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Qubad M, Dupont G, Hahn M, Martin SS, Puntmann V, Nagel E, Reif A, Bittner RA. When, Why and How to Re-challenge Clozapine in Schizophrenia Following Myocarditis. CNS Drugs 2024; 38:671-696. [PMID: 38951464 DOI: 10.1007/s40263-024-01100-4] [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] [Accepted: 06/03/2024] [Indexed: 07/03/2024]
Abstract
Clozapine-induced myocarditis (CIM) is among the most important adverse events limiting the use of clozapine as the most effective treatment for schizophrenia. CIM necessitates the immediate termination of clozapine, often resulting in its permanent discontinuation with considerable detrimental effects on patients' psychopathology and long-term outcome. Consequently, a clozapine re-challenge after CIM is increasingly regarded as a viable alternative, with published reports indicating a success rate of approximately 60%. However, published cases of re-challenges after CIM remain limited. Here, we provide a narrative review of the current state of research regarding the epidemiology, pathophysiology, risk factors, diagnosis and clinical management of CIM as well as a synthesis of current recommendations for re-challenging patients after CIM. This includes a step-by-step guide for this crucial procedure based on the current evidence regarding the pathophysiology and risk factors for CIM. Slow dose titration regimes and addressing risk factors including concomitant valproate and olanzapine are crucial both to prevent CIM and to ensure a safe and successful re-challenge. Furthermore, we discuss the utility of C-reactive protein, troponin, N-terminal-pro hormone and brain natriuretic peptide, therapeutic drug-monitoring and cardiac magnetic resonance imaging for CIM screening and diagnosis as well as for post-CIM re-challenges.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
| | - Gabriele Dupont
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Martina Hahn
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- Department of Mental Health, Varisano Hospital Frankfurt Hoechst, Frankfurt, Germany
| | - Simon S Martin
- Department of Radiology, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Valentina Puntmann
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Eike Nagel
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Robert A Bittner
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
- Ernst Strüngmann Institute for Neuroscience (ESI) in Cooperation with Max Planck Society, Frankfurt, Germany.
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Bellissima BL, Burns KE, Helsby NA, Kingston EL, Garavan F, Tingle MD. Clozapine metabolism and cardiotoxicity: A prospective longitudinal study. Int J Cardiol 2024; 403:131788. [PMID: 38244893 DOI: 10.1016/j.ijcard.2024.131788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 12/19/2023] [Accepted: 01/14/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Clozapine-induced myocarditis and cardiomyopathy are difficult to detect clinically and may be fatal if not detected early. The current/routine biomarkers for clozapine-induced myocarditis are non-specific indicators of inflammation (C-reactive protein) or cardiomyocyte damage (troponins I and T) that lack sensitivity, and for which changes often arise too late to be clinically useful. METHODS The Clozapine Safety Study was a prospective, longitudinal, observational study to determine what, if any, the plasma concentrations of clozapine, N-desmethylclozapine, and clozapine-N-oxide in patients contribute to cardiotoxicity. Samples were collected and analysed using liquid chromatography mass spectrometry over a 41-month period from patients in the Auckland District Health Board. RESULTS Sixty-seven patients were included. Six patients were diagnosed with myocarditis; none were diagnosed with cardiomyopathy in the study period. In patients not undergoing dose titration, clozapine biotransformation may shift to the N-oxide pathway rather than the N-desmethyl pathway with increasing dose. During dose titration, the timeframe in which myocarditis occurs, the rate of increase in the plasma concentration of clozapine-N-oxide, as well as the ratio of N-oxidation relative to N-desmethylation, were significantly higher in patients diagnosed with myocarditis. CONCLUSIONS The assessment of clozapine-N-oxide formation, and N-oxidation relative to N-desmethylation ratios during treatment, may help identify a biomarker to aid the early detection of patients at risk of developing clozapine-induced cardiotoxicity.
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Affiliation(s)
- Brandi L Bellissima
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Kathryn E Burns
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Nuala A Helsby
- Department of Molecular Medicine and Pathology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Ellen L Kingston
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Fintan Garavan
- Department of Forensic Pathology, Auckland District Health Board, LabPLUS, Auckland City Hospital, Gate 4, Grafton Road, PO Box 110031, Auckland, New Zealand.
| | - Malcom D Tingle
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
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Tirupati S, Arachchi MK. High rates of myocarditis with clozapine in the Hunter region of Australia. Schizophr Res 2024; 264:543-548. [PMID: 38330687 DOI: 10.1016/j.schres.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 01/09/2024] [Accepted: 01/22/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVE To study the causes of clozapine treatment discontinuation and measure clozapine-induced myocarditis (CIM) rates in an Australian region, to compare the observed rates of CMI with reports from Australia and the world, and discuss factors related to CIM incidence rates in the region. METHODS The study is a retrospective clinical audit of 327 patients prescribed clozapine. All patients were monitored by the mandatory CIM monitoring protocol for the first six weeks of treatment. The validity of a diagnosis of CIM was assessed using six criteria. Socio-demographic and clinical factors and clozapine prescription practices were analysed for their association with CIM. The study could not examine co-existing medical illness, co-prescribed psychotropic medication, genetics, and environmental factors. RESULTS CIM occurred in 9.8 % of the cohort after a mean treatment duration of 19.5 days. The diagnosis of CIM was considered valid in all cases. Gender, age at the start of treatment, ethnicity, cumulative clozapine dose, dose titration, and clozapine/norclozapine ratio were unrelated to CIM. CONCLUSION The CIM rate in the Hunter region was higher than in the rest of Australia and the world and increased after adopting the monitoring protocol. Over-diagnosis, patient's age and gender, ethnicity, cumulative clozapine dose, dosing titration, and clozapine metabolism rate were unrelated to the high occurrence rates. The possible role of comorbid illnesses, co-prescribed psychiatric medications, genetic, and environmental factors in the etiology of CIM requires further study. The reasons underlying the high rates of CIM in the Hunter region need further exploration.
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Affiliation(s)
- Srinivasan Tirupati
- Psychiatric Rehabilitation Service, Hunter New England Mental Health, Morisset, NSW 2264, Australia; School of Medicine and Public Health, Faculty of Health, The University of Newcastle, Callaghan, NSW 2308, Australia.
| | - Mahinda K Arachchi
- Psychiatric Rehabilitation Service, Hunter New England Mental Health, Morisset, NSW 2264, Australia
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Daniel P, Rajaree KM, Rudy L, Jafor S, Prasad S, Avanthika C, Jhaveri S. Myocarditis in patients on long-term antipsychotics -mechanism, management and recent updates. Heliyon 2023; 9:e13930. [PMID: 36923851 PMCID: PMC10008991 DOI: 10.1016/j.heliyon.2023.e13930] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 12/17/2022] [Accepted: 02/15/2023] [Indexed: 02/25/2023] Open
Abstract
Objective Clozapine is the first atypical antipsychotic drug and was frequently cited as the most effective antipsychotic for treatment-resistant schizophrenia, but it is associated with a concert of significant cardiotoxic side effects. Clozapine-induced Myocarditis (CIM) is diagnosed based on the combination of clinical symptoms, laboratory investigations, radiological findings, and sometimes biopsy. The literature on CIM management and clinical consensus on the best course of action is mixed. Methodology An all-language literature search on Medline, Cochrane, Embase, and Google Scholar until April 2022. The following search strings and Medical Subject Heading (MeSH) terms were used: "CIM," "clozapine," "cardiotoxicity," and "myocarditis." We explored the literature on CIM for its pathophysiology, diagnosis, monitoring, and management. Results The clinical features of CIM may be highly variable, ranging from asymptomatic disease to fulminant heart failure, and cessation of medication was the mainstay treatment of CIM, followed by supportive therapy. Other antipsychotics have also been linked with cardiotoxic side effects. Conclusion Despite being the most effective antipsychotic, clozapine is associated with a cardiotoxic side effect. Current literature suggests that these antipsychotic-related cardiotoxic events impact the treatment selection for schizophrenia and other psychotic disorders, and they must be kept in mind while designing new treatment protocols in the future.
