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Fernandez-Egea E, McCutcheon RA. Clozapine monitoring requirements: is it time for an update? Br J Psychiatry 2024:1-3. [PMID: 39359180 DOI: 10.1192/bjp.2024.150] [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] [Indexed: 10/04/2024]
Abstract
Oloyede and colleagues advocate for updating haematological monitoring requirements for clozapine, arguing that current protocols overestimate the risk of clozapine-induced agranulocytosis. Their research suggests that stringent monitoring may unnecessarily limit access to clozapine, a crucial treatment for resistant schizophrenia. The editorial supports calls for international consensus to carefully weigh the pros and cons of relaxing monitoring guidelines while ensuring comprehensive care for patients.
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Affiliation(s)
- Emilio Fernandez-Egea
- Cambridgeshire and Peterborough NHS Foundation Trust and Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Robert A McCutcheon
- Department of Psychiatry, University of Oxford, Oxford, Oxford Health NHS Foundation Trust, Oxford and Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK
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2
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Hart XM, Gründer G, Ansermot N, Conca A, Corruble E, Crettol S, Cumming P, Hefner G, Frajerman A, Howes O, Jukic MM, Kim E, Kim S, Maniscalco I, Moriguchi S, Müller DJ, Nakajima S, Osugo M, Paulzen M, Ruhe HG, Scherf-Clavel M, Schoretsanitis G, Serretti A, Spina E, Spigset O, Steimer W, Süzen SH, Uchida H, Unterecker S, Vandenberghe F, Verstuyft C, Zernig G, Hiemke C, Eap CB. Optimisation of pharmacotherapy in psychiatry through therapeutic drug monitoring, molecular brain imaging and pharmacogenetic tests: Focus on antipsychotics. World J Biol Psychiatry 2024:1-86. [PMID: 38913780 DOI: 10.1080/15622975.2024.2366235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 05/12/2024] [Accepted: 06/06/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND For psychotic disorders (i.e. schizophrenia), pharmacotherapy plays a key role in controlling acute and long-term symptoms. To find the optimal individual dose and dosage strategy, specialised tools are used. Three tools have been proven useful to personalise drug treatments: therapeutic drug monitoring (TDM) of drug levels, pharmacogenetic testing (PG), and molecular neuroimaging. METHODS In these Guidelines, we provide an in-depth review of pharmacokinetics, pharmacodynamics, and pharmacogenetics for 45 antipsychotics. Over 30 international experts in psychiatry selected studies that have measured drug concentrations in the blood (TDM), gene polymorphisms of enzymes involved in drug metabolism, or receptor/transporter occupancies in the brain (positron emission tomography (PET)). RESULTS Study results strongly support the use of TDM and the cytochrome P450 (CYP) genotyping and/or phenotyping to guide drug therapies. Evidence-based target ranges are available for titrating drug doses that are often supported by PET findings. CONCLUSION All three tools discussed in these Guidelines are essential for drug treatment. TDM goes well beyond typical indications such as unclear compliance and polypharmacy. Despite its enormous potential to optimise treatment effects, minimise side effects and ultimately reduce the global burden of diseases, personalised drug treatment has not yet become the standard of care in psychiatry.
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Affiliation(s)
- Xenia Marlene Hart
- Department of Molecular Neuroimaging, Medical Faculty Mannheim, Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Gerhard Gründer
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
- German Center for Mental Health (DZPG), Partner Site Mannheim, Heidelberg, Germany
| | - Nicolas Ansermot
- Department of Psychiatry, Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Lausanne University Hospital, Prilly, Switzerland
| | - Andreas Conca
- Dipartimento di Psichiatria, Comprensorio Sanitario di Bolzano, Bolzano, Italy
| | - Emmanuelle Corruble
- Service Hospitalo-Universitaire de Psychiatrie, Hôpital de Bicêtre, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
- Equipe MOODS, Inserm U1018, CESP (Centre de Recherche en Epidémiologie et Sante des Populations), Le Kremlin-Bicêtre, France
| | - Severine Crettol
- Department of Psychiatry, Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Lausanne University Hospital, Prilly, Switzerland
| | - Paul Cumming
- Department of Nuclear Medicine, Bern University Hospital, Bern, Switzerland
- School of Psychology and Counseling, Queensland University of Technology, Brisbane, Australia
| | - Gudrun Hefner
- Forensic Psychiatry, Vitos Clinic for Forensic Psychiatry, Eltville, Germany
| | - Ariel Frajerman
- Service Hospitalo-Universitaire de Psychiatrie, Hôpital de Bicêtre, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
- Equipe MOODS, Inserm U1018, CESP (Centre de Recherche en Epidémiologie et Sante des Populations), Le Kremlin-Bicêtre, France
| | - Oliver Howes
- Department of Psychosis Studies, IoPPN, King's College London, London, UK
- Faculty of Medicine, Institute of Clinical Sciences (ICS), Imperial College London, London, UK
| | - Marin M Jukic
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
- Pharmacogenetics Section, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
| | - Euitae Kim
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seoyoung Kim
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Ignazio Maniscalco
- Dipartimento di Psichiatria, Comprensorio Sanitario di Bolzano, Bolzano, Italy
| | - Sho Moriguchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Daniel J Müller
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
- Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Shinichiro Nakajima
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Martin Osugo
- Department of Psychosis Studies, IoPPN, King's College London, London, UK
- Faculty of Medicine, Institute of Clinical Sciences (ICS), Imperial College London, London, UK
| | - Michael Paulzen
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany
- JARA - Translational Brain Medicine, Alexianer Center for Mental Health, Aachen, Germany
| | - Henricus Gerardus Ruhe
- Department of Psychiatry, Radboudumc, Nijmegen, Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, Netherlands
| | - Maike Scherf-Clavel
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | | | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Werner Steimer
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich, Munich, Germany
| | - Sinan H Süzen
- Department of Pharmaceutic Toxicology, Faculty of Pharmacy, Ankara University, Ankara, Turkey
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Stefan Unterecker
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
| | - Frederik Vandenberghe
- Department of Psychiatry, Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Lausanne University Hospital, Prilly, Switzerland
| | - Celine Verstuyft
- Equipe MOODS, Inserm U1018, CESP (Centre de Recherche en Epidémiologie et Sante des Populations), Le Kremlin-Bicêtre, France
- Department of Molecular Genetics, Pharmacogenetics and Hormonology, Bicêtre University Hospital Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Gerald Zernig
- Department of Pharmacology, Medical University Innsbruck, Hall in Tirol, Austria
- Private Practice for Psychotherapy and Court-Certified Witness, Hall in Tirol, Austria
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy and Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Mainz, Germany
| | - Chin B Eap
- Department of Psychiatry, Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Lausanne University Hospital, Prilly, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, University of Lausanne, Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Lausanne, Switzerland
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Oloyede E, Bachmann CJ, Dzahini O, Lopez Alcaraz JM, Singh SD, Vallianatu K, Funk B, Whiskey E, Taylor D. Identifying clinically relevant agranulocytosis in people registered on the UK clozapine Central Non-Rechallenge Database: retrospective cohort study. Br J Psychiatry 2024:1-8. [PMID: 39149780 DOI: 10.1192/bjp.2024.104] [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] [Indexed: 08/17/2024]
Abstract
BACKGROUND Clozapine is the most effective antipsychotic for treatment-resistant psychosis. However, clozapine is underutilised in part because of potential agranulocytosis. Accumulating evidence indicates that below-threshold haematological readings in isolation are not diagnostic of life-threatening clozapine-induced agranulocytosis (CIA). AIMS To examine the prevalence and timing of CIA using different diagnostic criteria and to explore demographic differences of CIA in patients registered on the UK Central Non-Rechallenge Database (CNRD). METHOD We analysed data of all patients registered on the UK Clozaril® Patient Monitoring Service Central Non-Rechallenge Database (at least one absolute neutrophil count (ANC) < 1.5 × 109/L and/or white blood cell count < 3.0 × 109/L) between May 2000 and February 2021. We calculated prevalence rates of agranulocytosis using threshold-based and pattern-based criteria, stratified by demographic factors (gender, age and ethnicity). Differences in epidemiology based on rechallenge status and clozapine indication were explored. The proportion of patients who recorded agranulocytosis from a normal ANC was explored. RESULTS Of the 3029 patients registered on the CNRD with 283 726 blood measurements, 593 (19.6%) were determined to have threshold-based agranulocytosis and 348 (11.4%) pattern-based agranulocytosis. In the total sample (75 533), the prevalence of threshold-based agranulocytosis and pattern-based agranulocytosis was 0.8% and 0.5%, respectively. The median time to threshold-based agranulocytosis was 32 weeks (IQR 184) and 15 (IQR 170) weeks for pattern-based agranulocytosis. Among age groups, the prevalence of pattern-based agranulocytosis and threshold-based agranulocytosis was highest in the >48 age group. Prevalence rates were greatest for White (18%) and male individuals (13%), and lowest for Black individuals (0.1%). The proportion of people who were determined to have pattern-based agranulocytosis without passing through neutropenia was 70%. CONCLUSIONS Threshold-based definition of agranulocytosis may over-diagnose CIA. Monitoring schemes should take into consideration neutrophil patterns to correctly identify clinically relevant CIA. In marked contrast to previous studies, CIA occurred least in Black individuals and most in White individuals.
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Affiliation(s)
- Ebenezer Oloyede
- Pharmacy Department, Maudsley Hospital, London, UK
- Department of Psychiatry, University of Oxford, UK
| | | | - Olubanke Dzahini
- Pharmacy Department, Maudsley Hospital, London, UK
- Institute of Pharmaceutical Sciences, King's College London, UK
| | | | - Shaurya Dev Singh
- Institute of Information Science, Leuphana University, Lüneburg, Germany
| | | | - Burkhardt Funk
- Institute of Information Science, Leuphana University, Lüneburg, Germany
| | - Eromona Whiskey
- Pharmacy Department, Maudsley Hospital, London, UK
- National Psychosis Unit, Bethlem Royal Hospital, Beckenham, UK
| | - David Taylor
- Pharmacy Department, Maudsley Hospital, London, UK
- Institute of Pharmaceutical Sciences, King's College London, UK
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Cheng A, Buten S, Large M. Time for a change to clozapine haematological monitoring. Australas Psychiatry 2024; 32:342-345. [PMID: 38820548 DOI: 10.1177/10398562241258764] [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: 06/02/2024]
Abstract
OBJECTIVES This paper critiques the haematological monitoring guidelines for clozapine. It describes the history of clozapine, as well as the pathophysiology and epidemiology of clozapine-induced neutropenia (CIN) and agranulocytosis (CIA). The paper appraises the extant literature on mandatory clozapine haematological monitoring. CONCLUSION Contemporary Australian protocols for clozapine haematological monitoring are not consistent with the current evidence base. CIN and CIA are rare occurrences, and the associated risk of death is low. Potential modifications to existing guidelines include changing neutrophil thresholds for patients with benign ethnic neutropenia and reducing the frequency or removing haematological monitoring after two years of clozapine treatment.
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Affiliation(s)
- Adrian Cheng
- Department of Psychiatry, Prince of Wales Hospital, Sydney, NSW, Australia; and School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
| | - Sara Buten
- Department of Psychiatry, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Matthew Large
- Department of Psychiatry, Prince of Wales Hospital, Sydney, NSW, Australia; and School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
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Tanzer T, Pham B, Warren N, Barras M, Kisely S, Siskind D. Overcoming clozapine's adverse events: a narrative review of systematic reviews and meta-analyses. Expert Opin Drug Saf 2024; 23:811-831. [PMID: 38814794 DOI: 10.1080/14740338.2024.2362796] [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: 01/25/2024] [Accepted: 05/29/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Clozapine is the gold standard treatment for treatment-resistant schizophrenia, however adverse events remain a clinical challenge. AREAS COVERED This review presents a narrative synthesis of systematic reviews and meta-analyses that have reported the onset, incidence, prevalence, and management of clozapine's adverse events. We conducted a systematic literature search using PubMed, Embase, PsycINFO, OvidMEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews from inception to April 2024. EXPERT OPINION Effective management of clozapine's adverse events necessitates multi-faceted, individualized, and shared-decision strategies. Despite a lack of high-quality systematic evidence, expert inter-disciplinary solutions are provided to help address a critical need for clinical guidance. This 35-year update offers an evidence-based framework to assist clinicians, patients, and caregivers navigate the adverse events associated with clozapine therapy.
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Affiliation(s)
- Timothy Tanzer
- Princess Alexandra Hospital, Department of Pharmacy, Brisbane, Australia
- Medicine, University of Queensland, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Betty Pham
- Department of Pharmacy, Metro South Community and Oral Health, Brisbane, Australia
| | - Nicola Warren
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Michael Barras
- Princess Alexandra Hospital, Department of Pharmacy, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Steve Kisely
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Dan Siskind
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
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Alalawi A, Albalawi E, Aljohani A, Almutairi A, Alrehili A, Albalawi A, Aldhafiri A. Decoding Clozapine-Induced Agranulocytosis: Unraveling Interactions and Mitigation Strategies. PHARMACY 2024; 12:92. [PMID: 38921968 PMCID: PMC11207370 DOI: 10.3390/pharmacy12030092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/27/2024] Open
Abstract
Agranulocytosis represents a severe complication associated with the administration of clozapine. Clozapine is an antipsychotic medication that has demonstrated substantial efficacy in remediating refractory schizophrenia and various other psychiatric disorders. Nonetheless, it is crucial to monitor patients for neutropenia regularly during clozapine therapy. Therefore, this article aimed to delve into the prevalence of agranulocytosis during clozapine treatment by scrutinizing the extant literature to discern trends and correlations. This review endeavored to explore factors such as drug interactions, dose-related factors, duration of treatment, and genetic predispositions that could potentially influence the likelihood of patients developing agranulocytosis while undergoing clozapine therapy. Moreover, this review enunciates the ramifications of agranulocytosis on both patients and healthcare providers and meticulously evaluates the strategies to mitigate this risk and ensure optimal patient outcomes.
