, Shanghai 200032, China.
| | - Liliang Li
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China.
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Sandarsh S, Bishnoi RJ, Shashank RB, Miller BJ, Freudenreich O, McEvoy JP. Monitoring for myocarditis during treatment initiation with clozapine. Acta Psychiatr Scand 2021; 144:194-200. [PMID: 33997951 DOI: 10.1111/acps.13328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/24/2021] [Accepted: 05/11/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Clozapine use is associated with myocarditis. In this study, we investigated what clinical signs and symptoms, and/or laboratory test(s), alert clinicians to presumptive myocarditis (PrMy) most accurately and at the earliest time point. We also investigated the incidence of PrMy during the initial exposure to clozapine versus in patients restarted on clozapine after extended interruption of prior prolonged treatment. METHODS 100 patients admitted to state psychiatric hospital started on clozapine were recruited into the study. 76 patients were treated with clozapine for the first time and 24 patients were restarts. Creatine kinase (CK), troponin I (TROP), eosinophil count (EOS), and C-reactive protein (CRP) were obtained at baseline and weeks 1, 2, 3, and 4. Descriptive statistics were calculated for demographic and clinical variables. Student's t test and chi-squared test were used to compare means and proportions between initial exposure and restart groups. RESULTS Clinical features and laboratory tests suggestive of PrMy were seen in 4 patients (5.3%) in initial exposure group and none in restart group. 3.5% of TROP levels were abnormal in initial exposure group and no abnormal levels were found in the restart group. 30% and 46% of CK, 23% and 39% of CRP, and 14% and 23% of EOS were abnormal in initial exposure group and restart groups, respectively. CONCLUSIONS PrMy was common (5.3%) during clozapine initiation. Prospective management through serial laboratory monitoring with weekly TROP levels was sensitive enough to allow for timely clozapine discontinuation.
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Affiliation(s)
- Surya Sandarsh
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, Augusta, GA, USA.,East Central Regional Hospital, Augusta, GA, USA
| | - Ram J Bishnoi
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, Augusta, GA, USA.,East Central Regional Hospital, Augusta, GA, USA
| | - Reddy Beesam Shashank
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, Augusta, GA, USA.,East Central Regional Hospital, Augusta, GA, USA
| | - Brian J Miller
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Oliver Freudenreich
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Joseph P McEvoy
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, Augusta, GA, USA
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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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Sernoskie SC, Jee A, Uetrecht JP. The Emerging Role of the Innate Immune Response in Idiosyncratic Drug Reactions. Pharmacol Rev 2021; 73:861-896. [PMID: 34016669 DOI: 10.1124/pharmrev.120.000090] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Idiosyncratic drug reactions (IDRs) range from relatively common, mild reactions to rarer, potentially life-threatening adverse effects that pose significant risks to both human health and successful drug discovery. Most frequently, IDRs target the liver, skin, and blood or bone marrow. Clinical data indicate that most IDRs are mediated by an adaptive immune response against drug-modified proteins, formed when chemically reactive species of a drug bind to self-proteins, making them appear foreign to the immune system. Although much emphasis has been placed on characterizing the clinical presentation of IDRs and noting implicated drugs, limited research has focused on the mechanisms preceding the manifestations of these severe responses. Therefore, we propose that to address the knowledge gap between drug administration and onset of a severe IDR, more research is required to understand IDR-initiating mechanisms; namely, the role of the innate immune response. In this review, we outline the immune processes involved from neoantigen formation to the result of the formation of the immunologic synapse and suggest that this framework be applied to IDR research. Using four drugs associated with severe IDRs as examples (amoxicillin, amodiaquine, clozapine, and nevirapine), we also summarize clinical and animal model data that are supportive of an early innate immune response. Finally, we discuss how understanding the early steps in innate immune activation in the development of an adaptive IDR will be fundamental in risk assessment during drug development. SIGNIFICANCE STATEMENT: Although there is some understanding that certain adaptive immune mechanisms are involved in the development of idiosyncratic drug reactions, the early phase of these immune responses remains largely uncharacterized. The presented framework refocuses the investigation of IDR pathogenesis from severe clinical manifestations to the initiating innate immune mechanisms that, in contrast, may be quite mild or clinically silent. A comprehensive understanding of these early influences on IDR onset is crucial for accurate risk prediction, IDR prevention, and therapeutic intervention.