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Affiliation(s)
| | | | - Luna Rudy
- Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sadeque Jafor
- Al Mostaqbal Hospital, Jeddah, Kingdom of Saudi Arabia
| | - Sakshi Prasad
- Faculty of Medicine, National Pirogov Memorial Medical University, 21018, Vinnytsya, Ukraine
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Qubad M, Bittner RA. Second to none: rationale, timing, and clinical management of clozapine use in schizophrenia. Ther Adv Psychopharmacol 2023; 13:20451253231158152. [PMID: 36994117 PMCID: PMC10041648 DOI: 10.1177/20451253231158152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/24/2023] [Indexed: 03/31/2023] Open
Abstract
Despite its enduring relevance as the single most effective and important evidence-based treatment for schizophrenia, underutilization of clozapine remains considerable. To a substantial degree, this is attributable to a reluctance of psychiatrists to offer clozapine due to its relatively large side-effect burden and the complexity of its use. This underscores the necessity for continued education regarding both the vital nature and the intricacies of clozapine treatment. This narrative review summarizes all clinically relevant areas of evidence, which support clozapine's wide-ranging superior efficacy - for treatment-resistant schizophrenia (TRS) and beyond - and make its safe use eminently feasible. Converging evidence indicates that TRS constitutes a distinct albeit heterogeneous subgroup of schizophrenias primarily responsive to clozapine. Most importantly, the predominantly early onset of treatment resistance and the considerable decline in response rates associated with its delayed initiation make clozapine an essential treatment option throughout the course of illness, beginning with the first psychotic episode. To maximize patients' benefits, systematic early recognition efforts based on stringent use of TRS criteria, a timely offer of clozapine, thorough side-effect screening and management as well as consistent use of therapeutic drug monitoring and established augmentation strategies for suboptimal responders are crucial. To minimize permanent all-cause discontinuation, re-challenges after neutropenia or myocarditis should be considered. Owing to clozapine's unique efficacy, comorbid conditions including substance use and most somatic disorders should not dissuade but rather encourage clinicians to consider clozapine. Moreover, treatment decisions need to be informed by the late onset of clozapine's full effects, which for reduced suicidality and mortality rates may not even be readily apparent. Overall, the singular extent of its efficacy combined with the high level of patient satisfaction continues to distinguish clozapine from all other available antipsychotics.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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Richardson N, Greenway SC, Bousman CA. Clozapine-induced myocarditis and patient outcomes after drug rechallenge following myocarditis: A systematic case review. Psychiatry Res 2021; 305:114247. [PMID: 34715441 DOI: 10.1016/j.psychres.2021.114247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 10/16/2021] [Accepted: 10/18/2021] [Indexed: 01/29/2023]
Abstract
Clozapine is underutilized due, in part, to concerns about rare but severe adverse drug reactions, including cardiac inflammation and injury (myocarditis). Risk factors for clozapine-induced myocarditis are limited and predictors for the successful rechallenge of clozapine after an episode of myocarditis are even more poorly understood. We conducted a systematic review, in accordance with the PRISMA recommendation, of published case reports to describe demographic and clinical characteristics of patients with clozapine-induced myocarditis and identify potential markers of clozapine rechallenge success. A total of 180 cases from 88 articles were evaluated. Male cases of clozapine-associated myocarditis were more frequently reported than female cases by a ratio of 6:1. Less than half of patients reported the presence of chest pain (35%) or flu-like symptoms (43%) but increases in troponin or C-reactive protein were present in 87% of cases. Clozapine rechallenge was carried out in 34 (2 female) cases, with successful reintroduction in 22 (2 female) cases (64.7%) and one fatality (2.9%). No demographic or clinical markers were significantly associated with rechallenge success after correction for multiple testing. Standardized reporting of clozapine-induced myocarditis cases is needed to facilitate the identification of factors associated with successful rechallenge.
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Affiliation(s)
- Noah Richardson
- Department of Medical Genetics, University of Calgary, Calgary, AB, Canada
| | - Steven C Greenway
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Biochemistry and Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Chad A Bousman
- Department of Medical Genetics, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Psychiatry, University of Calgary, Calgary, AB, Canada; Department of Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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Bellissima BL, Vara A, Helsby N, Garavan F, Tingle MD. Incidence and investigation of potential risk-factors for clozapine-associated myocarditis and cardiomyopathy in a New Zealand cohort. Psychiatry Res 2021; 299:113873. [PMID: 33799127 DOI: 10.1016/j.psychres.2021.113873] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 03/13/2021] [Indexed: 11/18/2022]
Abstract
Clozapine is a uniquely effective antipsychotic indicated for treatment-resistant schizophrenia. However, its use is underutilised and often delayed for years due to potential adverse reactions including myocarditis and cardiomyopathy. The purpose of this study was to conduct a retrospective review of the clinical records of patients initiating clozapine in the Auckland District Health Board (ADHB) region to determine the incidence of clozapine-associated myocarditis and cardiomyopathy and to identify potential risk factors associated with these cardiotoxicities. The incidence of clozapine-associated myocarditis and cardiomyopathy over a two-year period in the ADHB region was 3.8% and 1.3% respectively.
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Affiliation(s)
- Brandi L Bellissima
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Alisha Vara
- Auckland Regional Psychiatric Registrar Training Programme, Auckland District Health Board, 2 Park Road, Grafton, Auckland, 1023, New Zealand.
| | - Nuala Helsby
- Department of Molecular Medicine and Pathology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Fintan Garavan
- Department of Forensic Pathology, Auckland District Health Board, LabPlus, Auckland City Hospital, Gate 4, Grafton Road PO Box 110031, Auckland, New Zealand
| | - Malcolm D Tingle
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
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Clozapine-Associated Myocarditis: A Protocol for Monitoring Upon Clozapine Initiation and Recommendations for How to Conduct a Clozapine Rechallenge. J Clin Psychopharmacol 2021; 41:180-185. [PMID: 33587399 DOI: 10.1097/jcp.0000000000001358] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Clozapine is the only medication with Food and Drug Administration approval for treatment-resistant schizophrenia. However, it is underutilized in the United States because of several life-threatening adverse effects, including clozapine-associated myocarditis (CAM), and a limited understanding of how to manage these complications. To date, recommendations for rechallenging patients with CAM that incorporate the cardiac literature or cardioprotective medications have not been developed. FINDINGS In this article, we outline a protocol developed with cardiologists and guided by the cardiac literature that provides direction on how to monitor for the initial development of CAM and how to rechallenge patients with CAM. Furthermore, we present 2 successful cases of clozapine rechallenge that were managed using this protocol. CONCLUSIONS In both cases, the patients showed marked improvement in their psychiatric symptoms and functioning, demonstrating the importance of considering rechallenge in patients after CAM.