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Affiliation(s)
- Ali Alalawi
- Drug Information Centre, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia;
| | - Enas Albalawi
- Pharmacy Department, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia;
| | - Abdullah Aljohani
- Medication Safety, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia;
| | - Abdullah Almutairi
- Inpatient Pharmacy, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia;
| | - Abdulraouf Alrehili
- Outpatient Pharmacy, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia;
| | - Areej Albalawi
- Laboratory Department, Madina Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia;
| | - Ahmed Aldhafiri
- Pharmacology and Toxicology Department, College of Pharmacy, Taibah University, Medina 42353, Saudi Arabia
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Silva E, Legge S, Casetta C, Whiskey E, Oloyede E, Gee S. Understanding clozapine-related blood dyscrasias. Developments, genetics, ethnicity and disparity: it's a CIN. BJPsych Bull 2024:1-6. [PMID: 38828731 DOI: 10.1192/bjb.2024.38] [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] [Indexed: 06/05/2024] Open
Abstract
Clozapine remains the gold standard intervention for treatment-resistant schizophrenia; however, it remains underused, especially for some minority groups. A significant impediment is concern about propensity to neutropenia. The aim of this article is to provide an update on current knowledge relating to: the pattern and incidence of severe blood dyscrasias; the effectiveness of current monitoring regimes in reducing harm; the mechanisms of and the distinctions between clozapine-induced neutropenia and agranulocytosis; benign ethnic neutropenia; and changes to the monitoring thresholds in the USA and other international variations. These all have implications for the practical use of clozapine; specifically, how barriers to initiating, maintaining and restarting clozapine can be understood and in many cases overcome, especially for patients from minority groups, potentially with simpler approaches than the use of lithium or G-CSF.
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Affiliation(s)
| | | | - Cecilia Casetta
- South London and Maudsley NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Eromona Whiskey
- South London and Maudsley NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Ebenezer Oloyede
- South London and Maudsley NHS Foundation Trust, London, UK
- University of Oxford, Oxford, UK
| | - Siobhan Gee
- South London and Maudsley NHS Foundation Trust, London, UK
- King's College London, London, UK
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Rubio JM, Kane JM, Tanskanen A, Tiihonen J, Taipale H. Long-term persistence of the risk of agranulocytosis with clozapine compared with other antipsychotics: a nationwide cohort and case-control study in Finland. Lancet Psychiatry 2024; 11:443-450. [PMID: 38697177 DOI: 10.1016/s2215-0366(24)00097-x] [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] [Received: 02/01/2024] [Revised: 03/09/2024] [Accepted: 03/13/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND Agranulocytosis is a life-threatening side-effect of clozapine, the only approved drug for treatment-resistant schizophrenia. The long-term profile of this complication has not yet been well established. Here we aim to describe the risk of clozapine-induced agranulocytosis over the long term. METHODS We used the entire population of Finland to identify people diagnosed with schizophrenia or schizoaffective disorder between 1972 and 2014 and developed a Kaplan-Meier model of time to diagnosis of agranulocytosis during clozapine versus non-clozapine treatment over a 22-year observation period (1996 to 2017). Next, we developed a nested case-control model for agranulocytosis matching by sex, age, time since diagnosis, and being in the incident cohort on a 1 to 5 ratio. Various durations of use for clozapine and non-clozapine antipsychotic treatment were compared to the modal antipsychotic use duration, deriving adjusted odds ratios (aORs) in a multivariable regression model. Recurrence and lethality rates for clozapine-induced agranulocytosis were described. These data reflect on all individuals with lived experience of schizophrenia in Finland during the study time, although individuals with lived experience were not included in the design of the study. FINDINGS We identified 61 769 people with schizophrenia or schizoaffective disorder (14 037 individuals treated with clozapine and 47 732 individuals treated with non-clozapine antipsychotics), with a mean age of 46·67 years (IQR 34·44-57·61), of whom 30 721 (49·7%) were female and 31 048 (50·3%) were male (data on ethnicity not available). Among those, 398 individuals were diagnosed with agranulocytosis (231 individuals treated with clozapine and 167 individuals treated with non-clozapine antipsychotics), representing a cumulative incidence of agranulocytosis for 1·37% (95% CI 0·58-3·16) on clozapine and 0·13% (0·04-0·23) on non-clozapine antipsychotics. In the case (n=398) versus control (n=1987) model, the risk of clozapine-induced agranulocytosis decreased steeply over time from an aOR of 36·01 (95% CI 16·79-77·22) for less than 6 months on clozapine to 4·38 (1·86-10·34) for clozapine use of 54 months or more. Only one of 3559 individuals starting clozapine died because of clozapine-induced agranulocytosis. INTERPRETATION The risk of clozapine-induced agranulocytosis decreases steeply over time but might be persistently greater than that of non-clozapine antipsychotics. This long-term risk excess seems small in absolute terms compared with the known magnitude of the advantages of clozapine in relevant outcomes, including life expectancy. Given the widespread underuse of clozapine, relaxing the long-term neutrophil monitoring could favour the advantages of long-term clozapine use, including greater life expectancy, without incurring the intolerable risk of clozapine-induced agranulocytosis. FUNDING Northwell Health and Sigrid Jusèlius Foundation.
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Affiliation(s)
- Jose M Rubio
- Northwell Health, New Hyde Park, NY, USA; Department of Psychiatry, Zucker Hillside Hospital, Glen Oaks, NY, USA; Institute of Behavioral Science, Feinstein Institutes of Medical Research, Manhasset, NY, USA.
| | - John M Kane
- Northwell Health, New Hyde Park, NY, USA; Department of Psychiatry, Zucker Hillside Hospital, Glen Oaks, NY, USA; Institute of Behavioral Science, Feinstein Institutes of Medical Research, Manhasset, NY, USA
| | - Antti Tanskanen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
| | - Jari Tiihonen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - Heidi Taipale
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland; School of Pharmacy, University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Chen WY, Chen PH, Pan CH, Su SS, Tsai SY, Chen CC, Kuo CJ. Clozapine and its protective effect on all-cause, natural, and suicide mortality in patients with schizophrenia: A nationwide cohort study in Taiwan. Schizophr Res 2024; 268:150-160. [PMID: 37479588 DOI: 10.1016/j.schres.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/23/2023]
Abstract
AIM Clozapine is indicated as the last-line agent for the treatment of refractory schizophrenia due to its side effects. This study included an Asian schizophrenia population and investigated the effect of clozapine on the risks of all-cause, natural, and suicide mortality. METHODS This study included a large-scale schizophrenia inpatient cohort derived from the National Health Insurance Research Database from January 1, 2001, to December 31, 2019 (n = 43,025). Of them, we selected those who received clozapine (clozapine cohort, n = 5800). From those who never used clozapine, we selected two individuals for each patient in the clozapine cohort by matching by age, sex, and the year of the index date (ratio: 1:2, control cohort, n = 11,583). The clozapine and nonclozapine control cohorts together were defined as the study cohort (n = 17,383). Multivariate Cox proportional-hazards regression with a time-dependent model was performed to investigate the effect of individual antipsychotic agents on mortality. RESULTS All individual first-generation antipsychotics were not associated with mortality risk. However, most individual second-generation antipsychotics exerted protective effects against all-cause and natural mortality. Furthermore, only clozapine and risperidone were significantly associated with a low risk of suicide mortality. Only clozapine exhibited a dose-dependent relationship with all-cause, natural, and suicide mortality. CONCLUSIONS This study provides robust evidence supporting the strong protective effect of clozapine on all-cause, suicide, and natural mortality risks in an Asian population. Under close monitoring, clozapine use can be advantageous in patients with schizophrenia who are at a high risk of suicide.
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Affiliation(s)
- Wen-Yin Chen
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan; School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Pao-Huan Chen
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Hung Pan
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan; Department of Psychology, National Chengchi University, Taipei, Taiwan
| | - Sheng-Siang Su
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan
| | - Shang-Ying Tsai
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chiao-Chicy Chen
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan; Department of Psychiatry, Mackay Medical College, Taipei, Taiwan
| | - Chian-Jue Kuo
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan; Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan.
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Kang N, Kim SH, Kim J, Kim S, Jang J, Yoon H, Lee J, Kim M, Kim YS, Kwon JS. Association between initial clozapine titration and pneumonia risk among patients with schizophrenia in a Korean tertiary hospital. Schizophr Res 2024; 268:107-113. [PMID: 37770376 DOI: 10.1016/j.schres.2023.09.029] [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: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/30/2023]
Abstract
Pneumonia is a significant adverse drug reaction (ADR) associated with clozapine, characterized by high mortality and potential linkage with other inflammatory responses. Despite the critical nature, research regarding the development of pneumonia during initial clozapine titration remains limited. This retrospective study included 1408 Korean inpatients with schizophrenia spectrum disorders. Data were collected from January 2000 to January 2023. Pneumonia developed in 3.5 % of patients within 8 weeks of clozapine initiation. Patients who developed pneumonia were taking a greater number and higher dose of antipsychotics at baseline (2.14 vs. 1.58, p < 0.001; 25.64 vs. 19.34, p = 0.012). The average onset occurred 17.24 days after initiation, on an average dose of 151.28 mg/day. Titration was either paused or slowed in most of these patients, with no reported fatalities. The types of pneumonia included aspiration pneumonia, mycoplasma pneumonia, bronchopneumonia, and COVID-19 pneumonia. Myocarditis, drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, and urinary tract infections were also identified. Logistic regression analysis revealed that a greater number of concomitant antipsychotics (odds ratio [OR] = 1.59, p = 0.027) and concomitant benzodiazepine use (OR = 2.33, p = 0.005) at baseline were associated with an increased risk of pneumonia. Overall, pneumonia development during clozapine titration is linked with other inflammatory ADRs, suggesting a shared immunological mechanism. Close monitoring is recommended, especially for patients taking multiple antipsychotics and benzodiazepines. Further studies involving repeated measures of clozapine concentrations at trough and steady state, along with a more detailed description of pneumonia types, are warranted.
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Affiliation(s)
- Nuree Kang
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Se Hyun Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea; Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Jayoun Kim
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sungkyu Kim
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jinhyeok Jang
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Heesoo Yoon
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeonghoon Lee
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Minah Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea; Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yong Sik Kim
- Department of Psychiatry, Nowon Eulji Medical Center, Eulji University, Seoul, Republic of Korea
| | - Jun Soo Kwon
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea; Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea; Institute of Human Behavioral Medicine, SNU-MRC, Seoul, Republic of Korea
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11
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Niitsu T, Yasui-Furukori N, Inada K, Kanazawa T, Iyo M, Ueno T, Hashimoto R. Current practice for clozapine-induced leukopenia in Japanese psychiatric hospitals: A nationwide survey. Schizophr Res 2024; 268:82-87. [PMID: 38038428 DOI: 10.1016/j.schres.2023.10.011] [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: 05/31/2023] [Revised: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 12/02/2023]
Abstract
Clozapine is an atypical antipsychotic used for treatment-resistant schizophrenia. In Japan, its use requires management by a blood monitoring system called the Clozaril Patient Monitoring Service (CPMS) for the early detection of serious side effects such as agranulocytosis, which is extremely rare. Monitoring services vary among the clozapine suppliers in different countries. Additionally, Japanese patients can be started on clozapine treatment exclusively through an 18-week inpatient admission at a psychiatric hospital capable of coordinating with a hematologist. One reported reason for the lack of widespread clozapine use in Japan is the difficulty in establishing collaboration with hematologists when agranulocytosis/leukopenia occurs. Hence, we conducted a nationwide web-based survey of CPMS-registered psychiatric facilities in Japan to determine the status of collaboration with hematology departments. Valid responses were received from the psychiatrists responsible for prescribing clozapine at 203 of the 547 facilities (response rate: 37.1 %). The largest number of psychiatric facilities (61 %) collaborated with hematologists at another facility with a psychiatry department, while psychiatrists in 32 % of the facilities worked with hematologists at their own facilities. Most patients with clozapine-induced agranulocytosis/leukopenia could be treated with clozapine discontinuation and follow-up in psychiatric inpatient units with the assistance of a hematologist. The actual workload of hematologists was limited, and the patients might experience the burden of repeated blood sampling. This study suggests that disseminating information regarding the status of collaborations with hematologists may promote the widespread use of clozapine in Japan. SHORT COMMENT FOR TWITTER: This study suggests that most patients with clozapine-induced agranulocytosis/leukopenia could be treated with clozapine discontinuation and follow-up in psychiatric inpatient units with the assistance of a hematologist.
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Affiliation(s)
- Tomihisa Niitsu
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Norio Yasui-Furukori
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan
| | - Ken Inada
- Department of Psychiatry, Kitasato University School of Medicine, Kanagawa, Japan
| | - Tetsufumi Kanazawa
- Department of Neuropsychiatry, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Masaomi Iyo
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takefumi Ueno
- National Hospital Organization, Hizen Psychiatric Medical Center, Saga, Japan
| | - Ryota Hashimoto
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
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12
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Schulte PFJ, Veerman SRT, Bakker B, Bogers JPAM, Jongkind A, Cohen D. Risk of clozapine-associated agranulocytosis and mandatory white blood cell monitoring: Can the regulations be relaxed? Schizophr Res 2024; 268:74-81. [PMID: 37770377 DOI: 10.1016/j.schres.2023.09.024] [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: 05/31/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/30/2023]
Abstract
After the introduction of clozapine eight Finnish patients died after developing agranulocytosis. Clozapine was withdrawn from the market and only reintroduced with strict mandatory white blood cell monitoring as long as treatment lasts and thresholds at which clozapine must be discontinued definitively. The fear of agranulocytosis and the need for intensive blood monitoring is the single most important barrier for prescribers and patients alike and leads to underprescription of the only effective and approved medication for treatment-resistant schizophrenia. We summarize evidence that the risk of agranulocytosis is smaller than perceived at the time of reintroduction, is concentrated in the first 18 weeks of treatment, is not greater than with other antipsychotics thereafter and that frequent blood monitoring has not demonstrably decreased the rate of agranulocytosis. Therefore we propose 1) mandatory monitoring of the absolute neutrophil count (ANC) exclusively during the first 18 weeks of clozapine treatment, 2) that thereafter the prescriber and the well-informed patient decide together about further monitoring frequency, 3) that clozapine treatment must be stopped if the ANC falls below 1.0 × 109/L. Continuation of clozapine or a rechallenge are possible if prescriber and patient determine that the benefits outweigh the risks. 4) National registries which control the haematologic monitoring are unnecessary and do not help to reduce clozapine-induced agranulocytosis. They should at least be restricted to the first 18 weeks of clozapine use.