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Affiliation(s)
- Samantha Christine Sernoskie
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy (S.C.S., J.P.U.), and Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (A.J., J.P.U.)
| | - Alison Jee
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy (S.C.S., J.P.U.), and Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (A.J., J.P.U.)
| | - Jack Paul Uetrecht
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy (S.C.S., J.P.U.), and Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (A.J., J.P.U.)
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Thymoquinone reduces mitochondrial damage and death of cardiomyocytes induced by clozapine. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2021; 394:1675-1684. [PMID: 33937934 DOI: 10.1007/s00210-021-02095-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
The generation of a reactive nitrenium ion by microsomal/mitochondrial cytochrome P450 (CYPs) from clozapine (CLZ) has been suggested as the main cause of cardiotoxicity by this drug. Previous studies indicated that thymoquinone (TQ) as an active constituent of Nigella sativa has pharmacological effects such as antioxidant, reactive oxygen species (ROS) scavenger, and inhibitory effect on CYPs enzymes. Therefore, we hypothesized that TQ with these pharmacological effects can reduce CLZ-induced toxicity in isolated cardiomyocytes and mitochondria. Rat left ventricular cardiomyocytes and mitochondria were isolated by collagenase perfusion and differential centrifugation respectively. Then, isolated cardiomyocytes and mitochondria were pretreated with different concentrations of TQ (1, 5, and 10 μmol/l) for 30 min and then followed by exposure to CLZ (50 μmol/l) for 6 h. After 6 h of incubation, using biochemical evaluations and flow cytometric analysis, the parameters of cellular toxicity including cytotoxicity, the level of oxidized/reduced glutathione (GSH/GSSG), malondialdehyde (MDA), reactive oxygen species (ROS) formation, lysosomal membrane integrity, mitochondria membrane potential (ΔΨm) collapse, and mitochondrial toxicity including succinate dehydrogenase (SDH) activity and mitochondrial swelling were analyzed. We observed a significant toxicity in isolated cardiomyocytes and mitochondria after exposure with CLZ which was related to ROS formation, oxidative stress, GSH depletion, lysosomal and mitochondrial damages, and mitochondrial dysfunction and swelling, while TQ pretreatment reverted the above toxic effect of CLZ on isolated cardiomyocytes and mitochondria. Our results indicate that TQ prevents and reverses CLZ-induced cytotoxicity and mitochondrial damages in isolated cardiomyocytes and mitochondria, providing an experimental basis for clinical treatment on CLZ-induced cardiotoxicity.
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Skelton L, Pugh R, Harries B, Blake L, Butler M, Sethi F. The COVID-19 pandemic from an acute psychiatric perspective: a London psychiatric intensive care unit experience. BJPsych Bull 2021; 45:76-79. [PMID: 32404229 PMCID: PMC7280557 DOI: 10.1192/bjb.2020.54] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The COVID-19 pandemic has put the UK's National Health Service under extreme pressure, and acute psychiatric services have had to rapidly adapt to a new way of working. This editorial describes the experience of a London psychiatric intensive care unit (PICU) where all nine in-patients ultimately tested COVID-19 positive.
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Affiliation(s)
- Luke Skelton
- South London and Maudsley NHS Foundation Trust, UK
| | - Ria Pugh
- South London and Maudsley NHS Foundation Trust, UK
| | | | - Lucy Blake
- South London and Maudsley NHS Foundation Trust, UK
| | | | - Faisil Sethi
- South London and Maudsley NHS Foundation Trust, UK
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45
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Markwerth P, Bajanowski T, Tzimas I, Dettmeyer R. Sudden cardiac death-update. Int J Legal Med 2021; 135:483-495. [PMID: 33349905 PMCID: PMC7751746 DOI: 10.1007/s00414-020-02481-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/09/2020] [Indexed: 02/06/2023]
Abstract
Sudden cardiac death (SCD) is one of the most common causes of death worldwide with a higher frequency especially in the young. Therefore, SCD is represented frequently in forensic autopsy practice, whereupon pathological findings in the heart can explain acute death. These pathological changes may not only include myocardial infarction, coronary thrombosis, or all forms of myocarditis/endocarditis but also rare diseases such as hereditary structural or arrythmogenic anomalies, lesions of the cardiac conduction system, or primary cardiac tumours.