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Implementation and Outcomes of a Clozapine-Associated Myocarditis Screening Program in a Region of South Australia-Lessons Learned. J Clin Psychopharmacol 2021; 40:250-258. [PMID: 32332460 DOI: 10.1097/jcp.0000000000001193] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Clozapine-associated myocarditis (CAM) is a serious complication, mostly occurring in the first month of treatment. Public mental health in South Australia introduced a screening protocol in 2011 using baseline and weekly C-reactive protein and troponin. The aim of this study was to assess protocol adherence and management of cases with positive screening results. METHODS We identified all patients commenced on clozapine in our area between 2012 and 2015. Those with abnormal C-reactive protein and/or troponin in the first 4 weeks of treatment were identified (potential cases). For those, we collected clinical characteristics and test results and reviewed their management. FINDINGS Protocol compliance increased to 80%. We identified 24 potential CAM cases, 8 at high risk based on established definition (7.6% of new commencements) and 9 formally diagnosed from 143 commenced on clozapine. Potential cases not meeting CAM definition were significantly more likely commenced on clozapine for the first time and have preexisting respiratory disease. Likely CAM cases were younger, and more often prescribed additional antipsychotics, specifically quetiapine. Seven (78%) of 9 patients diagnosed with CAM met published CAM definition. In 14 undiagnosed potential cases, 10 (71%) did not have timely testing to exclude CAM. CONCLUSIONS Maintaining a high index of suspicion, clinical monitoring and timely testing is important to supplement CAM screening protocols. More research is needed to identify those that can be safely rechallenged or even continue clozapine treatment with monitoring.
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Siskind D, Sidhu A, Cross J, Chua YT, Myles N, Cohen D, Kisely S. Systematic review and meta-analysis of rates of clozapine-associated myocarditis and cardiomyopathy. Aust N Z J Psychiatry 2020; 54:467-481. [PMID: 31957459 DOI: 10.1177/0004867419898760] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Clozapine is the most effective medication for treatment refractory schizophrenia, but is associated with cardiac adverse drug reactions. Myocarditis and cardiomyopathy are the most serious cardiac adverse drug reactions although reported rates of these conditions vary in the literature. We systematically reviewed and meta-analysed the event rates, the absolute death rates and case fatality rates of myocarditis and cardiomyopathy associated with clozapine. METHODS PubMed, EMBASE and PsycINFO were searched for studies that reported on the incidence of cardiomyopathy or myocarditis in people exposed to clozapine. Data were meta-analysed using a random effects model, with subgroup analysis on study size, time frame, region, quality, retrospective vs prospective, and diagnostic criteria of myocarditis or cardiomyopathy. RESULTS 28 studies of 258,961 people exposed to clozapine were included. The event rate of myocarditis was 0.007 (95% confidence interval [CI] = [0.003, 0.016]), absolute death rate was 0.0004 (95% CI = [0.0002, 0.0009]) and case fatality rate was 0.127 (95% CI = [0.034, 0.377]). The cardiomyopathy event rate was 0.006 (95% CI = [0.002, 0.023]), absolute death rate was 0.0003 (95% CI = [0.0001, 0.0012]) and case fatality rate was 0.078 (95% CI = [0.018, 0.285]). Few included studies provided information on criteria for diagnosis of myocarditis and cardiomyopathy. Event rates of cardiomyopathy and myocarditis were higher in Australia. CONCLUSION Clarity of diagnostic criteria for myocarditis remains a challenge. Observation bias may, in part, influence higher reported rates in Australia. Monitoring for myocarditis is warranted in the first 4 weeks, and treatment of comorbid metabolic syndrome and diabetes may reduce the risk of cardiomyopathy. The risks of myocarditis and cardiomyopathy are low and should not present a barrier to people with treatment refractory schizophrenia being offered a monitored trial of clozapine.
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Affiliation(s)
- Dan Siskind
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Ashneet Sidhu
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - John Cross
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Yee-Tat Chua
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Nicholas Myles
- Haematology Directorate, SA Pathology, Adelaide, SA, Australia
| | - Dan Cohen
- GGZ Noord-Holland-Noord, Heerhugowaard, The Netherlands
| | - Steve Kisely
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
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Kanniah G, Kumar S. Clozapine associated cardiotoxicity: Issues, challenges and way forward. Asian J Psychiatr 2020; 50:101950. [PMID: 32109805 DOI: 10.1016/j.ajp.2020.101950] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/28/2019] [Accepted: 02/09/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To review the published literature on clozapine associated cardiotoxicity (CACT), summarize diagnostic features, and evaluate monitoring procedures for safe clozapine re-challenge. RESULTS Clozapine-associated Myocarditis (CAM) - Incidence of early myocarditis (≤2 months) is infrequent but serious. Clinical diagnosis is confounded by variability in presentation and non-specificity of symptoms. Re-challenge considerations include clozapine impact on symptomatic severity and associated disability and risk of suicidality. Re-challenging is recommended only after full clinical resolution of myocarditis and cardiac function impairment, under closely controlled conditions, starting at very low dosage, extremely slow titration and frequent assays of lab and cardio biomarkers. Clozapine associated cardiomyopathy (CAC) -develops later but mortality has been reported at 12.5-24.0%. Re-challenge is generally not recommended due to paucity of outcome data. Monitoring Cardiac Toxicity: Plausible steps include closer clinical monitoring, repeated assays of biomarkers, and echocardiographic studies, and cardiac MRI changes with unremarkable findings of cardiac dysfunction with echocardiography. Subclinical clozapine associated cardiotoxicity is more prevalent than CAM and CAC. Diagnosis is often challenging due to non specific presentation. Active monitoring is recommended. Rechallenging is feasible but should be done under close monitoring conditions. A protocol is proposed based on literature review and clinical experience in order to reduce the risk of CACT. CONCLUSION Clozapine-associated myocarditis and cardiomyopathy may have been underreported worldwide. Identification of subclinical cardiotoxic effects can improve outcomes by earlier recognition before clinical manifestations of cardiac impairments. A pragmatic close clinical monitoring protocol including cardiac biomarkers aimed at timely detection of cardiac toxicity, in the initial phase of treatment is proposed.
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Affiliation(s)
- Guna Kanniah
- Waikato Clinical Campus, University of Auckland, New Zealand.
| | - Shailesh Kumar
- Waikato Clinical Campus, University of Auckland, New Zealand
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12
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Abstract
PURPOSE/BACKGROUND That clozapine is the only agent with an indication for treatment-resistant schizophrenia presents real challenges if clozapine-related myocarditis (CIM) occurs. Clinicians have chosen to rechallenge with a second trial of clozapine in the face of CIM. However, there is very limited literature of this topic. METHODS/PROCEDURES Three cases who underwent clozapine rechallenge after CIM are reviewed and discussed in the context of existing literature and current recommendations. FINDINGS/RESULTS We present 3 young male patients with schizophrenia and schizoaffective disorder who developed CIM during a first clozapine trial, stopped treatment, and subsequently underwent a second clozapine trial. In all cases, the rechallenge was discontinued owing to suspected CIM. A review of the literature includes reports of both successful and unsuccessful clozapine rechallenges after CIM and suggests certain risk factors. Clozapine rechallenge after CIM may be undertaken, as now occurs on occasion with agranulocytosis, although rates of success may be lower. Any such undertaking calls for education, careful monitoring, cautious titration, and a multidisciplinary approach. The balance of risk versus benefits must be considered, and strategies may include a drug holiday, more frequent monitoring upon reinitiation, and slower titration. IMPLICATIONS/CONCLUSIONS Pressure to undertake a rechallenge reflects clozapine's unique role in treatment-resistant schizophrenia and absence of other comparable options. However, it is not without risk, and more research is needed to understand those at increased risk, as well as established strategies that diminish this.