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Affiliation(s)
- Peter F J Schulte
- Mental Health Services Noord-Holland-Noord, Alkmaar, the Netherlands; Dutch Clozapine Collaboration Group, Castricum, the Netherlands.
| | - Selene R T Veerman
- Mental Health Services Noord-Holland-Noord, Alkmaar, the Netherlands; Dutch Clozapine Collaboration Group, Castricum, the Netherlands.
| | - Bert Bakker
- Dutch Clozapine Collaboration Group, Castricum, the Netherlands
| | - Jan P A M Bogers
- Dutch Clozapine Collaboration Group, Castricum, the Netherlands; High Care Clinics, Mental Health Service Rivierduinen, Oegstgeest, the Netherlands.
| | - Amy Jongkind
- Dutch Clozapine Collaboration Group, Castricum, the Netherlands; Early Detection and Intervention Team, Reinier van Arkel, 's-Hertogenbosch, the Netherlands.
| | - Dan Cohen
- Mental Health Services Noord-Holland-Noord, Alkmaar, the Netherlands; Dutch Clozapine Collaboration Group, Castricum, the Netherlands.
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13
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O'Donoghue B, Mora L, Bismark M, Thompson A, McGorry P. Identifying and managing treatment resistance early with the integration of a clozapine clinic within an early intervention for psychosis service. Early Interv Psychiatry 2024. [PMID: 38783545 DOI: 10.1111/eip.13578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 04/29/2024] [Accepted: 05/12/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Despite being the most effective antipsychotic medication for treatment-resistant psychosis, clozapine is often under-utilized with long delays to initiation. AIMS This study aimed to determine whether the integration of a clozapine clinic within an early intervention for psychosis service resulted in a change in the rate and time to initiation of clozapine, the number of trials of different antipsychotic medications prior to clozapine, community initiation and discontinuation rates. METHODS A clozapine clinic was established in the Early Psychosis Prevention and Intervention Centre in Melbourne. This was a pre- and post-evaluation study design. The 'clozapine clinic' cohort included those who commenced on clozapine from 01 January 2016 to 30 June 2018. RESULTS Prior to the clozapine clinic, 24 young people commenced clozapine over the 30-month period compared to 36 in the clozapine clinic cohort (RR = 1.30, 95% CI: 0.75-2.28, p = .32). In the pre-clozapine clinic cohort, 4.6% of all those with a first episode of psychosis were commenced on clozapine compared to 6% in the clozapine clinic cohort. Prior to the clozapine clinic, the median time to the commencement of clozapine was 72 weeks (IQR: 38, 87), compared to 53.5 weeks (IQR: 38, 81.5) in the clozapine clinic (Z = -0.86, p = .393). The mean number of different antipsychotic medications prior to commencing clozapine remained stable at 3.2 (SD ± 1.1) in both cohorts (t = -0.20, p = .841). There was a lower rate of discontinuation in the clozapine clinic (43.5% vs. 14.7%, HR = 0.30, 95% CI: 0.09-0.98, p = .046). CONCLUSIONS While this study was underpowered and there are limitations to the naturalistic study design, the findings lend support to the integration of a clozapine clinic within early intervention for psychosis services.
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Affiliation(s)
- Brian O'Donoghue
- Department of Psychiatry, University College Dublin, Dublin, Ireland
- Department of Psychiatry, St Vincents University Hospital, Dublin, Ireland
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, Parkville, Victoria, Australia
| | - Linda Mora
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Marie Bismark
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
- Te Whatu Ora, Kapiti Coast, New Zealand
| | - Andrew Thompson
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, Parkville, Victoria, Australia
| | - Patrick McGorry
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, Parkville, Victoria, Australia
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14
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Casetta C, Santosh P, Bayley R, Bisson J, Byford S, Dixon C, Drake RJ, Elvins R, Emsley R, Fung N, Hayes D, Howes O, James A, James K, Jones R, Killaspy H, Lennox B, Marchant L, McGuire P, Oloyede E, Rogdaki M, Upthegrove R, Walters J, Egerton A, MacCabe JH. CLEAR - clozapine in early psychosis: study protocol for a multi-centre, randomised controlled trial of clozapine vs other antipsychotics for young people with treatment resistant schizophrenia in real world settings. BMC Psychiatry 2024; 24:122. [PMID: 38355533 PMCID: PMC10865566 DOI: 10.1186/s12888-023-05397-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/22/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Clozapine is an antipsychotic drug with unique efficacy, and it is the only recommended treatment for treatment-resistant schizophrenia (TRS: failure to respond to at least two different antipsychotics). However, clozapine is also associated with a range of adverse effects which restrict its use, including blood dyscrasias, for which haematological monitoring is required. As treatment resistance is recognised earlier in the illness, the question of whether clozapine should be prescribed in children and young people is increasingly important. However, most research to date has been in older, chronic patients, and evidence regarding the efficacy and safety of clozapine in people under age 25 is lacking. The CLEAR (CLozapine in EARly psychosis) trial will assess whether clozapine is more effective than treatment as usual (TAU), at the level of clinical symptoms, patient rated outcomes, quality of life and cost-effectiveness in people below 25 years of age. Additionally, a nested biomarker study will investigate the mechanisms of action of clozapine compared to TAU. METHODS AND DESIGN This is the protocol of a multi-centre, open label, blind-rated, randomised controlled effectiveness trial of clozapine vs TAU (any other oral antipsychotic monotherapy licenced in the British National Formulary) for 12 weeks in 260 children and young people with TRS (12-24 years old). AIM AND OBJECTIVES The primary outcome is the change in blind-rated Positive and Negative Syndrome Scale scores at 12 weeks from baseline. Secondary outcomes include blind-rated Clinical Global Impression, patient-rated outcomes, quality of life, adverse effects, and treatment adherence. Patients will be followed up for 12 months and will be invited to give consent for longer term follow-up using clinical records and potential re-contact for further research. For mechanism of action, change in brain magnetic resonance imaging (MRI) biomarkers and peripheral inflammatory markers will be measured over 12 weeks. DISCUSSION The CLEAR trial will contribute knowledge on clozapine effectiveness, safety and cost-effectiveness compared to standard antipsychotics in young people with TRS, and the results may guide future clinical treatment recommendation for early psychosis. TRIAL REGISTRATION ISRCTN Number: 37176025, IRAS Number: 1004947. TRIAL STATUS In set-up. Protocol version 4.0 01/08/23. Current up to date protocol available here: https://fundingawards.nihr.ac.uk/award/NIHR131175# /.
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Affiliation(s)
- C Casetta
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
- South London and Maudsley NHS Foundation Trust, London, UK.
| | - P Santosh
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - R Bayley
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - J Bisson
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - S Byford
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - C Dixon
- Wonford House Hospital, Devon Partnership NHS Trust, Exeter, UK
| | - R J Drake
- Division of Psychology & Mental Health, University of Manchester, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - R Elvins
- Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - R Emsley
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - N Fung
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - D Hayes
- South London and Maudsley NHS Foundation Trust, London, UK
| | - O Howes
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - A James
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - K James
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - R Jones
- Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - H Killaspy
- Division of Psychiatry, University College London, London, UK
| | - B Lennox
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - L Marchant
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - P McGuire
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - E Oloyede
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - M Rogdaki
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - R Upthegrove
- Institute for Mental Health, University of Birmingham, Birmingham, UK
- Birmingham Early Intervention Service, Birmingham Womens and Childrens NHS Foundation Trust, Birmingham, UK
| | - J Walters
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - A Egerton
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - J H MacCabe
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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15
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Dell’Osso L, Bonelli C, Nardi B, Giovannoni F, Pronestì C, Cremone IM, Amatori G, Pini S, Carpita B. Rethinking Clozapine: Lights and Shadows of a Revolutionary Drug. Brain Sci 2024; 14:103. [PMID: 38275523 PMCID: PMC10813979 DOI: 10.3390/brainsci14010103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
The current literature globally highlights the efficacy of Clozapine in several psychiatric disorders all over the world, with an FDA indication for reducing the risk of repeated suicidal behavior in patients with schizophrenia or schizoaffective disorder. A growing field of research is also stressing a possible broader beneficial effect of Clozapine in promoting neuroprotection and neurotrophism. However, this drug is linked to several life-threatening side effects, such as agranulocytosis, myocarditis and seizures, that limit its use in daily clinical practice. For this work, a search was performed on PubMed using the terms "Clozapine indications", "Clozapine adverse effects", "Clozapine regenerative effects", and "Clozapine neuroplasticity" with the aim of reviewing the scientific literature on Clozapine's treatment indications, adverse effects and potential regenerative role. The results confirmed the efficacy of clozapine in clinical practice, although limited by its adverse effects. It appears crucial to raise awareness among clinicians about the potential benefits of using Clozapine, as well educating medical personnel about its risks and the early identification of possible adverse effects and their management.
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Affiliation(s)
| | - Chiara Bonelli
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 67 Via Roma, 56126 Pisa, Italy; (L.D.); (B.N.); (F.G.); (C.P.); (I.M.C.); (G.A.); (S.P.); (B.C.)
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16
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Groenewald FCE, Kok RM. Side effects of clozapine in older adults with treatment-resistant schizophrenia compared to younger adults. Int J Geriatr Psychiatry 2024; 39:e6051. [PMID: 38180349 DOI: 10.1002/gps.6051] [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: 10/06/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVES To study the differences in side effects of clozapine between older adults aged ≥55 years and younger adults aged 18-55 years with treatment-resistant schizophrenia. METHODS A retrospective cohort study in a large mental health institute in the Netherlands. All patients diagnosed with treatment-resistant schizophrenia who started with clozapine between 2011 and 2020 (N = 284) were included. We compared the number and type of side effects reported in the electronic patient files as well as the number of treatment discontinuations and the time until discontinuation, both due to side effects, of older adults versus younger adults. RESULTS In the younger age group (N = 183), the number of reported side effects was significantly higher in the first 3 months of treatment (Mann-Whitney U = 7341.5, p = 0.004) and after those 3 months (Mann-Whitney U = 5668.5, p < 0.001) compared with the number reported in the older age group (N = 101). Sedation, hypersalivation, dizziness, tachycardia, heartburn, nausea, weight gain, and constipation were reported significantly more often in the younger age group, and only extrapyramidal symptoms were reported significantly more often in the older age group. There was no significant difference in the number of treatment discontinuations due to side effects (23% vs. 21.8%, Chi-2 = 0.051, df = 1, p = 0.821) and time until discontinuation due to side effects (b = 0.091, SE = 0.335, p = 0.798) between younger and older adults. CONCLUSIONS Side effects of clozapine were reported significantly less often in older patients compared with younger patients. Older patients did not discontinue treatment due to side effects more often or earlier than younger patients. Older patients with schizophrenia may not be more vulnerable to side effects than younger adults.
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Affiliation(s)
| | - Rob M Kok
- Department Old Age Psychiatry, Parnassia Group, Den Haag, The Netherlands
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17
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Northwood K, Myles N, Clark SR, Every-Palmer S, Myles H, Kisely S, Warren N, Siskind D. Evaluating the epidemiology of clozapine-associated neutropenia among people on clozapine across Australia and Aotearoa New Zealand: a retrospective cohort study. Lancet Psychiatry 2024; 11:27-35. [PMID: 38040009 DOI: 10.1016/s2215-0366(23)00343-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Clozapine is associated with the risk of serious neutropenia. However, this risk might decrease over time, meaning that indefinite absolute neutrophil count (ANC) monitoring could be unnecessary. We aimed to determine the epidemiology and timing of clozapine-associated neutropenia outcomes, to investigate variables that might contribute to the odds of neutropenia, and to determine risk of competing neutropenic events during clozapine treatment. METHODS We performed a retrospective analysis of the Australian and New Zealand Viatris Pharmacovigilance system (one of two monitoring databases for these two countries) between June 6, 1990, and Oct 25, 2022. Patients were excluded from analysis if they commenced clozapine before 1990, did not have a haematology test within 2 weeks of commencement date, or had no follow-up. We measured minor neutropenia (ANC 1·0-1·5 × 109 per L) and serious neutropenia (ANC <1·0 × 109 per L) leading to cessation of clozapine within 6 weeks of the neutropenic event. We determined the rates of minor and serious neutropenia and calculated odds ratios (ORs) for the likelihood of neutropenia leading to cessation. For serious neutropenia leading to cessation, we used time-to-event to calculate rolling weekly averages and to perform competing risk analysis of outcomes using Cox proportional hazards models and a Fine-Gray subdistribution hazards regression model. For the subset of data where information on previous clozapine use was available, we did an analysis for participants who did and did not have previous clozapine exposure. FINDINGS We included 26 630 people, with 2·6 million ANC values. Within the total cohort, 17 585 people (66%) were male, 9025 (33·9%) female, and 20 (0·1%) other gender, and the mean age was 36·1 years (SD 13·7). We did not have data on race or ethnicity. Of the 26 630 people taking clozapine, 1146 (4·3%) had minor neutropenia, 313 (1·2%) had serious neutropenia leading to cessation, and 223 (0·8%) had serious neutropenia unrelated to clozapine without cessation. In people with no previous exposure to clozapine (n=15 973), the cumulative incidence of serious neutropenia leading to cessation was 0·9% at 18 weeks and 1·4% at 2 years; the weekly incidence rate for serious neutropenia leading to cessation peaked at 9 weeks (0·128%) and fell to a rolling average weekly incidence of 0·001% by 2 years. For minor neutropenia, the cumulative incidence was 1·7% at 18 weeks and 3·5% at 2 years; the weekly incidence rate peaked at 9 weeks (0·218%) and fell to a stable rolling average of 0·01%. The median time to a serious neutropenic event leading to cessation was 17 weeks (IQR 9·96-102). Previous clozapine exposure reduced the risk of serious neutropenia leading to cessation (OR 0·19, 95% CI 0·12-0·31; p <0·0001). INTERPRETATION Most serious neutropenia leading to clozapine cessation occurs within 18 weeks of treatment and becomes negligible after 2 years. Weekly haematological monitoring after the first 18 weeks could be safely reduced to once every 4 weeks and ceased after 2 years unless clinically indicated. Clozapine retrial after interruption with 2 cumulative years of unremarkable testing might not require further haematological monitoring. A serious neutropenia ANC threshold of ≤1·0 × 109 per L could be used in more jurisdictions. FUNDING None.