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Affiliation(s)
- P Markwerth
- Institute for Forensic Medicine, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany.
| | - T Bajanowski
- Institute for Forensic Medicine, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - I Tzimas
- Institute for Forensic Medicine, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - R Dettmeyer
- Institute for Forensic Medicine, University Hospital Gießen, Giessen, Germany
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46
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Myles H, Large M. Considering the impact of viral illness on the aetiology of clozapine myocarditis. Aust N Z J Psychiatry 2021; 55:226. [PMID: 32698608 DOI: 10.1177/0004867420945793] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Hannah Myles
- Northern Adelaide Local Health Network, Adelaide, SA, Australia.,School of Medicine, The University of Adelaide, Adelaide, SA, Australia
| | - Matthew Large
- School of Psychiatry, University of New South Wales, Kensington, NSW, Australia
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Implementation and Outcomes of a Clozapine-Associated Myocarditis Screening Program in a Region of South Australia-Lessons Learned. J Clin Psychopharmacol 2021; 40:250-258. [PMID: 32332460 DOI: 10.1097/jcp.0000000000001193] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Clozapine-associated myocarditis (CAM) is a serious complication, mostly occurring in the first month of treatment. Public mental health in South Australia introduced a screening protocol in 2011 using baseline and weekly C-reactive protein and troponin. The aim of this study was to assess protocol adherence and management of cases with positive screening results. METHODS We identified all patients commenced on clozapine in our area between 2012 and 2015. Those with abnormal C-reactive protein and/or troponin in the first 4 weeks of treatment were identified (potential cases). For those, we collected clinical characteristics and test results and reviewed their management. FINDINGS Protocol compliance increased to 80%. We identified 24 potential CAM cases, 8 at high risk based on established definition (7.6% of new commencements) and 9 formally diagnosed from 143 commenced on clozapine. Potential cases not meeting CAM definition were significantly more likely commenced on clozapine for the first time and have preexisting respiratory disease. Likely CAM cases were younger, and more often prescribed additional antipsychotics, specifically quetiapine. Seven (78%) of 9 patients diagnosed with CAM met published CAM definition. In 14 undiagnosed potential cases, 10 (71%) did not have timely testing to exclude CAM. CONCLUSIONS Maintaining a high index of suspicion, clinical monitoring and timely testing is important to supplement CAM screening protocols. More research is needed to identify those that can be safely rechallenged or even continue clozapine treatment with monitoring.
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Taub S, Hoshen M, Balicer R, Kamhi-Nesher S, Weizman A, Krivoy A. Metabolic predictors for mortality among patients treated with long-term clozapine - A longitudinal study. Eur Neuropsychopharmacol 2020; 41:63-69. [PMID: 32981820 DOI: 10.1016/j.euroneuro.2020.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/03/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023]
Abstract
Clozapine is the only antipsychotic compound indicated for refractory-schizophrenia. However, it is associated with emergent metabolic dysregulation and cardiovascular risk which may lead to mortality. In this study we aimed to explore predictors for mortality in a large cohort of schizophrenia patients treated with long-term clozapine, using the electronic medical records of the largest health care provider in Israel. Among 27,929 patients diagnosed with schizophrenia, 1817 were prescribed clozapine during the years 2012-2014. We compared patients who survived (n=1705) and patients who died (n=112) during the 3-year follow-up period. Socio-demographic background, cardiovascular morbidity, medication prescriptions and health-care utilization were compared between groups. Cox proportional hazard models were used to assess the association of variables with survival. Chronic hypertension was found to be the only metabolic factor associated with significant hazard ratio (HR) for mortality (HR: 1.55 95% CI: 1.03-2.34). Moreover, those who died had more prevalent ischemic heart disease (14% vs 3%, p<0.005) as well as more frequent hospitalizations (0.01±0.02 vs 0.11±0.18 average per month, p<0.005), for longer periods (2.22±9.87 vs 20.38±33.76 days per month, p<0.005). Among those who died, less patients received prescriptions of statins for hyperlipidemia (13.7% vs. 52.9% in survivors, p<0.005) and hypoglycemics for diabetes mellitus (16.3% vs. 67.1% in survivors, p<0.005). Inadequate treatment of metabolic syndrome, under chronic clozapine treatment, was found to be an independent predictor for mortality. Adequate rigorous regimen for diagnosis and treatment of metabolic risk factors, especially hyperlipidemia and diabetes mellitus, might lower complications rate and prolong life expectancy among this population.