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Espinosa González MDC, Nuevo Fernández L. Cardiogenic shock and multiorgan dysfunction secondary to clozapine. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2019; 14:68-69. [PMID: 31722848 DOI: 10.1016/j.rpsm.2019.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 06/24/2019] [Accepted: 07/30/2019] [Indexed: 10/25/2022]
Affiliation(s)
| | - Laura Nuevo Fernández
- Servicio de Psiquiatría, Hospital General Universitario de Ciudad Real (HGUCR), Ciudad Real, España
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Sweeney M, Whiskey E, Patel RK, Tracy DK, Shergill SS, Plymen CM. Understanding and managing cardiac side-effects of second-generation antipsychotics in the treatment of schizophrenia. BJPSYCH ADVANCES 2019. [DOI: 10.1192/bja.2019.49] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
SUMMARYSecond-generation antipsychotic medications (SGAs) have advanced the treatment of schizophrenia over the past 30 years. However, a number of potentially life-threatening cardiac side-effects associated with these treatments concern and can discourage prescribers from administering these evidence-based treatments. This review provides a practical, psychiatrist-oriented understanding of the relative frequencies, mechanisms, investigations and treatments associated with these cardiac toxicities. We aim to highlight that these are relatively rare complications of an effective class of drug and to promote the advantages of early involvement of cardiologists in the psychiatric multidisciplinary team to guide the investigation and management of these conditions.LEARNING OBJECTIVESAfter reading this article you will be able to:
•understand the relative incidence of cardiotoxic side-effects of the various SGAs•perform preliminary investigations to diagnose the common cardiotoxic side-effects of SGAs•understand the treatments for these cardiac side-effects and the role of cardiologists involved the care of these patients.
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Higgins JM, San C, Lagnado G, Chua D, Mihic T. Incidence and Management of Clozapine-Induced Myocarditis in a Large Tertiary Hospital. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2019; 64:561-567. [PMID: 30599763 PMCID: PMC6681512 DOI: 10.1177/0706743718816058] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Clozapine, an antipsychotic reserved for management of treatment-resistant schizophrenia, is associated with severe adverse effects, including myocarditis. This study aims to determine the incidence of clozapine-induced myocarditis at a large tertiary hospital compared to what is reported in the literature. METHODS Medical records of adult patients admitted to psychiatry units receiving clozapine between January 1, 2010, and July 31, 2016, were retrospectively reviewed. Cases of clozapine-induced myocarditis were defined as having elevated C-reactive protein (CRP) or detectable troponin and at least 1 sign or symptom of myocarditis, in the absence of alternative plausible aetiologies. The primary outcome was incidence of clozapine-induced myocarditis during the study period. Secondary outcomes included rate and description of the management of clozapine-induced myocarditis. RESULTS In total, 316 patients were screened; 10 patients met the case definition for clozapine-induced myocarditis. The incidence of this adverse drug reaction over the study period was 3.16%. Reduced left ventricular ejection fraction was observed in 60% of cases, and electrocardiography changes were noted in 60% of cases. Clozapine was discontinued in all cases. Rechallenge was performed in 2 patients; recurrent CRP elevation resulted in discontinuation in each case. Medications for management of myocarditis were used in 50% of cases. Although 2 patients required transfer to critical care, the in-hospital mortality rate was 0%. CONCLUSIONS The incidence of clozapine-induced myocarditis at the study hospital was consistent with the higher range reported in the literature. Further research is necessary to elucidate risk factors, definitive diagnostic criteria, and effective management of clozapine-induced myocarditis.
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Affiliation(s)
- Julia M Higgins
- 1 Pharmacy Department, St. Paul's Hospital, Vancouver, British Columbia
| | - Cindy San
- 1 Pharmacy Department, St. Paul's Hospital, Vancouver, British Columbia
| | - Gillian Lagnado
- 1 Pharmacy Department, St. Paul's Hospital, Vancouver, British Columbia
| | - Doson Chua
- 1 Pharmacy Department, St. Paul's Hospital, Vancouver, British Columbia
| | - Tamara Mihic
- 1 Pharmacy Department, St. Paul's Hospital, Vancouver, British Columbia
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Sackey BK, Moore TA, Cupples NL, Gutierrez CA. Clozapine-induced myocarditis: Two case reports and review of clinical presentation and recognition. Ment Health Clin 2018; 8:303-308. [PMID: 30397572 PMCID: PMC6213891 DOI: 10.9740/mhc.2018.11.303] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Myocarditis is a potentially fatal cardiac disease marked by inflammation of the heart muscle. With a noted black-box warning, rates of clozapine-induced myocarditis are reportedly as high as 3%. Since the first case of clozapine-induced myocarditis was documented in 1994, more than 250 cases have been described in literature with an approximate 33% case-fatality rate. We report 2 cases of patients with primary psychotic disorders treated with clozapine, who developed signs and symptoms of myocarditis. The first was a 35-year-old white male patient with a primary diagnosis of schizoaffective disorder (bipolar type) who was initiated on clozapine after nonresponse to several therapies. On day 26, the patient was admitted to the emergency department for chest pain presenting with eosinophilia and notable elevations in several biomarkers, including troponin and C-reactive protein. The second patient was a 45-year-old black male who was initiated on clozapine for treatment-resistant schizophrenia. On day 13, the patient reported cardiac-related concerns (tachycardia) and flu-like symptoms resulting in hospitalization. Similarly, this patient demonstrated elevated biomarkers (troponin and creatine kinase). Both patients experienced resolution of symptoms after discontinuation of clozapine. Clozapine was not rechallenged for either patient. Review of literature further elucidates the relationship between clozapine and myocarditis, including potential risk factors, pathophysiology, and symptom presentation. Due to the potentially fatal nature of this condition, clinical vigilance and awareness is warranted upon initiation of clozapine through monitoring of symptoms along with cardiac and inflammatory biomarkers as indicated.