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Affiliation(s)
- Korinne Northwood
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, QLD, Australia; Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
| | - Nicholas Myles
- Discipline of Psychiatry, Adelaide University, Adelaide, SA, Australia
| | - Scott R Clark
- Discipline of Psychiatry, Adelaide University, Adelaide, SA, Australia
| | - Susanna Every-Palmer
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand
| | - Hannah Myles
- Northern Adelaide Health Network, Adelaide, SA, Australia
| | - Steve Kisely
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, QLD, Australia; Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
| | - Nicola Warren
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, QLD, Australia
| | - Dan Siskind
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, QLD, Australia; Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia.
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18
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Magistri C, Mellini C. Clozapine-Associated Agranulocytosis: A Systematic Review. Is It Really So Frighteningly Common? J Clin Psychopharmacol 2023; 43:527-533. [PMID: 37930206 DOI: 10.1097/jcp.0000000000001765] [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: 09/30/2023]
Abstract
BACKGROUND Clozapine is a very effective therapeutic option for schizophrenic disorders that have been refractory to most other therapies. This extremely positive aspect clashes easily with an adverse effect of the drug that is deemed to be a very dangerous one: agranulocytosis. We asked whether the mandatory strict hematological follow-up prescribed in the black box warning of clozapine's label is proportioned to the actual incidence of agranulocytosis, considering that is the main reason that such a drug is often used only late in the treatment course. METHODS We carried out a systematic review of reports examining clozapine administration and agranulocytosis incidence. We specifically selected those where mild and moderate neutropenia was not used as a trigger to stop administration of clozapine, to better estimate the sheer incidence of agranulocytosis when clozapine was continued even with mild hematological effect, where detected. We used PubMed, MEDLINE, EMBASE, Cochrane, and ScienceDirect databases to identify clinical studies conducted between January 1975 and April 2023. RESULTS We included 14 studies, mostly retrospective ones, that examined the incidence of hematological adverse effects in patients using clozapine. A total of 2354 subjects were included. The mean age of the subjects was 33.5 years. The mean duration of observation of subjects who took clozapine was 800 days, with a mean daily dose of 319.5 mg per day. Of the 2354 subjects examined, we found that 11 of them experienced agranulocytosis (0.47%). CONCLUSIONS These results suggest the evidence of a lower incidence of agranulocytosis than previously estimated and are in line with more recent meta-analyses. We may therefore think that clinical practice may demand a revision of the approach that both psychiatrists and supervising organizations often take when talking about clozapine.
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Affiliation(s)
- Carlo Magistri
- From the Department of Psychiatry, Mental Health Center of Viterbo, Local Health Authority of Viterbo, Viterbo
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19
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Fukuyama K, Motomura E, Okada M. A Novel Gliotransmitter, L-β-Aminoisobutyric Acid, Contributes to Pathophysiology of Clinical Efficacies and Adverse Reactions of Clozapine. Biomolecules 2023; 13:1288. [PMID: 37759688 PMCID: PMC10526296 DOI: 10.3390/biom13091288] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
Clozapine is listed as one of the most effective antipsychotics and has been approved for treating treatment-resistant schizophrenia (TRS); however, several type A and B adverse reactions, including weight gain, metabolic complications, cardiotoxicity, convulsions, and discontinuation syndromes, exist. The critical mechanisms of clinical efficacy for schizophrenia, TRS, and adverse reactions of clozapine have not been elucidated. Recently, the GABA isomer L-β-aminoisobutyric acid (L-BAIBA), a protective myokine in the peripheral organs, was identified as a candidate novel transmission modulator in the central nervous system (CNS). L-BAIBA activates adenosine monophosphate-activated protein kinase (AMPK) signalling in both the peripheral organs and CNS. Activated AMPK signalling in peripheral organs is an established major target for treating insulin-resistant diabetes, whereas activated AMPK signalling in the hypothalamus contributes to the pathophysiology of weight gain and metabolic disturbances. Clozapine increases L-BAIBA synthesis in the hypothalamus. In addition, the various functions of L-BAIBA in the CNS have recently been elucidated, including as an activator of GABA-B and group-III metabotropic glutamate (III-mGlu) receptors. Considering the expressions of GABA-B and III-mGlu receptors (localised in the presynaptic regions), the activation of GABA-B and III-mGlu receptors can explain the distinct therapeutic advantages of clozapine in schizophrenia or TRS associated with N-methyl-D-aspartate (NMDA) receptor disturbance compared with other atypical antipsychotics via the inhibition of the persistent tonic hyperactivation of thalamocortical glutamatergic transmission in the prefrontal cortex. L-BAIBA has also been identified as a gliotransmitter, and a detailed exploration of the function of L-BAIBA in tripartite synaptic transmission can further elucidate the pathophysiology of effectiveness for treating TRS and/or specific adverse reactions of clozapine.
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Affiliation(s)
| | | | - Motohiro Okada
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan; (K.F.); (E.M.)
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20
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Oloyede E, Dunnett D, Taylor D, Clark I, MacCabe JH, Whiskey E, Onwumere J. The lived experience of clozapine discontinuation in patients and carers following suspected clozapine-induced neutropenia. BMC Psychiatry 2023; 23:413. [PMID: 37291505 PMCID: PMC10249299 DOI: 10.1186/s12888-023-04902-w] [Citation(s) in RCA: 2] [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: 03/03/2023] [Accepted: 05/25/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Clozapine is the treatment of choice in refractory psychosis. In most countries, clozapine must be stopped indefinitely if white blood cells fall below a defined threshold during routine monitoring. Despite evidence of severe adverse consequences of clozapine discontinuation, published accounts on the lived experiences and perspectives of patients and carers are scarce. METHOD We completed semi-structured interviews with patients (n = 4) and family carers (n = 4) on experiences of clozapine cessation following suspected drug-induced neutropenia. Interviews were audio-recorded, transcribed and analysed thematically. RESULTS The two overarching themes comprised:(i) stress of clozapine below threshold neutrophil results and (ii) patient and carer priorities. CONCLUSIONS There is a suggested need for evidence-based pharmacological and psychological approaches to support patients and carers after clozapine cessation. Such approaches will minimise the potentially negative physical and emotional sequela in the aftermath of a below threshold neutrophil result and reduce the likelihood of experiencing additional health and social inequalities after clozapine discontinuation.
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Affiliation(s)
- Ebenezer Oloyede
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK.
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, King's College London, London, UK.
- University of Oxford, Department of Psychiatry , Warneford, United Kingdom.
| | - Danielle Dunnett
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, King's College London, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College, London 5th Floor, Franklin-Wilkins Building 150 Stamford Street, London, SE1 9NH, UK
| | - Ivana Clark
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College, London 5th Floor, Franklin-Wilkins Building 150 Stamford Street, London, SE1 9NH, UK
| | - James H MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, King's College London, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
- NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
| | - Eromona Whiskey
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College, London 5th Floor, Franklin-Wilkins Building 150 Stamford Street, London, SE1 9NH, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Juliana Onwumere
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
- NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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21
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Fukuyama K, Motomura E, Okada M. Enhanced L-β-Aminoisobutyric Acid Is Involved in the Pathophysiology of Effectiveness for Treatment-Resistant Schizophrenia and Adverse Reactions of Clozapine. Biomolecules 2023; 13:biom13050862. [PMID: 37238731 DOI: 10.3390/biom13050862] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
Clozapine is an effective antipsychotic for the treatment of antipsychotic-resistant schizophrenia; however, specific types of A/B adverse effects and clozapine-discontinuation syndromes are also well known. To date, both the critical mechanisms of clinical actions (effective for antipsychotic-resistant schizophrenia) and the adverse effects of clozapine remain to be elucidated. Recently, we demonstrated that clozapine increased the synthesis of L-β-aminoisobutyric acid (L-BAIBA) in the hypothalamus. L-BAIBA is an activator of the adenosine monophosphate-activated protein kinase (AMPK), glycine receptor, GABAA receptor, and GABAB receptor (GABAB-R). These targets of L-BAIBA overlap as potential targets other than the monoamine receptors of clozapine. However, the direct binding of clozapine to these aminoacidic transmitter/modulator receptors remains to be clarified. Therefore, to explore the contribution of increased L-BAIBA on the clinical action of clozapine, this study determined the effects of clozapine and L-BAIBA on tripartite synaptic transmission, including GABAB-R and the group-III metabotropic glutamate receptor (III-mGluR) using cultured astrocytes, as well as on the thalamocortical hyper-glutamatergic transmission induced by impaired glutamate/NMDA receptors using microdialysis. Clozapine increased astroglial L-BAIBA synthesis in time/concentration-dependent manners. Increased L-BAIBA synthesis was observed until 3 days after clozapine discontinuation. Clozapine did not directly bind III-mGluR or GABAB-R, whereas L-BAIBA activated these receptors in the astrocytes. Local administration of MK801 into the reticular thalamic nucleus (RTN) increased L-glutamate release in the medial frontal cortex (mPFC) (MK801-evoked L-glutamate release). Local administration of L-BAIBA into the mPFC suppressed MK801-evoked L-glutamate release. These actions of L-BAIBA were inhibited by antagonists of III-mGluR and GABAB-R, similar to clozapine. These in vitro and in vivo analyses suggest that increased frontal L-BAIBA signaling likely plays an important role in the pharmacological actions of clozapine, such as improving the effectiveness of treating treatment-resistant schizophrenia and several clozapine discontinuation syndromes via the activation of III-mGluR and GABAB-R in the mPFC.
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Affiliation(s)
- Kouji Fukuyama
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan
| | - Eishi Motomura
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan
| | - Motohiro Okada
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan
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22
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Yadav N, Jagota G, Grover S. Recurrence of clozapine associated bicytopenia (Leucopenia and Anaemia) while rechallenge: A case report. Asian J Psychiatr 2023; 85:103619. [PMID: 37163945 DOI: 10.1016/j.ajp.2023.103619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/30/2023] [Accepted: 05/05/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Nidhi Yadav
- Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Gopika Jagota
- Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Sandeep Grover
- Post Graduate Institute of Medical Education & Research, Chandigarh, India.
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23
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Oloyede E, Dzahini O, Abolou Z, Gee S, Whiskey E, Malhotra D, Hussain M, Osborne I, Casetta C, McGuire P, MacCabe JH, Taylor D. Clinical impact of reducing the frequency of clozapine monitoring: controlled mirror-image cohort study. Br J Psychiatry 2023:1-7. [PMID: 37092691 PMCID: PMC10391318 DOI: 10.1192/bjp.2023.44] [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] [Indexed: 04/25/2023]
Abstract
BACKGROUND To minimise infection during COVID-19, the clozapine haematological monitoring interval was extended from 4-weekly to 12-weekly intervals in South London and Maudsley NHS Foundation Trust. AIMS To investigate the impact of this temporary policy change on clinical and safety outcomes. METHOD All patients who received clozapine treatment with extended (12-weekly) monitoring in a large London National Health Service trust were included in a 1-year mirror-image study. A comparison group was selected with standard monitoring. The proportion of participants with mild to severe neutropenia and the proportion of participants attending the emergency department for clozapine-induced severe neutropenia treatment during the follow-up period were compared. Psychiatric hospital admission rates, clozapine dose and concomitant psychotropic medication in the 1 year before and the 1 year after extended monitoring were compared. All-cause clozapine discontinuation at 1-year follow-up was examined. RESULTS Of 569 participants, 459 received clozapine with extended monitoring and 110 controls continued as normal. The total person-years were 458 in the intervention group and 109 in the control group, with a median follow-up time of 1 year in both groups. During follow-up, two participants (0.4%) recorded mild to moderate neutropenia in the intervention group and one (0.9%) in the control group. There was no difference in the incidence of haematological events between the two groups (IRR = 0.48, 95% CI 0.02-28.15, P = 0.29). All neutropenia cases in the intervention group were mild, co-occurring during COVID-19 infection. The median number of admissions per patient during the pre-mirror period remained unchanged (0, IQR = 0) during the post-mirror period. There was one death in the control group, secondary to COVID-19 infection. CONCLUSIONS There was no evidence that the incidence of severe neutropenia was increased in those receiving extended monitoring.
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Affiliation(s)
- Ebenezer Oloyede
- South London and Maudsley NHS Foundation Trust, London, UK; and Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Olubanke Dzahini
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
| | - Zadro Abolou
- Barnet, Enfield and Haringey Mental Health Trust, London, UK
| | - Siobhan Gee
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
| | - Eromona Whiskey
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
| | | | - Masuma Hussain
- South West London and St George's Mental Health NHS Trust, London, UK
| | - Ian Osborne
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
| | - Cecilia Casetta
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Philip McGuire
- Barnet, Enfield and Haringey Mental Health Trust, London, UK
| | - James H MacCabe
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
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24
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Yang CC, Wang XY, Chou PH, Lin CH. Valproate-related neutropenia and lithium-related leukocytosis in patients treated with clozapine: a retrospective cohort study. BMC Psychiatry 2023; 23:170. [PMID: 36922799 PMCID: PMC10018892 DOI: 10.1186/s12888-023-04659-2] [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: 12/30/2022] [Accepted: 03/06/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Neutropenia is a noteworthy side effect of clozapine, which might warrant this drugs' discontinuance for safety. Studies have revealed that the risk of neutropenia increases with concurrent administration of valproate, but the evidence was limited. Conversely, lithium may have an ameliorating effect on clozapine-induced neutropenia. This study explored the effects of valproate and lithium on white blood cell counts in patients treated with clozapine. METHODS We retrospectively investigated the electronic medical records from one tertiary psychiatric hospital in Taiwan and enrolled patients discharged between January 1, 2006, and December 31, 2017, with clozapine prescriptions. We scrutinized their demographic data, medications, and hematological results at discharge and during follow-up outpatient clinic visits over the subsequent 3 years. Patients were classified into four groups: clozapine only (CLO), clozapine and valproate (CLO + VAL), clozapine and lithium (CLO + Li), and clozapine, valproate, and lithium (CLO + VAL + Li). We also identified hematological events (neutropenia or leukocytosis) of these patients during outpatient follow-ups. RESULTS Of the included 1084 patients, 55(5.1%) developed neutropenia. Concurrent valproate use (odds ratio [OR] = 3.49) and older age (p = .007) were identified as risk factors. Moreover, 453 (41.79%) patients developed leukocytosis. Younger age; male sex; and concurrent use of lithium (OR = 3.39, p < .001), clozapine daily dosage, and benzodiazepines were the risk factors for leukocytosis. CONCLUSION Concurrent valproate use and older age are associated with the development of neutropenia in patients treated with clozapine. Concurrent lithium usage, younger age, male sex, and concurrent benzodiazepine use might be related to leukocytosis.