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Affiliation(s)
- Sharon Taub
- Geha Mental Health Center, Petach-Tikva, Israel.
| | - Moshe Hoshen
- Clalit Research Institute, Clalit Health Services, Tel-Aviv, Israel
| | - Ran Balicer
- Clalit Research Institute, Clalit Health Services, Tel-Aviv, Israel; Public Health Department, Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel
| | - Shiri Kamhi-Nesher
- Geha Mental Health Center, Petach-Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Abraham Weizman
- Geha Mental Health Center, Petach-Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Felsenstein Medical Research Center, Petah Tikva, Israel
| | - Amir Krivoy
- Geha Mental Health Center, Petach-Tikva, Israel; Clalit Research Institute, Clalit Health Services, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Psychosis Studies Department, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
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van der Horst MZ, van Houwelingen F, Luykx JJ. Isolated nausea and vomiting as the cardinal presenting symptoms of clozapine-induced myocarditis: a case report. BMC Psychiatry 2020; 20:568. [PMID: 33246443 PMCID: PMC7694895 DOI: 10.1186/s12888-020-02955-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 11/15/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Clozapine is an atypical antipsychotic proven to be superior in the treatment of treatment-resistant schizophrenia. Myocarditis is a rare, but well-known complication of treatment with clozapine. Only few cases have been reported in which nausea and vomiting were prominent symptoms. This is the first described report in which nausea and vomiting were the only presenting symptoms of clozapine-induced myocarditis. CASE PRESENTATION We report a case of a 58-year-old woman, suffering from schizoaffective disorder, who is being treated with clozapine. Two weeks after initiation of clozapine, she developed nausea and vomiting, in absence of any other clinical symptoms. Laboratory examination and magnetic resonance imaging confirmed the diagnosis of clozapine-induced myocarditis. Clozapine was discontinued and the patient recovered fully. CONCLUSIONS This case emphasizes the importance of recognizing myocarditis as a cause of isolated nausea and vomiting in patients treated with clozapine. Early recognition improves clinical outcome and reduces mortality.
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Affiliation(s)
- M. Z. van der Horst
- grid.5477.10000000120346234Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands ,grid.5477.10000000120346234Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands ,Outpatient Second Opinion Clinic, GGNet Mental Health, Warnsveld, The Netherlands
| | - F. van Houwelingen
- grid.5477.10000000120346234Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands ,grid.5477.10000000120346234Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - J. J. Luykx
- grid.5477.10000000120346234Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands ,grid.5477.10000000120346234Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands ,Outpatient Second Opinion Clinic, GGNet Mental Health, Warnsveld, The Netherlands
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Arzuk E, Karakuş F, Orhan H. Bioactivation of clozapine by mitochondria of the murine heart: Possible cause of cardiotoxicity. Toxicology 2020; 447:152628. [PMID: 33166605 DOI: 10.1016/j.tox.2020.152628] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/26/2020] [Accepted: 11/03/2020] [Indexed: 01/11/2023]
Abstract
The mechanism of clozapine-associated cardiotoxicity has not been elucidated. The formation of a reactive nitrenium ion from the drug has been suggested as the cause, however, the reason why the heart is a target remains unknown. The heart is one of the most perfused organs; therefore, it contains a large number of mitochondria per cell; these organelles are responsible for both oxygen metabolism and energy production due to high energy expenditure. Given that mitochondria play critical roles in cellular homeostasis and maintenance, this study tested the hypothesis that cardiac mitochondria are both a target and initiator of clozapine-induced cardiotoxicity through activating the drug. We investigated whether murine heart receives a relatively high amount of systemically administered drug (20 mg/kg, i.p., Wistar albino rats) and whether cardiac mice (Swiss albino) and rat (Wistar albino) mitochondria locally activate clozapine (100 μM) to a reactive metabolite. We observed a relatively large distribution of clozapine to heart tissue as well as the formation of reactive metabolites by cardiac mitochondria in situ. Mitochondrial cytochrome P450 enzymes (CYP) in cardiac tissue responsible for biotransformation of clozapine were also characterized. CYP3A4 has been found to be the major enzyme catalyzes CLZ bioactivation, while CYP1A largely and CYP3A4 partially catalyzes the formation of stable metabolites of CLZ. At 100 μM concentration, clozapine caused a significant decline in mitochondrial oxygen consumption rate in vitro as much as positive control (antimycin A), while it did not induce mitochondrial permeability transition pore opening. These data provide an explanation as to why the heart is a target for clozapine adverse effects.
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Affiliation(s)
- Ege Arzuk
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Ege University, 35040 Bornova-İzmir, Turkey
| | - Fuat Karakuş
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Ege University, 35040 Bornova-İzmir, Turkey
| | - Hilmi Orhan
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Ege University, 35040 Bornova-İzmir, Turkey.
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