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Affiliation(s)
- Bryan K Sackey
- (Corresponding author) Mental Health Clinical Pharmacy Specialist, Pharmacy Department, South Texas Veterans Healthcare System, San Antonio, Texas; Adjoint Assistant Professor, Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas,
| | - Troy A Moore
- Mental Health Clinical Pharmacy Specialist, Pharmacy Department, South Texas Veterans Healthcare System, San Antonio, Texas; Director, American Society of Health-System Pharmacists-Accredited Postgraduate Year 2 Psychiatric Pharmacy Residency Program; Assistant Professor, Division of Community Recovery, Research and Training, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Nicole L Cupples
- Mental Health Clinical Pharmacy Specialist, Pharmacy Department, South Texas Veterans Healthcare System, San Antonio, Texas; Adjoint Assistant Professor, Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas
| | - Cynthia A Gutierrez
- Associate Chief, Clinical Pharmacy Programs and Mental Health Clinical Pharmacy Specialist, Pharmacy Department, South Texas Veterans Healthcare System, San Antonio, Texas; Assistant Clinical Professor, Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas
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Abstract
BACKGROUND Clozapine is widely prescribed for treatment-refractory schizophrenia, but its use is limited by many potentially life-threatening adverse effects. The risk of rechallenge after these complications has never been comprehensively assessed in controlled studies. Thus, clinical guidelines must rely on the published case reports. The number of such reports is likely to increase over time, and updated analyses of larger samples are needed, as they may lead to changes in clinical guidelines. STUDY QUESTIONS How safe is the clozapine rechallenge after life-threatening adverse effects? STUDY DESIGN The published case reports of clozapine rechallenge were identified in a MEDLINE search. We added 121 cases reported from 2012 through 2017 to the 138 cases reported from 1972 through 2011 analyzed by us in a previous publication. The 95% confidence intervals (CIs) of the successful rechallenge rate were calculated for each adverse effect with at least 5 published case reports. The rechallenge was considered a valid clinical option when the lower end of the CI range was at least 50%. RESULTS A successful outcome was documented in 128/203 patients rechallenged after neutropenia (63.0%, CI, 56.0%-69.6%), 3/17 after agranulocytosis (17.7%, CI, 4.7%-44.2%), 11/17 after myocarditis (64.7%, CI, 38.6%-84.7%), and 7/7 after neuroleptic malignant syndrome (100%, CI, 56.1%-100%). Among the 15 patients with other clozapine-induced adverse effects, the rechallenge was successful in those with eosinophilia, cardiac complications other than myocarditis (QTc prolongation, pericarditis, cardiomyopathy, and atrial flutter), and gastrointestinal hypomotility. The rechallenge failed in patients who had developed pancreatitis or renal insufficiency. CONCLUSION Clozapine rechallenge is a reasonable clinical option after return to baseline for patients who had developed neutropenia and neuroleptic malignant syndrome, but not after agranulocytosis or myocarditis. Data are insufficient to formulate rechallenge guidelines for any other clozapine-related adverse effects.
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18
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Knoph KN, Morgan RJ, Palmer BA, Schak KM, Owen AC, Leloux MR, Patel M, Leung JG. Clozapine-induced cardiomyopathy and myocarditis monitoring: A systematic review. Schizophr Res 2018; 199:17-30. [PMID: 29548760 DOI: 10.1016/j.schres.2018.03.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 02/27/2018] [Accepted: 03/04/2018] [Indexed: 02/02/2023]
Abstract
The use of clozapine requires monitoring the absolute neutrophil count because of the risk of agranulocytosis, but other potentially fatal adverse events associated with clozapine (specifically, myocarditis and cardiomyopathy) do not have mandatory procedures. We performed a systematic review of English-language articles to synthesize an evidence-based approach for myocarditis and cardiomyopathy monitoring. Articles published from January 1988 through February 2017 were identified through a search of Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Web of Science, Scopus, and Google Scholar. Selected articles were required to relate to myocarditis or cardiomyopathy in humans from exposure to clozapine. A total of 144 articles were included. Recommendations varied widely. Some authors recommended baseline laboratory monitoring, with or without follow-up testing, for C-reactive protein, creatine kinase MB, and troponin. Electrocardiography was commonly recommended, and echocardiography was less commonly recommended. The expense of monitoring was a consideration. A unanimous recommendation was to stop the use of clozapine and seek a cardiovascular consultation if myocarditis or cardiomyopathy is suspected. Although there is general agreement on which tests to perform for confirming myocarditis and cardiomyopathy, preemptive screening for these clozapine-induced conditions is controversial, and cost and barriers for the use of clozapine are concerns. For asymptomatic patients receiving clozapine, testing could include baseline electrocardiography, echocardiography as part of a cardiac consultation if patients have cardiac disease or risk factors, and monitoring of C-reactive protein and troponin as indicated.
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Affiliation(s)
- Kristen N Knoph
- Pharmacy Services, Mayo Clinic, Rochester, MN, United States
| | - Robert J Morgan
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Brian A Palmer
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Kathryn M Schak
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Amanda C Owen
- Pharmacy Services, Mayo Clinic, Rochester, MN, United States
| | - Megan R Leloux
- Pharmacy Services, Mayo Clinic, Rochester, MN, United States
| | - Mayur Patel
- Pharmacy Services, Mayo Clinic, Rochester, MN, United States
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Hollingworth SA, Winckel K, Saiepour N, Wheeler AJ, Myles N, Siskind D. Clozapine-related neutropenia, myocarditis and cardiomyopathy adverse event reports in Australia 1993-2014. Psychopharmacology (Berl) 2018; 235:1915-1921. [PMID: 29589067 DOI: 10.1007/s00213-018-4881-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 03/12/2018] [Indexed: 12/19/2022]
Abstract
RATIONALE Clozapine is the gold-standard medicine for treating refractory schizophrenia but there are some notable serious adverse events (AE). We aimed to analyse reported rates of clozapine cardiac and haematological AEs in Australia. METHODS Using data from the Therapeutic Goods Administration, we examined all reported clozapine AEs (1993-2014) with a specific focus on neutropenia, myocarditis and cardiomyopathy. We related AEs to clozapine-dispensing data in Queensland, scaled up to Australia. RESULTS There were 8561 AEs reported: neutropenia (13.7%), myocarditis (9.3%) and cardiomyopathy (3.8%). Reported rates of myocarditis and cardiomyopathy increased after 1999 following a myocarditis case series from Sydney. Cardiomyopathy AE rates have remained stable since then but myocarditis AEs have increased steadily. Neutropenia was more common in women, while cardiomyopathy and myocarditis were more common in men. There were five, 13, and two reported deaths from neutropenia, myocarditis, and cardiomyopathy, respectively. CONCLUSIONS The rates of serious AEs (including deaths) are low and likely an underestimate of true rates and need to be considered by clinicians in balancing the risks and benefits. Continued education on the monitoring and treatment of these AEs for consumers, carers and health professionals is essential and reporting these to the relevant national reporting agency is crucial.
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Affiliation(s)
- Samantha A Hollingworth
- School of Pharmacy, The University of Queensland, 20 Cornwall St, Woolloongabba, QLD, 4102, Australia.