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Affiliation(s)
- Chia-Chun Yang
- Department of General Psychiatry, Taoyuan Psychiatric Center, No. 71, Longshou St., Taoyuan Dist, 33058 Taoyuan City, Taiwan
| | - Xi-Yu Wang
- Department of General Psychiatry, Taoyuan Psychiatric Center, No. 71, Longshou St., Taoyuan Dist, 33058 Taoyuan City, Taiwan
| | - Po-Han Chou
- Department of Psychiatry, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Ching-Hua Lin
- grid.414813.b0000 0004 0582 5722Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
- grid.412019.f0000 0000 9476 5696Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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25
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Copeland CS, Wallman P, Morgan D, Owen E, Taylor D. A case-control study of antipsychotic use and pneumonia-related mortality in the United Kingdom. Acta Psychiatr Scand 2023; 147:301-313. [PMID: 36651563 DOI: 10.1111/acps.13532] [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: 08/25/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND AIM There is increasing evidence linking antipsychotic use with pneumonia, but limited evidence of an effect on pneumonia-related outcomes such as mortality. In this study, we aimed to examine the association of pneumonia-related death with specific antipsychotic exposure. METHOD Deaths analysed were those reported to a UK-based drug-related deaths database, the National Programme on Substance Abuse Deaths (NPSAD), between 1997 and September 2020. We conducted a case-control study with cases defined as pneumonia-related deaths and controls as cases with alternative causes of death. Cases were analysed by considering drugs detected at post-mortem (PM) and by drugs prescribed to the deceased at the time of their death with calculated odds ratios (ORs) adjusted to account for confounders. RESULTS There were 2467 PM cases and 40,128 controls; 1818 prescribed cases and 28,018 controls. Second generation antipsychotics (SGAs) were robustly associated with an increased risk of pneumonia-related death compared with those not prescribed or taking antipsychotics (PM detection adjusted OR [AOR] 1·34 [95% CI 1·15-1·55]; prescribed AOR 1·28 [95% CI 1·11-1·49]). First generation antipsychotics had no clear association with death from pneumonia (PM detection AOR 1·06 [95% CI 0·77-1·47]; prescribed AOR 0·91 [95% CI 0·71-1·17]). Amongst SGAs, olanzapine was associated with an increased risk of death due to pneumonia (PM detection AOR 1·49 [95% CI 1·22-1·82]; prescribed AOR 1·44 [95% CI 1·18-1·76]) as was quetiapine (PM detection AOR 1·34 [95% CI 1·07-1·66]; prescribed AOR 1·28 [95% CI 1·01-1·64]). CONCLUSION Olanzapine and quetiapine were found to increase the risk of pneumonia-related death in this NPSAD sample to a clinically important extent.
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Affiliation(s)
- Caroline S Copeland
- Institute of Pharmaceutical Sciences, King's College London, London, UK.,Centre for Pharmaceutical Medicine Research, King's College London, London, UK
| | - Phoebe Wallman
- Divisons of Pharmacy and Pathology, South London and Maudsley NHS Foundation Trust, London, UK
| | - David Morgan
- Institute of Pharmaceutical Sciences, King's College London, London, UK.,Centre for Pharmaceutical Medicine Research, King's College London, London, UK
| | - Eleanor Owen
- Institute of Pharmaceutical Sciences, King's College London, London, UK
| | - David Taylor
- Institute of Pharmaceutical Sciences, King's College London, London, UK.,Divisons of Pharmacy and Pathology, South London and Maudsley NHS Foundation Trust, London, UK
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Corbeil O, Béchard L, Fournier É, Plante M, Thivierge MA, Lafrenière CÉ, Huot-Lavoie M, Brodeur S, Essiambre AM, Roy MA, Demers MF. Clozapine rechallenge or continuation despite neutropenia or agranulocytosis using colony-stimulating factor: A systematic review. J Psychopharmacol 2023; 37:370-377. [PMID: 36794520 PMCID: PMC10363950 DOI: 10.1177/02698811231154111] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
OBJECTIVES Rechallenge/continuation of clozapine in association with colony-stimulating factors (CSFs) following neutropenia/agranulocytosis has been reported, but many questions remain unanswered about efficacy and safety. This systematic review aims to assess the efficacy and safety of rechallenging/continuing clozapine in patients following neutropenia/agranulocytosis using CSFs. METHODS MEDLINE, Embase, PsycInfo, and Web of Science databases were searched from inception date to July 31, 2022. Articles screening and data extraction were realized independently by two reviewers, according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 systematic review guidance. Included articles had to report on at least one case where clozapine was rechallenged/continued using CSFs despite previous neutropenia/agranulocytosis. RESULTS Eight hundred forty articles were retrieved; 34 articles met the inclusion criteria, totaling 59 individual cases. Clozapine was successfully rechallenged/continued in 76% of patients for an average follow-up period of 1.9 years. There was a trend toward better efficacy reported in case reports/series, compared with consecutive case series (overall success rates of 84% and 60%, respectively, p-value = 0.065). Two administration strategies were identified, "as-needed" and prophylactic, both yielding similar success rates (81% and 80%, respectively). Only mild and transient adverse events were documented. CONCLUSIONS Although limited by the relatively small number of published cases, factors such as time of onset to first neutropenia and severity of the episode did not seem to impact the outcome of a subsequent clozapine rechallenge using CSFs. While the efficacy of this strategy remains to be further adequately evaluated in more rigorous study designs, its long-term innocuity warrants considering its use more proactively in the management of clozapine hematological adverse events as to maintain this treatment for as many individuals as possible.
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Affiliation(s)
- Olivier Corbeil
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada
| | - Laurent Béchard
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada
| | - Émilien Fournier
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada
| | - Maude Plante
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada
| | - Marc-André Thivierge
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | | | - Maxime Huot-Lavoie
- CERVO Brain Research Centre, Québec City, QC, Canada.,Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Sébastien Brodeur
- Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada.,Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Anne-Marie Essiambre
- CERVO Brain Research Centre, Québec City, QC, Canada.,School of Psychology, Faculty of Social Sciences, Université Laval, Québec City, QC, Canada
| | - Marc-André Roy
- Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada.,Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Marie-France Demers
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada
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27
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Pharmacometric modeling of drug adverse effects: an application of mixture models in schizophrenia spectrum disorder patients treated with clozapine. J Pharmacokinet Pharmacodyn 2023; 50:21-31. [PMID: 36380133 DOI: 10.1007/s10928-022-09833-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022]
Abstract
Clozapine has superior efficacy to other antipsychotics yet is underutilized due to its adverse effects, such as neutropenia, weight gain, and tachycardia. The current investigation aimed to introduce a pharmacometric approach to simultaneously model drug adverse effects, with examples from schizophrenia spectrum patients receiving clozapine. The adverse drug effects were represented as a function of time by incorporating a mixture model to describe individual susceptibility to the adverse effects. Applications of the proposed method were presented by analyzing retrospective data from patients' medical records in Psychiatric Clinic, Penang General Hospital. Tachycardia, weight gain, and absolute neutrophils count (ANC) decrease were best described by an offset, a piecewise linear, and a transient surge function, respectively. 42.9% of the patients had all the adverse effects, including weight gain (0.01 kg/m2 increase every week over a baseline of 24.7 kg/m2 until stabilizing at 279 weeks), ANC decrease (20% decrease from 4540 cells/µL week 12-20.8), and tachycardia (14% constant increase over a baseline of 87.9 bpm for a clozapine maintenance dose of 450 mg daily). 32.5% of the patients had only tachycardia, while the remaining 24.6% had none of the adverse effects. A new pharmacometric approach was proposed to describe adverse drug effects with examples of clozapine-induced weight gain, ANC drop, and tachycardia. The current approach described the longitudinal time changes of continuous data while assessing patient susceptibility. Furthermore, the model revealed the possible co-existence of ANC drop and weight gain; thus, neutrophil monitoring might predict future changes in body weight.
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28
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Srour A, Eltorki Y, Malik H, Alabdulla MA, Hassan MH, Ahmed Al Subaiey M, Michael Haddad P. Patients' and primary carers' views on clozapine treatment for schizophrenia: A cross-sectional study in Qatar. Saudi Pharm J 2023; 31:214-221. [PMID: 36942276 PMCID: PMC10023528 DOI: 10.1016/j.jsps.2022.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022] Open
Abstract
Subjective views of clozapine treatment among patients with schizophrenia in the Middle East and North African MENA Region have not previously been assessed. Globally, few studies have assessed the views of carers to clozapine treatment. We conducted a cross-sectional survey, using a clinician administered structured interview, of patients with schizophrenia/schizoaffective disorder prescribed clozapine in Qatar, and their primary carers. Participants were asked to rate clozapine against prior their antipsychotic treatment in terms of specific benefits and side effects. Forty-two patients and 33 carers participated in the study. Of the patients, two thirds were male, approximately half were Qatari and the mean age was 33.9 years. Patients and carers rated clozapine as superior to prior antipsychotic treatment on all 7 potential benefits inquired about. The greatest perceived benefit was improved mood. Patients rated clozapine as less likely to cause extrapyramidal side effects but more likely to cause 18 other potential side effects compared to prior antipsychotic treatment, with the greatest difference being for nocturnal salivation, increased appetite, and constipation. Nearly half of patients (48 %) and two thirds of carers (64 %) stated that they would have preferred to start clozapine earlier in their illness. Sixty percent of patients and 37 % of carers regarded the information that they had received from health professionals on clozapine as inadequate. Less than half of patients and approximately-two thirds of carers had adequate knowledge of haematological monitoring for clozapine. Generally, there were significantly positive correlation between patients and carers regarding the overall side effects of clozapine treatment. Likewise, improvement in hearing voices paranoid thoughts correlated with improved quality of life. In summary, the results show that patients and carers appreciate the benefits of clozapine despite its side effects being problematic. The results support clozapine being offered earlier in treatment and services providing more information on clozapine to patients and carers.
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Affiliation(s)
- Ahmad Srour
- Department of Psychiatry, Hamad Medical Corporation, Qatar
| | - Yassin Eltorki
- Department of Psychiatry, Hamad Medical Corporation, Qatar
- College of Pharmacy, Qatar University, Qatar
- Corresponding author at: Clinical Pharmacy Specialist, Mental Health Service, Pharmacy Department Hamad Medical Corporation, P.O.Box 3050, Doha, Qatar.
| | - Humayun Malik
- Department of Psychiatry, Hamad Medical Corporation, Qatar
| | - Majid A Alabdulla
- Department of Psychiatry, Hamad Medical Corporation, Qatar
- College of Medicine, Qatar University, Qatar
| | | | | | - Peter Michael Haddad
- Department of Psychiatry, Hamad Medical Corporation, Qatar
- College of Medicine, Qatar University, Qatar
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
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Giles G, Varghese S, Shymko G, Nguyen T, Waters F. Clozapine Therapy and COVID-19: A Systematic Review of the Prevalence Rates, Health Outcomes, Hematological Markers, and Patient Perspectives. Schizophr Bull 2023; 49:53-67. [PMID: 36242537 PMCID: PMC9620749 DOI: 10.1093/schbul/sbac148] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND/OBJECTIVES There have been concerns that clozapine treatment may undermine the capacity of the body to fight infection and increase the vulnerability to contracting COVID-19. This review of recent cohort studies investigated (1) whether people with a severe psychiatric disorder are at increased risk of COVID-19 and complications, (2) the immunological response of clozapine-users who contract COVID-19, and (3) patients' perspectives on COVID-19 and the pandemic response. METHODS A systematic search of EMBASE, Medline, Pubmed, and PsycINFO databases using PRISMA guidelines using "COVID-19", "clozapine", and "vaccination" terms. RESULTS 18 studies (out of 330 identified) met all criteria (N = 119 054 including 8045 on clozapine). There was no strong evidence that clozapine users may be at increased risk of contracting COVID-19 or developing complications after adjusting for medical comorbidities. Hematological studies showed temporary reductions in neutrophils in COVID-19-positive patients and vaccination suggesting a clozapine effect in defence against infection. Vaccination studies did not report major adverse effects. Increased plasma levels of clozapine and neutropenia however point to COVID-19-related interference of clozapine metabolism. Patient surveys reported limited impact on mental health and positive attitudes regarding pandemic response. CONCLUSION This review did not find compelling evidence that the immune system of clozapine users put them at risk of COVID-19 and further complications. Evidence of drug-infection interactions however points to the importance of adhering to consensus guidelines about clozapine therapy during the pandemic. More evidence using longitudinal designs is required to examine the longer-term effects of COVID-19 and vaccination in this vulnerable population.
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Affiliation(s)
- Grace Giles
- South Metropolitan Health Service, Peel and Rockingham Kwinana (PaRK) Mental Health Service, Rockingham, Western Australia, 6168, Australia
| | - Sunny Varghese
- South Metropolitan Health Service, Peel and Rockingham Kwinana (PaRK) Mental Health Service, Rockingham, Western Australia, 6168, Australia
| | - Gordon Shymko
- South Metropolitan Health Service, Peel and Rockingham Kwinana (PaRK) Mental Health Service, Rockingham, Western Australia, 6168, Australia
| | - Thinh Nguyen
- South Metropolitan Health Service, Peel and Rockingham Kwinana (PaRK) Mental Health Service, Rockingham, Western Australia, 6168, Australia
- Division of Psychiatry, School of Medicine, The University of Western Australia, 35 Stirling Highway, Perth, Western Australia, 6009, Australia
| | - Flavie Waters
- Division of Psychiatry, School of Medicine, The University of Western Australia, 35 Stirling Highway, Perth, Western Australia, 6009, Australia
- School of Psychological Sciences, The University of Western Australia, 35 Stirling Highway, Perth, Western Australia, 6009, Australia
- Clinical Research Centre, Graylands Hospital Campus, North Metropolitan Area Services-Mental Health, Brockway Road, Mount Claremont, Perth, Western Australia, 6010, Australia
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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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Oloyede E, Blackman G, Whiskey E, Bachmann C, Dzahini O, Shergill S, Taylor D, McGuire P, MacCabe J. Clozapine haematological monitoring for neutropenia: a global perspective. Epidemiol Psychiatr Sci 2022; 31:e83. [PMID: 36426600 PMCID: PMC9714212 DOI: 10.1017/s204579602200066x] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/27/2022] Open
Abstract
AIMS Clozapine is licensed for treatment-resistant psychosis and remains underutilised. This may berelated to the stringent haematological monitoring requirements that are mandatory in most countries. We aimed to compare guidelines internationally and develop a novel Stringency Index. We hypothesised that the most stringent countries would have increased healthcare costs and reduced prescription rates. METHOD We conducted a literature review and survey of guidelines internationally. Guideline identification involved a literature review and consultation with clinical academics. We focused on the haematological monitoring parameters, frequency and thresholds for discontinuation and rechallenge after suspected clozapine-induced neutropenia. In addition, indicators reflecting monitoring guideline stringency were scored and visualised using a choropleth map. We developed a Stringency Index with an international panel of clozapine experts, through a modified-Delphi-survey. The Stringency Index was compared to health expenditure per-capita and clozapine prescription per 100 000 persons. RESULTS One hundred twocountries were included, from Europe (n = 35), Asia (n = 24), Africa (n = 20), South America (n = 11), North America (n = 7) and Oceania and Australia (n = 5). Guidelines differed in frequency of haematological monitoring and discontinuation thresholds. Overall, 5% of included countries had explicit guidelines for clozapine-rechallenge and 40% explicitly prohibited clozapine-rechallenge. Furthermore, 7% of included countries had modified discontinuation thresholds for benign ethnic neutropenia. None of the guidelines specified how long haematological monitoring should continue. The most stringent guidelines were in Europe, and the least stringent were in Africa and South America. There was a positive association (r = 0.43, p < 0.001) between a country's Stringency Index and healthcare expenditure per capita. CONCLUSIONS Recommendations on how haematological function should be monitored in patients treated with clozapine vary considerably between countries. It would be useful to standardise guidelines on haematological monitoring worldwide.
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Affiliation(s)
- Ebenezer Oloyede
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Graham Blackman
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Eromona Whiskey
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College, London 5th Floor, Franklin-Wilkins Building 150 Stamford Street, LondonSE1 9NH, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Christian Bachmann
- Department of Child and Adolescent Psychiatry, Universitätsklinikum Ulm, Steinhövelstr. 5, 89075, Ulm, Germany
- Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Olubanke Dzahini
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Sukhi Shergill
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College, London 5th Floor, Franklin-Wilkins Building 150 Stamford Street, LondonSE1 9NH, UK
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - James MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
- NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
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Oloyede E, Whiskey E, Casetta C, Dzahini O, Dunnett D, Gandhi S, Gaughran F, Shergill S, McGuire P, MacCabe JH, Taylor D. Relaxation of the criteria for entry to the UK Clozapine Central Non-Rechallenge Database: a modelling study. Lancet Psychiatry 2022; 9:636-644. [PMID: 35772414 DOI: 10.1016/s2215-0366(22)00188-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/22/2022] [Accepted: 05/04/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Clozapine is uniquely effective in treatment-resistant psychosis. In the UK, patients must discontinue clozapine indefinitely if they are placed on the Central Non-Rechallenge Database (CNRD) after their haematological parameters fall below particular thresholds. Under exceptional circumstances, patients can be rechallenged on clozapine under an off-licence agreement. In the USA in 2015, restrictive practice was discontinued to allow greater flexibility for clozapine maintenance. The absolute neutrophil count leading to treatment interruption was lowered from less than 1·5 × 109/L to less than 1·0 × 109/L and platelet and white cell count monitoring were ceased. We aimed to investigate the implications of a similar policy change on clozapine use in the UK. METHODS This was a modelling study of all patients registered on the UK CNRD. First, we determined the proportion of patients placed on the database in the UK who would have had to discontinue clozapine treatment under the US Food and Drug Administration (FDA) criteria. Second, we compared the haematological characteristics of patients who did or did not meet FDA criteria for discontinuing clozapine, including the time to registration from clozapine initiation and the proportion of cases of severe neutropenia at registration. Third, we investigated the success rates of clozapine re-challenge for patients that had been placed on the CNRD. Successful rechallenge was defined as no recurrence of CNRD registration. FINDINGS Between May 2, 2002 and March 1, 2021, 3731 patients were placed on the CNRD, with a mean age of 47 years (SD 15), including 1420 (38%) women and 2311 (62%) men, of whom 3089 (83%) were White, 360 (10%) were Black, 190 (5%) were Asian, and 92 (2%) were classified as other. 566 (15%) of 3731 patients met the equivalent criteria for clozapine discontinuation under the FDA guidelines. The median time to CNRD registration from clozapine initiation was 1·6 years (IQR 0·2-4·9). Data for 519 rechallenged patients were examined; 419 (81%) were successful. Clozapine rechallenge success rates were broadly similar between individuals who did not meet the US CNRD registration criteria (36 [78%] of 46) and those who did meet the criteria (383 [81%] of 473). INTERPRETATION Implementing the revised FDA monitoring criteria in the UK would substantially reduce clozapine discontinuation for haematological reasons, which would greatly improve the mental health outcomes of these patients without having a major effect on their physical health. FUNDING None.
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Affiliation(s)
- Ebenezer Oloyede
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Eromona Whiskey
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK; National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Pharmaceutical Science, King's College, London, UK
| | - Cecilia Casetta
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Olubanke Dzahini
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Pharmaceutical Science, King's College, London, UK
| | - Danielle Dunnett
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Shreyans Gandhi
- Kings College Hospital London NHS Foundation Trust, London, UK
| | - Fiona Gaughran
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
| | - Sukhi Shergill
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - James H MacCabe
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Pharmaceutical Science, King's College, London, UK
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Islam F, Hain D, Lewis D, Law R, Brown LC, Tanner JA, Müller DJ. Pharmacogenomics of Clozapine-induced agranulocytosis: a systematic review and meta-analysis. THE PHARMACOGENOMICS JOURNAL 2022; 22:230-240. [PMID: 35710824 PMCID: PMC9363274 DOI: 10.1038/s41397-022-00281-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 05/03/2022] [Accepted: 05/30/2022] [Indexed: 11/16/2022]
Abstract
Although clozapine is the most effective pharmacotherapy for treatment-resistant schizophrenia, it is under-utilized, and initiation is often delayed. One reason is the occurrence of a potentially fatal adverse reaction, clozapine-induced agranulocytosis (CIA). Identifying genetic variations contributing to CIA would help predict patient risk of developing CIA and personalize treatment. Here, we (1) review existing pharmacogenomic studies of CIA, and (2) conduct meta-analyses to identify targets for clinical implementation. A systematic literature search identified studies that included individuals receiving clozapine who developed CIA and controls who did not. Results showed that individuals carrying the HLA-DRB1*04:02 allele had nearly sixfold (95% CI 2.20–15.80, pcorrected = 0.03) higher odds of CIA with a negative predictive value of 99.3%. Previously unreplicated alleles, TNFb5, HLA-B*59:01, TNFb4, and TNFd3 showed significant associations with CIA after multiple-testing corrections. Our findings suggest that a predictive HLA-DRB1*04:02-based pharmacogenomic test may be promising for clinical implementation but requires further investigation.
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Clozapine Rechallenge or Continuation Despite Neutropenia, an Extended Follow-up of a Consecutive Quebec Case Series. J Clin Psychopharmacol 2022; 42:391-395. [PMID: 35546087 DOI: 10.1097/jcp.0000000000001556] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clozapine is the most efficacious antipsychotic for treatment-resistant schizophrenia. However, clozapine-induced neutropenia may warrant treatment discontinuation, hindering recovery. Several case reports describe clozapine rechallenge or continuation despite neutropenia, although many are subject to selective reporting, with incomplete information and short follow-up periods. Thus, consecutive case series, devoid of such bias, with long-term comprehensive follow-up are needed to better assess this practice. This study aimed to describe consecutively the evolution of every patient in the Québec City catchment area for whom clozapine was either reintroduced after neutropenia during a previous clozapine trial or was maintained despite a first neutropenia. METHODS Patients were identified through clozapine's national hematological monitoring database and their medical records between January 1, 2000, and October 22, 2017. RESULTS Twenty-three patients were identified, 8 continued clozapine despite neutropenia, while 15 discontinued clozapine and attempted rechallenge; among the latter, 4 patients were successfully rechallenged after agranulocytosis without the use of granulocyte colony-stimulating factors, which is the largest published consecutively. A total of 6 patients experienced further neutropenia episodes. Every patient who had a neutropenia recurrence also had a possible explanation for neutropenia other than exposure to clozapine. After a median follow-up of 4.8 years, 16 patients were still on clozapine and 3 cases discontinued because of a hematological event. CONCLUSIONS This study adds further data on the subject of clozapine rechallenge or continuation despite neutropenia. Clozapine rechallenge after agranulocytosis may be less perilous than first thought, but a systematic review on this specific subject is needed.
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Prolonged Agranulocytosis Despite a Granulocyte Colony-Stimulating Factor Treatment During Clozapine Treatment: A Case Report. J Clin Psychopharmacol 2022; 42:217-219. [PMID: 35149610 DOI: 10.1097/jcp.0000000000001517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Mace S, Dzahini O, Cornelius V, Langerman H, Oloyede E, Taylor D. Incident infection during the first year of treatment - A comparison of clozapine and paliperidone palmitate long-acting injection. J Psychopharmacol 2022; 36:232-237. [PMID: 34991402 DOI: 10.1177/02698811211058973] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To examine the risk of infection in patients prescribed clozapine compared with patients prescribed paliperidone palmitate long-acting injection (PPLAI). METHOD A retrospective, 1-year, cohort study conducted on events occurring in eligible patients beginning treatment for the first time with clozapine or PPLAI between June 2017 and June 2019 in a UK mental health trust providing in-patient and out-patient services. RESULTS The study included 64 patients starting clozapine and 120 patients starting PPLAI. Incidence of infection was greater in clozapine starters than in PPLAI starters (28% vs 6%; p = 0.001; adjusted odds ratio 5.82 (95% confidence interval (CI) = 2.15-15.76, p = 0.001). Infectious episodes in clozapine patients were not related to changes in neutrophil counts. Incident infection in the clozapine group was highest in the first 3 months of treatment. The most commonly reported infection in the clozapine group was chest infection; however, the majority of infections were non-chest-related. CONCLUSION Patients starting clozapine showed a substantially increased likelihood of infection compared with patients starting PPLAI.
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Affiliation(s)
- Shubhra Mace
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK.,Institute of Pharmaceutical Science, King's College, London, UK
| | - Olubanke Dzahini
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK.,Institute of Pharmaceutical Science, King's College, London, UK
| | | | - Hadar Langerman
- Institute of Pharmaceutical Science, King's College, London, UK
| | - Ebenezer Oloyede
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK.,Institute of Pharmaceutical Science, King's College, London, UK
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A Decrease of Neutrophils After COVID-19 Vaccination in a Treatment-Resistant Patient With Schizophrenia Taking Clozapine. J Clin Psychopharmacol 2022; 42:324-325. [PMID: 35149611 PMCID: PMC9042211 DOI: 10.1097/jcp.0000000000001527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ohlis A, Sörberg Wallin A, Sarafis A, Sjöqvist H, MacCabe JH, Ahlen J, Dalman C. Clozapine treatment and risk of severe COVID-19 infection. Acta Psychiatr Scand 2022; 145:79-85. [PMID: 34676888 PMCID: PMC8653206 DOI: 10.1111/acps.13379] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/09/2021] [Accepted: 10/18/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate whether patients with clozapine treatment are at an increased risk of a more severe COVID-19 infection as compared with patients on other antipsychotic drugs. METHODS In this register-based cohort study, all residents (age 18 or older) in the Stockholm Region with a psychotic disorder diagnosis and antipsychotic treatment were included (N = 8 233) and followed from 1 March 2020 to 14 January 2021. The exposure was defined as clozapine treatment and the outcome measures (indicating a more severe COVID-19 infection) were: inpatient care, care within intensive care unit or death due to COVID-19 infection. Differences in outcome rates between exposed (n = 966) and unexposed (other antipsychotics; n = 7 267) were examined using Cox proportional hazards models and expressed as hazard ratios (HR) with 95% confidence intervals (CI). RESULTS No statistically significant differences in outcome rates were found between the two groups of patients after adjusting for age, sex and residence in retirement homes. The adjusted HR for the exposed compared to the unexposed was 0.96 (95% CI: 0.54, 1.70) for inpatient care; 1.69 (0.48, 5.93) for care in intensive care unit (ICU); and 0.86 (0.26, 2.80) for death. Regarding inpatient care, additional adjusting for country of birth, living in socioeconomically vulnerable areas, number of care visits during the previous year, and comorbid medical illnesses did not alter the results. CONCLUSIONS Our results may add support to the present guidelines, recommending sustained clozapine treatment during the current COVID-19 pandemic with careful monitoring and readiness to alter drug doses as needed.
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Affiliation(s)
- Anna Ohlis
- Department of Global Public HealthKarolinska InstitutetStockholmSweden,Centre for Epidemiology and Community MedicineStockholm County CouncilStockholmSweden
| | - Alma Sörberg Wallin
- Department of Global Public HealthKarolinska InstitutetStockholmSweden,Centre for Epidemiology and Community MedicineStockholm County CouncilStockholmSweden
| | - Anna Sarafis
- Department of Global Public HealthKarolinska InstitutetStockholmSweden,Centre for Epidemiology and Community MedicineStockholm County CouncilStockholmSweden
| | - Hugo Sjöqvist
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - James H. MacCabe
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK,South London and Maudsley NHS Foundation TrustLondonUK
| | - Johan Ahlen
- Department of Global Public HealthKarolinska InstitutetStockholmSweden,Centre for Epidemiology and Community MedicineStockholm County CouncilStockholmSweden
| | - Christina Dalman
- Department of Global Public HealthKarolinska InstitutetStockholmSweden,Centre for Epidemiology and Community MedicineStockholm County CouncilStockholmSweden
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Sernoskie SC, Lobach AR, Kato R, Jee A, Weston JK, Uetrecht J. Clozapine induces an acute proinflammatory response that is attenuated by inhibition of inflammasome signaling: implications for idiosyncratic drug-induced agranulocytosis. Toxicol Sci 2021; 186:70-82. [PMID: 34935985 PMCID: PMC8883353 DOI: 10.1093/toxsci/kfab154] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Although clozapine is a highly efficacious schizophrenia treatment, it is under-prescribed due to the risk of idiosyncratic drug-induced agranulocytosis (IDIAG). Clinical data indicate that most patients starting clozapine experience a transient immune response early in treatment and a similar response has been observed in clozapine-treated rats, but the mechanism by which clozapine triggers this transient inflammation remains unclear. Therefore, the aim of this study was to characterize the role of inflammasome activation during the early immune response to clozapine using in vitro and in vivo models. In both differentiated and nondifferentiated human monocytic THP-1 cells, clozapine, but not its structural analogues fluperlapine and olanzapine, caused inflammasome-dependent caspase-1 activation and IL-1β release that was inhibited using the caspase-1 inhibitor yVAD-cmk. In Sprague Dawley rats, a single dose of clozapine caused an increase in circulating neutrophils and a decrease in lymphocytes within hours of drug administration along with transient spikes in the proinflammatory mediators IL-1β, CXCL1, and TNF-α in the blood, spleen, and bone marrow. Blockade of inflammasome signaling using the caspase-1 inhibitor VX-765 or the IL-1 receptor antagonist anakinra attenuated this inflammatory response. These data indicate that caspase-1-dependent IL-1β production is fundamental for the induction of the early immune response to clozapine and, furthermore, support the general hypothesis that inflammasome activation is a common mechanism by which drugs associated with the risk of idiosyncratic reactions trigger early immune system activation. Ultimately, inhibition of inflammasome signaling may reduce the risk of IDIAG, enabling safer, more frequent use of clozapine in patients.