| | - Karl Winckel
- School of Pharmacy, The University of Queensland, 20 Cornwall St, Woolloongabba, QLD, 4102, Australia.,Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD, 4102, Australia
| | - Nargess Saiepour
- School of Public Health, The University of Queensland, Herston Rd, Herston, QLD, 4006, Australia
| | - Amanda J Wheeler
- Menzies Health Institute Queensland, Meadowbrook, QLD, 4103, Australia.,Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, New Zealand
| | - Nicholas Myles
- SA Pathology, PO Box 14 Rundle Mall, Adelaide, SA, 5000, Australia
| | - Dan Siskind
- Metro South Addiction and Mental Health Service, 228 Logan Road, Woolloongabba, QLD, 4102, Australia.,School of Medicine, The University of Queensland, Herston Rd, Herston, QLD, 4006, Australia
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20
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Bellissima BL, Tingle MD, Cicović A, Alawami M, Kenedi C. A systematic review of clozapine-induced myocarditis. Int J Cardiol 2018; 259:122-129. [DOI: 10.1016/j.ijcard.2017.12.102] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 12/12/2017] [Accepted: 12/27/2017] [Indexed: 12/11/2022]
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21
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De Berardis D, Rapini G, Olivieri L, Di Nicola D, Tomasetti C, Valchera A, Fornaro M, Di Fabio F, Perna G, Di Nicola M, Serafini G, Carano A, Pompili M, Vellante F, Orsolini L, Martinotti G, Di Giannantonio M. Safety of antipsychotics for the treatment of schizophrenia: a focus on the adverse effects of clozapine. Ther Adv Drug Saf 2018; 9:237-256. [PMID: 29796248 PMCID: PMC5956953 DOI: 10.1177/2042098618756261] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/10/2018] [Indexed: 12/15/2022] Open
Abstract
Clozapine, a dibenzodiazepine developed in 1961, is a multireceptorial atypical antipsychotic approved for the treatment of resistant schizophrenia. Since its introduction, it has remained the drug of choice in treatment-resistant schizophrenia, despite a wide range of adverse effects, as it is a very effective drug in everyday clinical practice. However, clozapine is not considered as a top-of-the-line treatment because it may often be difficult for some patients to tolerate as some adverse effects can be particularly bothersome (i.e. sedation, weight gain, sialorrhea etc.) and it has some other potentially dangerous and life-threatening side effects (i.e. myocarditis, seizures, agranulocytosis or granulocytopenia, gastrointestinal hypomotility etc.). As poor treatment adherence in patients with resistant schizophrenia may increase the risk of a psychotic relapse, which may further lead to impaired social and cognitive functioning, psychiatric hospitalizations and increased treatment costs, clozapine adverse effects are a common reason for discontinuing this medication. Therefore, every effort should be made to monitor and minimize these adverse effects in order to improve their early detection and management. The aim of this paper is to briefly summarize and provide an update on major clozapine adverse effects, especially focusing on those that are severe and potentially life threatening, even if most of the latter are relatively uncommon.
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Affiliation(s)
- Domenico De Berardis
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, p.zza Italia 1, 64100 Teramo, Italy
| | - Gabriella Rapini
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, Teramo, Italy
| | - Luigi Olivieri
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, Teramo, Italy
| | - Domenico Di Nicola
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, Teramo, Italy
| | - Carmine Tomasetti
- Polyedra Research Group, Teramo, Italy Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine ‘Federico II’ Naples, Naples, Italy
| | - Alessandro Valchera
- Polyedra Research Group, Teramo, Italy Villa S. Giuseppe Hospital, Hermanas Hospitalarias, Ascoli Piceno, Italy
| | - Michele Fornaro
- Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine ‘Federico II’ Naples, Naples, Italy
| | - Fabio Di Fabio
- Polyedra Research Group, Teramo, Italy Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Giampaolo Perna
- Hermanas Hospitalarias, FoRiPsi, Department of Clinical Neurosciences, Villa San Benedetto Menni, Albese con Cassano, Como, Italy Department of Psychiatry and Neuropsychology, University of Maastricht, Maastricht, The Netherlands Department of Psychiatry and Behavioral Sciences, Leonard Miller School of Medicine, University of Miami, Florida, USA
| | - Marco Di Nicola
- Institute of Psychiatry and Psychology, Catholic University of Sacred Heart, Rome, Italy
| | - Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy
| | - Alessandro Carano
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, Hospital ‘Madonna Del Soccorso’, San Benedetto del Tronto, Italy
| | - Maurizio Pompili
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Federica Vellante
- Department of Neuroscience, Imaging and Clinical Science, Chair of Psychiatry, University ‘G. D’Annunzio’, Chieti, Italy
| | - Laura Orsolini
- Polyedra Research Group, Teramo, Italy Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Herts, UK
| | - Giovanni Martinotti
- Department of Neuroscience, Imaging and Clinical Science, Chair of Psychiatry, University ‘G. D’Annunzio’, Chieti, Italy
| | - Massimo Di Giannantonio
- Department of Neuroscience, Imaging and Clinical Science, Chair of Psychiatry, University ‘G. D’Annunzio’, Chieti, Italy
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Abstract
Myocarditis occurs in about 3% of those initiated on clozapine but monitoring reduces the risk of serious outcome. Cardiomyopathy may develop after myocarditis, or from prolonged tachycardia. Monitoring using echocardiography is not deemed cost effective. Tachycardia, orthostatic hypotension and reduced heart rate variability are a group of clozapine-related adverse effects associated with autonomic dysfunction and may have serious consequences in the long term. Elevated heart rate and poor heart rate variability can be treated with a β-blocker or a non-dihydropyridine calcium channel blocker, while orthostatic hypotension can be alleviated by increased fluid intake and abdominal binding, but may require pharmacological intervention. Adequate correction for heart rate may show that clozapine does not prolong the QT interval. Other cardiovascular effects, pulmonary embolism, metabolic syndrome, sudden cardiac death and particularly the excessive mortality from cardiovascular disease events may be more strongly associated with the combination of mental illness, lifestyle factors and poor treatment of cardiovascular disease and its risk factors than with clozapine treatment. In view of the efficacy of clozapine and the evidence of reduced mortality relative to other antipsychotics, clozapine should be prescribed when indicated and recipients should be enrolled in lifestyle programmes to increase exercise and improve diet, and referred for diagnosis and treatment of cardiovascular disease and its risk factors.
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23
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Katta N, Balla S, Aggarwal K. Clozapine-induced hypersensitivity myocarditis presenting as sudden cardiac death. AUTOPSY AND CASE REPORTS 2017; 6:9-13. [PMID: 28210568 PMCID: PMC5304556 DOI: 10.4322/acr.2016.054] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 11/22/2016] [Indexed: 01/21/2023] Open
Abstract
Hypersensitivity myocarditis is a rare but serious adverse effect of clozapine, a commonly used psychiatric drug. We report the case of sudden cardiac death from clozapine-induced hypersensitivity myocarditis diagnosed at autopsy. A 54-year-old Caucasian male on clozapine therapy for bipolar disorder presented with a sudden onset of shortness of breath. Laboratory studies were significant for elevated N-terminal prohormone of brain natriuretic peptide. During his hospital stay, the patient died of sudden cardiac arrest from ventricular tachycardia. The autopsy revealed hypersensitivity myocarditis, which usually occurs in the first 4 weeks after the initiation of clozapine. A 4-week monitoring protocol, including laboratory assessment of troponin and C-reactive protein, may assist in the early diagnosis of this potentially fatal condition.
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Affiliation(s)
- Natraj Katta
- Division of Cardiovascular Medicine - Department of Medicine - University of Missouri School of Medicine, Columbia/MO, USA
| | - Sudarshan Balla
- Division of Cardiovascular Medicine - Department of Medicine - University of Missouri School of Medicine, Columbia/MO, USA
| | - Kul Aggarwal
- Division of Cardiovascular Medicine - Department of Medicine - University of Missouri School of Medicine, Columbia/MO, USA
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24
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Abstract
Clozapine is exceptionally effective in psychotic disorders and can reduce suicidal risk. Nevertheless, its use is limited due to potentially life-threatening adverse effects, including myocarditis and cardiomyopathy. Given their clinical importance, we systematically reviewed research on adverse cardiac effects of clozapine, aiming to improve estimates of their incidence, summarize features supporting their diagnosis, and evaluate proposed monitoring procedures. Incidence of early (≤2 months) myocarditis ranges from <0.1 to 1.0 % and later (3-12 months) cardiomyopathy about 10 times less. Diagnosis rests on relatively nonspecific symptoms, ECG changes, elevated indices of myocardial damage, cardiac MRI findings, and importantly, echocardiographic evidence of developing ventricular failure. Treatment involves stopping clozapine and empirical applications of steroids, diuretics, beta-blockers, and antiangiotensin agents. Mortality averages approximately 25 %. Safety of clozapine reuse remains uncertain. Systematic studies are needed to improve knowledge of the epidemiology, avoidance, early identification, and treatment of these adverse effects, with effective and practicable monitoring protocols.