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Affiliation(s)
| | - Alexandra R Lobach
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto, Toronto, ON, M5S 3M2, Canada
| | - Ryuji Kato
- Department of Cardiovascular Pharmacotherapy and Toxicology, Faculty of Pharmacy, Osaka Medical and Pharmaceutical University, Osaka, 569-1094, Japan
| | - Alison Jee
- Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - J Kyle Weston
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto, Toronto, ON, M5S 3M2, Canada
| | - Jack Uetrecht
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto, Toronto, ON, M5S 3M2, Canada.,Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A8, Canada
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40
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Ramli FF, Ali A, Syed Hashim SA, Kamisah Y, Ibrahim N. Reduction in Absolute Neutrophil Counts in Patient on Clozapine Infected with COVID-19. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111289. [PMID: 34769806 PMCID: PMC8582734 DOI: 10.3390/ijerph182111289] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 12/12/2022]
Abstract
Despite its severe adverse effects, such as agranulocytosis, clozapine is the primary treatment for treatment-resistant schizophrenia. The established clozapine monitoring system has contributed to reducing agranulocytosis incidence and mortality rates. However, the pandemic coronavirus disease 2019 (COVID-19) has caused changes in the monitoring system. This review aimed to assess the current evidence on the neutrophil changes in the patient on clozapine treatment and infected with COVID-19. Individual cases reported various absolute neutrophil count (ANC) levels, normal, reduced, or elevated. No agranulocytosis case was reported. One case had a borderline moderate-severe ANC level, but the patient was in the 18-week period of clozapine treatment. A cumulative analysis of case the series initially reported inconclusive results. However, a more recent study with a larger sample size reported a significant reduction in the ANC during COVID-19 infection. Nevertheless, this effect is transient as no significant difference was found between the baseline and the post-infection period in ANC levels. In conclusion, COVID-19 is associated with a temporary reduction in ANC levels. The results supported the recommendation to reduce the frequency of clozapine monitoring in the eligible candidates. However, more data are required to confirm the current findings given the limitations, including study design, sample size, and statistical analysis.
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Affiliation(s)
- Fitri Fareez Ramli
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia; (S.A.S.H.); (Y.K.)
- Department of Psychiatry, University of Oxford, Oxford OX3 7JX, UK
- Correspondence: ; Tel.: +60-3-9145-9545
| | - Adli Ali
- Department of Pediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia;
- Infection and Immunology Health and Advanced Medicine Cluster, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Syed Alhafiz Syed Hashim
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia; (S.A.S.H.); (Y.K.)
| | - Yusof Kamisah
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia; (S.A.S.H.); (Y.K.)
| | - Normala Ibrahim
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia;
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Wagner E, Siafis S, Fernando P, Falkai P, Honer WG, Röh A, Siskind D, Leucht S, Hasan A. Efficacy and safety of clozapine in psychotic disorders-a systematic quantitative meta-review. Transl Psychiatry 2021; 11:487. [PMID: 34552059 PMCID: PMC8458455 DOI: 10.1038/s41398-021-01613-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/19/2021] [Accepted: 09/07/2021] [Indexed: 02/08/2023] Open
Abstract
A recent increase in the literature regarding the evidence base for clozapine has made it increasingly difficult for clinicians to judge "best evidence" for clozapine use. As such, we aimed at elucidating the state-of-the-art for clozapine with regard to efficacy, effectiveness, tolerability, and management of clozapine and clozapine-related adverse events in neuropsychiatric disorders. We conducted a systematic PRISMA-conforming quantitative meta-review of available meta-analytic evidence regarding clozapine use. Primary outcome effect sizes were extracted and transformed into relative risk ratios (RR) and standardized mean differences (SMD). The methodological quality of meta-analyses was assessed using the AMSTAR-2 checklist. Of the 112 meta-analyses included in our review, 61 (54.5%) had an overall high methodological quality according to AMSTAR-2. Clozapine appears to have superior effects on positive, negative, and overall symptoms and relapse rates in schizophrenia (treatment-resistant and non-treatment-resistant subpopulations) compared to first-generation antipsychotics (FGAs) and to pooled FGAs/second-generation antipsychotics (SGAs) in treatment-resistant schizophrenia (TRS). Despite an unfavorable metabolic and hematological adverse-event profile compared to other antipsychotics, hospitalization, mortality and all-cause discontinuation (ACD) rates of clozapine surprisingly show a pattern of superiority. Our meta-review outlines the superior overall efficacy of clozapine compared to FGAs and most other SGAs in schizophrenia and suggests beneficial efficacy outcomes in bipolar disorder and Parkinson's disease psychosis (PDP). More clinical studies and subsequent meta-analyses are needed beyond the application of clozapine in schizophrenia-spectrum disorders and future studies should be directed into multidimensional clozapine side-effect management to foster evidence and to inform future guidelines.
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Affiliation(s)
- Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.
| | - Spyridon Siafis
- grid.15474.330000 0004 0477 2438Department of Psychiatry and Psychotherapy, School of Medicine, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Piyumi Fernando
- grid.7307.30000 0001 2108 9006Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Peter Falkai
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - William G. Honer
- grid.17091.3e0000 0001 2288 9830Department of Psychiatry, The University of British Columbia, Vancouver, Canada
| | - Astrid Röh
- grid.7307.30000 0001 2108 9006Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Dan Siskind
- grid.1003.20000 0000 9320 7537School of Medicine, University of Queensland, Brisbane, Australia ,Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Stefan Leucht
- grid.15474.330000 0004 0477 2438Department of Psychiatry and Psychotherapy, School of Medicine, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Alkomiet Hasan
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany ,grid.7307.30000 0001 2108 9006Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, Medical Faculty, University of Augsburg, Augsburg, Germany
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Valladales-Restrepo LF, Peña-Verjan NM, Vargas-Díaz K, Machado-Alba JE. Potentially inappropriate prescriptions of antipsychotic and anticholinergic drugs in patients with Parkinson's disease. Neurodegener Dis Manag 2021; 11:361-371. [PMID: 34525848 DOI: 10.2217/nmt-2021-0021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aim: The objective was to determine the prevalence of the potentially inappropriate antipsychotics and anticholinergics used in patients with Parkinson's disease. Materials & methods: A cross-sectional study identified the prescription of antipsychotics, anticholinergics and drugs for the treatment of Parkinson's disease. The anticholinergic burden was evaluated, and quetiapine and clozapine were considered to be adequate antipsychotics. Results: 2965 patients with Parkinson's disease were identified. The presence of psychiatric disorders and other neurological pathologies was associated with a greater probability of receiving potentially inappropriate antipsychotic prescriptions. The presence of greater number of comorbidities was associated with a greater probability of receiving anticholinergics. Conclusion: Older age and associated comorbidities, especially psychiatric and neurological comorbidities, increase the likelihood of patients with Parkinson's disease being prescribed antipsychotics and anticholinergics.
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Affiliation(s)
- Luis Fernando Valladales-Restrepo
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia.,Semillero de investigación en Farmacología Geriátrica, Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, 660003, Risaralda, Colombia.,Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
| | - Nathalia Marcela Peña-Verjan
- Semillero de investigación en Farmacología Geriátrica, Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, 660003, Risaralda, Colombia
| | - Katherine Vargas-Díaz
- Semillero de investigación en Farmacología Geriátrica, Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, 660003, Risaralda, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
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Vandevelde A, Métivier L, Dollfus S. Impact cérébral structurel et fonctionnel de la Clozapine chez les patients souffrant de schizophrénie : revue systématique des études longitudinales en neuroimagerie. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:683-700. [PMID: 33131322 PMCID: PMC8329901 DOI: 10.1177/0706743720966459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIF L'objectif de cette revue est d'identifier les corrélats anatomo-fonctionnels cérébraux lors d'un traitement par clozapine (CLZ) ainsi que les marqueurs anatomo-fonctionnels prédictifs de la réponse à la CLZ. MÉTHODES Nous avons réalisé une revue systématique de la littérature avec les bases de données MEDLINE et Web of Science afin d'identifier et d'examiner toutes les études longitudinales en neuroimagerie investiguant l'impact cérébral de la CLZ. RÉSULTATS 30 études ont été incluses et analysées. La CLZ induit une diminution du volume et de la perfusion dans les noyaux gris centraux chez les patients répondeurs. Un plus grand volume de substance grise et perfusion dans ces structures avant l'instauration de la CLZ étaient associés à une meilleure réponse au traitement. La diminution de volume et de perfusion au niveau du cortex préfrontal (CPF) est observée malgré l'instauration de CLZ mais de façon moins importante chez les patients sous CLZ que chez les patients sous antipsychotiques typiques. Un plus grand volume au niveau du CPF avant l'instauration de la CLZ est associé à une meilleure réponse clinique dans la majorité des études. Enfin, la CLZ semble induire une réduction des altérations au niveau de la substance blanche. CONCLUSION Les corrélats anatomo-fonctionnels de la CLZ différent de ceux des autres antipsychotiques avec une action spécifique de la CLZ au niveau des ganglions de la base et du CPF pouvant participer à sa supériorité en termes de réponse clinique. Plusieurs données cliniques et d'imagerie conduisent à l'hypothèse d'un meilleur pronostic associé à une instauration plus rapide de la CLZ.
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Affiliation(s)
- Anaïs Vandevelde
- Normandie Univ, UNICAEN, ISTS, EA 7466, GIP 55388Cyceron, boulevard Henri-Becquerel, 14000 Caen, France.,26962Normandie Univ, UNICAEN, UFR de médecine (Medical School), 14000 Caen, France.,Anaïs Vandevelde et Lucie Métivier ont participé de la même façon à ce travail et sont co-premier auteurs
| | - Lucie Métivier
- 26962Normandie Univ, UNICAEN, UFR de médecine (Medical School), 14000 Caen, France.,CHU de Caen, centre Esquirol, service de psychiatrie, 14000 Caen, France.,Anaïs Vandevelde et Lucie Métivier ont participé de la même façon à ce travail et sont co-premier auteurs
| | - Sonia Dollfus
- Normandie Univ, UNICAEN, ISTS, EA 7466, GIP 55388Cyceron, boulevard Henri-Becquerel, 14000 Caen, France.,26962Normandie Univ, UNICAEN, UFR de médecine (Medical School), 14000 Caen, France.,CHU de Caen, centre Esquirol, service de psychiatrie, 14000 Caen, France
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44
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Oloyede E, Casetta C, Dzahini O, Segev A, Gaughran F, Shergill S, Mijovic A, Helthuis M, Whiskey E, MacCabe JH, Taylor D. There Is Life After the UK Clozapine Central Non-Rechallenge Database. Schizophr Bull 2021; 47:1088-1098. [PMID: 33543755 PMCID: PMC8266568 DOI: 10.1093/schbul/sbab006] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS In the United Kingdom, patients on clozapine whose hematological parameters fall below certain thresholds are placed on the Central Non-Rechallenge Database (CNRD), meaning that they cannot be prescribed clozapine again except under exceptional circumstances. This practice was discontinued in the United States in 2015 by expanding the hematological monitoring guidelines, allowing more patients to receive clozapine. Our objective was to investigate the implications this policy change would have on clozapine utilization in the United Kingdom. METHODS This was an observational, retrospective analysis of patients registered on the CNRD in a large mental health trust. The first objective was to compare the number of patients placed on the CNRD under the United Kingdom and the US Food and Drug Administration (FDA) criteria. The second objective was to explore the hematological and clinical outcomes of CNRD patients. The third objective was to investigate the hematological outcomes of patients rechallenged on clozapine after nonrechallengeable status. RESULTS One hundred and fifteen patients were placed on CNRD from 2002 to 2019, of whom 7 (6%) met the equivalent criteria for clozapine discontinuation under the FDA guidelines. Clinical outcomes, as measured by the Clinical Global Impression-Severity scale, were worse 3 months after clozapine cessation than on clozapine (t = -7.4862; P < .001). Sixty-two (54%) patients placed on CNRD were rechallenged. Fifty-nine of those (95%) were successfully rechallenged; 3 patients were placed back on CNRD, only one of which would have had to stop clozapine again under FDA criteria. CONCLUSION Implementation of the updated FDA's monitoring criteria in the United Kingdom would significantly reduce clozapine discontinuation due to hematological reasons. The evidence suggests an urgent need for revising the UK clozapine monitoring guidelines to improve outcomes in treatment-resistant schizophrenia.