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25
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Fehily SR, Forlano R, Fitzgerald PB. C-reactive protein: an early critical sign of clozapine-related myocarditis. Australas Psychiatry 2016; 24:181-4. [PMID: 26400456 DOI: 10.1177/1039856215604482] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We present a case of clozapine-related myocarditis, with a rising C-reactive protein as the only initial evidence supporting the diagnosis. METHOD An otherwise healthy young male presenting with treatment-resistant schizophrenia was started on clozapine. Monitoring was performed. RESULTS At day 18 he developed fever, tachycardia and a raised C-reactive protein, while troponin levels and echocardiogram remained normal. CONCLUSIONS Current protocols monitoring for myocarditis have their limitations and can often only be used to support a presumptive diagnosis of myocarditis. In keeping with the current clozapine monitoring guidelines, we demonstrate that a rise in C-reactive protein levels can be a critical early sign of myocarditis warranting close monitoring and serious consideration for cessation of clozapine.
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Affiliation(s)
- Sasha R Fehily
- Resident Medical Officer, Department of Psychiatry, Alfred Health, Melbourne, VIC, Australia
| | - Rosaria Forlano
- Consultant Psychiatrist, Department of Psychiatry, Alfred Health, Melbourne, VIC, Australia
| | - Paul B Fitzgerald
- Consultant Psychiatrist, Professor of Psychiatry and Deputy Director, Department of Psychiatry, Alfred Health, Melbourne, VIC, and; Monash Alfred Psychiatry Research Centre, The Alfred and Monash University Central Clinical School, Melbourne, VIC, Australia
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26
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Youssef DL, Narayanan P, Gill N. Incidence and risk factors for clozapine-induced myocarditis and cardiomyopathy at a regional mental health service in Australia. Australas Psychiatry 2016; 24:176-80. [PMID: 26400457 DOI: 10.1177/1039856215604480] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the incidence of clozapine-induced myocarditis and cardiomyopathy and identify risk factors. METHOD A cohort of 129 patients initiated on clozapine at Toowoomba Mental Health Service from year 2000 until 2011 was examined to evaluate cases of myocarditis and cardiomyopathy. Risk factors were analysed using multivariable logistic regression. RESULTS The incidence of clozapine-induced myocarditis and cardiomyopathy was 3.88% and 4.65% (or 2.26 per 100 patient years), respectively. A significant association was identified between clozapine-induced myocarditis and SSRI use (p = 0.043). Subclinical cardiomyopathy was identified in the absence of symptoms in the majority of cases. CONCLUSIONS These results illustrate a high incidence of clozapine-induced myocarditis as well as cardiomyopathy, reinforcing the need for a standardised, mandatory monitoring scheme. Concomitant SSRI use as one such potential predictor merits further study.
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Affiliation(s)
- Daniel L Youssef
- Honours Researcher, Rural Clinical School, University of Queensland, Toowoomba, QLD, Australia; RMO, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Pradeep Narayanan
- Consultant Cardiologist, Toowoomba Hospital, Toowoomba, QLD, Australia
| | - Neeraj Gill
- Associate Professor of Rural Psychiatry, Rural Clinical School, University of Queensland, Toowoomba, QLD, and; Medical Director, Adult and Older Persons Mental Health, Gold Coast Health, Gold Coast, QLD, Australia
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27
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Left Ventricular Thrombus as a Complication of Clozapine-Induced Cardiomyopathy: A Case Report and Brief Literature Review. Case Rep Cardiol 2015; 2015:835952. [PMID: 26664756 PMCID: PMC4667025 DOI: 10.1155/2015/835952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 11/07/2015] [Indexed: 11/17/2022] Open
Abstract
A 48-year-old male with history of schizoaffective disorder on clozapine presented with chest pain, dyspnea, and new left bundle branch block. He underwent coronary angiography, which revealed no atherosclerosis. The patient's workup was unrevealing for a cause for the cardiomyopathy and thus it was thought that clozapine was the offending agent. The patient was taken off clozapine and started on guideline directed heart failure therapy. During the course of hospitalization, he was also discovered to have a left ventricular (LV) thrombus for which he received anticoagulation. To our knowledge, this is the first case report of clozapine-induced cardiomyopathy complicated by a LV thrombus.
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28
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Clozapine-Induced Myocarditis: Prevention and Considerations in Rechallenge. PSYCHOSOMATICS 2015; 56:685-90. [DOI: 10.1016/j.psym.2015.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 06/26/2015] [Accepted: 07/06/2015] [Indexed: 11/17/2022]
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29
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Ronaldson KJ, Fitzgerald PB, McNeil JJ. Clozapine-induced myocarditis, a widely overlooked adverse reaction. Acta Psychiatr Scand 2015; 132:231-40. [PMID: 25865238 DOI: 10.1111/acps.12416] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2015] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We review the published cases of clozapine-induced myocarditis and describe reasons for the higher incidence in Australia (>1%) than elsewhere (<0.1%). METHOD Medline was searched to September 2014 using 'clozapine' as the sole term. RESULTS A total of around 250 cases of clozapine-induced myocarditis have been published. Fever among patients commencing clozapine has been reported internationally, and very few of these cases were investigated for myocarditis. The time to onset of fever is consistent with its being part of a prodrome of undiagnosed myocarditis, and the risk factors are similar to those for myocarditis. In more severe cases, clozapine is discontinued, avoiding fatalities which may occur with myocarditis. Furthermore, cases of sudden death and respiratory illness may well have been undiagnosed myocarditis. The diagnosis of myocarditis is confounded by the non-specific nature of the signs and symptoms, and it depends on appropriate investigations being conducted at the time of myocardial involvement or, for fatal cases, the affected area of the myocardium being sampled for histology. CONCLUSION It is likely that the incidence of myocarditis is around 3%. Implementation of monitoring procedures will increase case ascertainment and result in more patients benefiting from this valuable medication.