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Affiliation(s)
- Ebenezer Oloyede
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Cecilia Casetta
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Olubanke Dzahini
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King’s College, London, UK
| | - Aviv Segev
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Fiona Gaughran
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Sukhi Shergill
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Alek Mijovic
- Kings College Hospital NHS Foundation Trust, London, UK
| | | | - Eromona Whiskey
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
- NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
| | - James Hunter MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
- NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King’s College, London, UK
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Goldstone LW, DiPaula BA, Werremeyer A, Botts S, Hepburn B, Liu HY, Duckworth K, Young AS, Kelly DL. The Role of Board-Certified Psychiatric Pharmacists in Expanding Access to Care and Improving Patient Outcomes. Psychiatr Serv 2021; 72:794-801. [PMID: 33940946 DOI: 10.1176/appi.ps.202000066] [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] [Indexed: 12/01/2022]
Abstract
Although approximately 20% of adults in the United States experience a mental health condition annually, there continues to be a gap in the provision of care because of a shortage of behavioral health providers. The National Council for Behavioral Health Medical Director Institute has recommended that the number of board-certified psychiatric pharmacists (BCPPs), who are clinical pharmacists with advanced specialized training and experience in the treatment of patients with psychiatric and substance use disorders, be expanded to help meet this need. Although BCPPs currently assist in expanding care access, improving medication-related outcomes, and reducing health care costs by working collaboratively with physicians and other health care providers, BCPPs are often underutilized. This lack of utilization results in lost opportunity to better address the needs of persons with psychiatric or substance use disorders and to meet these needs in a timely manner. Here, the authors bring attention to five key areas-opioid use disorder, antipsychotic use among children, long-acting injectable antipsychotics, clozapine use, and transitions of care and care coordination-in which BCPPs, along with other pharmacists, provide evidence-based care and could be more extensively used as a collaborative solution to the mental health and substance use disorder crisis in the United States.
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Affiliation(s)
- Lisa W Goldstone
- School of Pharmacy, University of Southern California, Los Angeles (Goldstone); School of Pharmacy (DiPaula) and School of Medicine (Kelly), University of Maryland, Baltimore; School of Pharmacy, North Dakota State University, Fargo (Werremeyer); Kaiser Permanente and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver (Botts); National Association of State Mental Health Program Directors, Alexandria, Virginia (Hepburn); University of Nebraska Medical Center, Lincoln (Liu); National Alliance on Mental Illness, Arlington, Virginia (Duckworth); Department of Psychiatry, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles (Young); Maryland Psychiatric Research Center, Baltimore (Kelly)
| | - Bethany A DiPaula
- School of Pharmacy, University of Southern California, Los Angeles (Goldstone); School of Pharmacy (DiPaula) and School of Medicine (Kelly), University of Maryland, Baltimore; School of Pharmacy, North Dakota State University, Fargo (Werremeyer); Kaiser Permanente and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver (Botts); National Association of State Mental Health Program Directors, Alexandria, Virginia (Hepburn); University of Nebraska Medical Center, Lincoln (Liu); National Alliance on Mental Illness, Arlington, Virginia (Duckworth); Department of Psychiatry, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles (Young); Maryland Psychiatric Research Center, Baltimore (Kelly)
| | - Amy Werremeyer
- School of Pharmacy, University of Southern California, Los Angeles (Goldstone); School of Pharmacy (DiPaula) and School of Medicine (Kelly), University of Maryland, Baltimore; School of Pharmacy, North Dakota State University, Fargo (Werremeyer); Kaiser Permanente and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver (Botts); National Association of State Mental Health Program Directors, Alexandria, Virginia (Hepburn); University of Nebraska Medical Center, Lincoln (Liu); National Alliance on Mental Illness, Arlington, Virginia (Duckworth); Department of Psychiatry, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles (Young); Maryland Psychiatric Research Center, Baltimore (Kelly)
| | - Sheila Botts
- School of Pharmacy, University of Southern California, Los Angeles (Goldstone); School of Pharmacy (DiPaula) and School of Medicine (Kelly), University of Maryland, Baltimore; School of Pharmacy, North Dakota State University, Fargo (Werremeyer); Kaiser Permanente and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver (Botts); National Association of State Mental Health Program Directors, Alexandria, Virginia (Hepburn); University of Nebraska Medical Center, Lincoln (Liu); National Alliance on Mental Illness, Arlington, Virginia (Duckworth); Department of Psychiatry, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles (Young); Maryland Psychiatric Research Center, Baltimore (Kelly)
| | - Brian Hepburn
- School of Pharmacy, University of Southern California, Los Angeles (Goldstone); School of Pharmacy (DiPaula) and School of Medicine (Kelly), University of Maryland, Baltimore; School of Pharmacy, North Dakota State University, Fargo (Werremeyer); Kaiser Permanente and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver (Botts); National Association of State Mental Health Program Directors, Alexandria, Virginia (Hepburn); University of Nebraska Medical Center, Lincoln (Liu); National Alliance on Mental Illness, Arlington, Virginia (Duckworth); Department of Psychiatry, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles (Young); Maryland Psychiatric Research Center, Baltimore (Kelly)
| | - Howard Y Liu
- School of Pharmacy, University of Southern California, Los Angeles (Goldstone); School of Pharmacy (DiPaula) and School of Medicine (Kelly), University of Maryland, Baltimore; School of Pharmacy, North Dakota State University, Fargo (Werremeyer); Kaiser Permanente and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver (Botts); National Association of State Mental Health Program Directors, Alexandria, Virginia (Hepburn); University of Nebraska Medical Center, Lincoln (Liu); National Alliance on Mental Illness, Arlington, Virginia (Duckworth); Department of Psychiatry, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles (Young); Maryland Psychiatric Research Center, Baltimore (Kelly)
| | - Ken Duckworth
- School of Pharmacy, University of Southern California, Los Angeles (Goldstone); School of Pharmacy (DiPaula) and School of Medicine (Kelly), University of Maryland, Baltimore; School of Pharmacy, North Dakota State University, Fargo (Werremeyer); Kaiser Permanente and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver (Botts); National Association of State Mental Health Program Directors, Alexandria, Virginia (Hepburn); University of Nebraska Medical Center, Lincoln (Liu); National Alliance on Mental Illness, Arlington, Virginia (Duckworth); Department of Psychiatry, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles (Young); Maryland Psychiatric Research Center, Baltimore (Kelly)
| | - Alexander S Young
- School of Pharmacy, University of Southern California, Los Angeles (Goldstone); School of Pharmacy (DiPaula) and School of Medicine (Kelly), University of Maryland, Baltimore; School of Pharmacy, North Dakota State University, Fargo (Werremeyer); Kaiser Permanente and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver (Botts); National Association of State Mental Health Program Directors, Alexandria, Virginia (Hepburn); University of Nebraska Medical Center, Lincoln (Liu); National Alliance on Mental Illness, Arlington, Virginia (Duckworth); Department of Psychiatry, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles (Young); Maryland Psychiatric Research Center, Baltimore (Kelly)
| | - Deanna L Kelly
- School of Pharmacy, University of Southern California, Los Angeles (Goldstone); School of Pharmacy (DiPaula) and School of Medicine (Kelly), University of Maryland, Baltimore; School of Pharmacy, North Dakota State University, Fargo (Werremeyer); Kaiser Permanente and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver (Botts); National Association of State Mental Health Program Directors, Alexandria, Virginia (Hepburn); University of Nebraska Medical Center, Lincoln (Liu); National Alliance on Mental Illness, Arlington, Virginia (Duckworth); Department of Psychiatry, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles (Young); Maryland Psychiatric Research Center, Baltimore (Kelly)
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46
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Govind R, Fonseca de Freitas D, Pritchard M, Hayes RD, MacCabe JH. Clozapine treatment and risk of COVID-19 infection: retrospective cohort study. Br J Psychiatry 2021; 219:368-374. [PMID: 32713374 PMCID: PMC7417985 DOI: 10.1192/bjp.2020.151] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/10/2020] [Accepted: 07/21/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Clozapine, an antipsychotic with unique efficacy in treatment-resistant psychosis, is associated with increased susceptibility to infection, including pneumonia. AIMS To investigate associations between clozapine treatment and increased risk of COVID-19 infection in patients with schizophrenia-spectrum disorders who are receiving antipsychotic medications in a geographically defined population in London, UK. METHOD Using information from South London and Maudsley NHS Foundation Trust (SLAM) clinical records, via the Clinical Record Interactive Search system, we identified 6309 individuals who had an ICD-10 diagnosis of schizophrenia-spectrum disorders and were taking antipsychotics at the time of the COVID-19 pandemic onset in the UK. People who were on clozapine treatment were compared with those on any other antipsychotic treatment for risk of contracting COVID-19 between 1 March and 18 May 2020. We tested associations between clozapine treatment and COVID-19 infection, adjusting for gender, age, ethnicity, body mass index (BMI), smoking status and SLAM service use. RESULTS Of 6309 participants, 102 tested positive for COVID-19. Individuals who were on clozapine had increased risk of COVID-19 infection compared with those who were on other antipsychotic medication (unadjusted hazard ratio HR = 2.62, 95% CI 1.73-3.96), which was attenuated after adjusting for potential confounders, including clinical contact (adjusted HR = 1.76, 95% CI 1.14-2.72). CONCLUSIONS These findings provide support for the hypothesis that clozapine treatment is associated with an increased risk of COVID-19 infection. Further research will be needed in other samples to confirm this association. Potential clinical implications are discussed.
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Affiliation(s)
- Risha Govind
- Institute of Psychiatry, Psychology and Neuroscience, King's College London; and National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and King's College London, UK
| | - Daniela Fonseca de Freitas
- Institute of Psychiatry, Psychology and Neuroscience, King's College London; and National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and King's College London, UK
| | - Megan Pritchard
- Institute of Psychiatry, Psychology and Neuroscience, King's College London; and National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and King's College London, UK
| | - Richard D. Hayes
- Institute of Psychiatry, Psychology and Neuroscience, King's College London; and National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and King's College London, UK
| | - James H. MacCabe
- Institute of Psychiatry, Psychology and Neuroscience, King's College London; and National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and King's College London; and National Psychosis Unit, South London and Maudsley NHS Foundation Trust, London, UK
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47
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Wadoo O, Karim MA, ElTorki Y, Riaz S, Latoo J, Alabdulla M. Clozapine prescribing and safety during COVID-19. Asian J Psychiatr 2021; 60:102658. [PMID: 33895435 PMCID: PMC8035804 DOI: 10.1016/j.ajp.2021.102658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/08/2021] [Indexed: 11/26/2022]
Affiliation(s)
| | | | | | | | | | - Majid Alabdulla
- Hamad Medical Corporation, Qatar; College of Medicine Qatar University, Qatar.
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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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Clozapine-Associated Leukopenia and Agranulocytosis in Western Cape, South Africa: A 3-Year Retrospective Cohort Study. J Clin Psychopharmacol 2021; 41:250-254. [PMID: 33843819 DOI: 10.1097/jcp.0000000000001394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Clozapine may cause life-threatening hematological side effects (HSEs). Hematological side effect incidence data from Sub-Saharan Africa are lacking. Furthermore, clozapine reduces cellular immunity, and it is unknown whether clozapine is a risk factor for tuberculosis or whether HIV is a risk factor for developing HSEs. We assessed the incidence of HSEs in South Africans from the Western Cape Province on clozapine, and the secondary objective was to determine the association of HIV and tuberculosis with clozapine exposure. METHODS We conducted a 24-week retrospective descriptive study of patients initiated on clozapine between January 2015 and December 2017 using anonymized data from the Provincial Health Data Centre. A control group of patients initiated on risperidone was selected. RESULTS We identified 23,328 patients and included 5213 who had white blood cell monitoring (n = 1047 clozapine, n = 4166 risperidone). The incidence of leukopenia in patients on clozapine was 0.38% (95% confidence interval [CI], 0.01%-0.76%) measured over a 24-week period and was 0.41% in patients on risperidone (95% CI, 0.21%-0.6%) (P = 0.91). The incidence of agranulocytosis in patients on clozapine was 0.19% (95% CI, 0.00%-0.46%) measured over a 24-week period and was 0.24% in patients on risperidone (95% CI, 0.09%-0.39%) (P = 0.266). HIV-infected patients had a 7.46 times increased risk of developing leukopenia (95% CI, 3.37-16.48; P < 0.01). Patients who developed leukopenia had a 6.24 times increased risk of contracting tuberculosis (95% CI, 1.84-21.11; P < 0.01). CONCLUSIONS Our incidence of clozapine-induced HSEs was lower than previously reported and not significantly different compared with risperidone. HIV infection was associated with HSEs. Patients with HSEs had an increased risk of developing tuberculosis.
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Whiskey E, Barnard A, Oloyede E, Dzahini O, Taylor DM, Shergill SS. An evaluation of the variation and underuse of clozapine in the United Kingdom. Acta Psychiatr Scand 2021; 143:339-347. [PMID: 33501659 DOI: 10.1111/acps.13280] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Clozapine is the only licensed treatment for treatment refractory schizophrenia. Despite this, it remains grossly underused relative to the prevalence of refractory schizophrenia. The extent of underuse and the degree of regional variation in prescribing in the United Kingdom is unknown. It is also unclear, how the UK compares with other European countries in rates of clozapine prescribing. METHODS We obtained data relating to all clozapine prescribing in the UK from the relevant clozapine registries. We examined regional variation in clozapine use across England, corrected for the known prevalence of severe mental illness (SMI). We also compared the UK rate of clozapine use per 100,000 population to that described in other European countries. FINDINGS There is substantial variation in clozapine prescribing across different regions of England and only about a third of potentially eligible patients were prescribed the drug in the UK. Clozapine prescribing rate in the UK was lower than in several European countries. INTERPRETATION There is clear regional inequity in access to the most effective treatment in refractory schizophrenia in England. Strategies to increase clozapine use, by overcoming both real and perceived barriers, are urgently necessary to reduce treatment inequity for patients with refractory schizophrenia.
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Affiliation(s)
- Eromona Whiskey
- Pharmacy Department, South London & Maudsley NHS Foundation Trust, London, UK.,Institute of Pharmaceutical Sciences, King's College, London, UK.,Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neurosciences, Kings College, London, UK
| | - Alex Barnard
- Clinical Research Network CRN, National Institute for Health Research NIHR, London, UK
| | - Ebenezer Oloyede
- Pharmacy Department, South London & Maudsley NHS Foundation Trust, London, UK.,Institute of Pharmaceutical Sciences, King's College, London, UK.,Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neurosciences, Kings College, London, UK
| | - Olubanke Dzahini
- Pharmacy Department, South London & Maudsley NHS Foundation Trust, London, UK.,Institute of Pharmaceutical Sciences, King's College, London, UK
| | - David M Taylor
- Pharmacy Department, South London & Maudsley NHS Foundation Trust, London, UK.,Institute of Pharmaceutical Sciences, King's College, London, UK
| | - Sukhwinder S Shergill
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neurosciences, Kings College, London, UK
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