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Affiliation(s)
- K J Ronaldson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - P B Fitzgerald
- Monash Alfred Psychiatry Research Centre, Monash University Central Clinical School and The Alfred Hospital, Melbourne, VIC, Australia
| | - J J McNeil
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Happell B, Galletly C, Castle D, Platania-Phung C, Stanton R, Scott D, McKenna B, Millar F, Liu D, Browne M, Furness T. Scoping review of research in Australia on the co-occurrence of physical and serious mental illness and integrated care. Int J Ment Health Nurs 2015. [PMID: 26220151 DOI: 10.1111/inm.12142] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The physical health of people with serious mental illness (SMI) has become a focal area of research. The aim of the present study was to ascertain the attention and distribution of research from within Australia on physical illness and SMI co-occurrence, and to identify gaps. A scoping review of peer-reviewed research literature from Australia, published between January 2000 and March 2014, was undertaken through an electronic literature search and coding of papers to chart trends. Four trends are highlighted: (i) an almost threefold increase in publications per year from 2000-2006 to 2007-2013; (ii) a steady release of literature reviews, especially from 2010; (iii) health-related behaviours, smoking, integrated-care programmes, and antipsychotic side-effects as the most common topics presented; and (iv) paucity of randomized, controlled trials on integrated-care models. Despite a marked increase in research attention to poorer physical health, there remains a large gap between research and the scale of the problem previously identified. More papers were descriptive or reviews, rather than evaluations of interventions. To foster more research, 12 research gaps are outlined. Addressing these gaps will facilitate the reduction of inequalities in physical health for people with SMI. Mental health nurses are well placed to lead multidisciplinary, consumer-informed research in this area.
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Affiliation(s)
- Brenda Happell
- Synergy, Nursing and Midwifery Research Centre, University of Canberra and ACT Health, Canberra Hospital, ACT, Canberra, Australia
| | - Cherrie Galletly
- The Adelaide Clinic, Adelaide, South Australia, Australia.,School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - David Castle
- St Vincent's Hospital, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Chris Platania-Phung
- Synergy, Nursing and Midwifery Research Centre, University of Canberra and ACT Health, Canberra Hospital, ACT, Canberra, Australia
| | - Robert Stanton
- Central Queensland University, Central Queensland University, School of Human Health and Social Sciences, Bundaberg, Queensland, Australia
| | - David Scott
- Central Queensland University, School of Medical and Applied Sciences, Melbourne, Victoria, Australia
| | - Brian McKenna
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Melbourne, Victoria, Australia.,NorthWestern Mental Health, Melbourne, Victoria, Australia
| | | | - Dennis Liu
- Northern Mental Health Service, Salisbury, South Australia, Australia
| | - Matthew Browne
- Central Queensland University, Central Queensland University, School of Human Health and Social Sciences, Bundaberg, Queensland, Australia
| | - Trentham Furness
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Melbourne, Victoria, Australia.,NorthWestern Mental Health, Melbourne, Victoria, Australia
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Abstract
This preliminary prospective study evaluated cardiac status in 15 treatment-resistant schizophrenia patients (aged 18-55 years) without evidence of cardiovascular disease. Patients underwent clinical assessment, blood tests, ECG, and echocardiography before and during clozapine treatment for 4 weeks as doses increased from 25 to 100 mg/day. Serum concentrations of high-sensitivity C-reactive protein, troponin-I, brain natriuretic peptide, and clozapine+norclozapine were assayed at week 3; ECG and echocardiography were repeated at week 4. At moderate serum drug concentrations (124 ng/ml), the heart rate increased by 10% and high-sensitivity C-reactive protein levels were slightly elevated, but troponin-I and brain natriuretic peptide levels were not elevated. Echocardiographic indices indicated declining left ventricular (LV) diastolic and systolic function in 60-80% of participants, with an increase in systolic pulmonary artery pressure, A-wave velocity, and LV myocardial performance index by 16-24% in 60-80% of participants and a decrease in the E/A ratio by 29% in 73% of participants - all uncorrelated with drug concentrations. Early treatment with moderate doses of clozapine was associated with subclinical but substantial decreases in LV functioning in surprisingly high proportions of participants. Studies with more participants, higher drug doses, and long-term follow-up are needed to confirm and determine the course of the observed abnormalities and to evaluate their relationship with rare clinical cardiotoxicity associated with clozapine.
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Emul M, Kalelioglu T. Etiology of cardiovascular disease in patients with schizophrenia: current perspectives. Neuropsychiatr Dis Treat 2015; 11:2493-503. [PMID: 26491327 PMCID: PMC4599145 DOI: 10.2147/ndt.s50006] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular morbidity and mortality are important problems among patients with schizophrenia. A wide spectrum of reasons, ranging from genes to the environment, are held responsible for causing the cardiovascular risk factors that may lead to shortening the life expectancy of patients with schizophrenia. Here, we have summarized the etiologic issues related with the cardiovascular risk factors in schizophrenia. First, we focused on heritable factors associated with cardiovascular disease and schizophrenia by mentioning studies about genetics-epigenetics, in the first-episode or drug-naïve patients. In this context, the association and candidate gene studies about metabolic disturbances in schizophrenia are reviewed, and the lack of the effects of epigenetic/posttranscriptional factors such as microRNAs is mentioned. Increased rates of type 2 diabetes mellitus and disrupted metabolic parameters in schizophrenia are forcing clinicians to struggle with metabolic syndrome parameters and related issues, which are also the underlying causes for the risk of having cardiometabolic and cardiovascular etiology. Second, we summarized the findings of metabolic syndrome-related entities and discussed the influence of the illness itself, antipsychotic drug treatment, and the possible disadvantageous lifestyle on the occurrence of metabolic syndrome (MetS) or diabetes mellitus. Third, we emphasized on the risk factors of sudden cardiac death in patients with schizophrenia. We reviewed the findings on the arrhythmias such as QT prolongation, which is a risk factor for Torsade de Pointes and sudden cardiac death or P-wave prolongation that is a risk factor for atrial fibrillation. For example, the use of antipsychotics is an important reason for the prolongation of QT and some other cardiac autonomic dysfunctions. Additionally, we discussed relatively rare issues such as myocarditis and cardiomyopathy, which are important for prognosis in schizophrenia that may have originated from the use of antipsychotic medication. In conclusion, we considered that the studies and awareness about physical needs of patients with schizophrenia are increasing. It seems logical to increase cooperation and shared care between the different health care professionals to screen and treat cardiovascular disease (CVD)-risk factors, MetS, and diabetes in patients with psychiatric disorders, because some risk factors of MetS or CVD are avoidable or at least modifiable to decrease high mortality in schizophrenia. We suggested that future research should focus on conducting an integrated system of studies based on a holistic biopsychosocial evaluation.
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Affiliation(s)
- Murat Emul
- Department of Psychiatry, Medical School of Cerrahpasa, Istanbul University, Istanbul, Turkey
| | - Tevfik Kalelioglu
- Department of Psychiatry, Bakırkoy Mental Health Research and Training Hospital, Istanbul, Turkey
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Clozapine-related pericarditis during titration phase in a patient with resistant schizophrenia and concomitant valproate treatment: a case report. J Clin Psychopharmacol 2014; 34:649-51. [PMID: 25006818 DOI: 10.1097/jcp.0000000000000179] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Alawami M, Wasywich C, Cicovic A, Kenedi C. A systematic review of clozapine induced cardiomyopathy. Int J Cardiol 2014; 176:315-20. [PMID: 25131906 DOI: 10.1016/j.ijcard.2014.07.103] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 06/15/2014] [Accepted: 07/26/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clozapine is a unique anti-psychotic medication that is most effective in the treatment of refractory schizophrenia and reducing suicidality. Cardiomyopathy is among the side effects of this medication that limits its use. There are a number of case reports, case series and expert opinion papers discussing clozapine induced cardiomyopathy, but there is no evidence-based review of the subject to guide clinicians. METHODS We undertook a systematic review of the literature on cardiomyopathy associated with clozapine. The primary systemic search was in MEDLINE but EMBASE, PsycINFO, and Cochrane were searched and manufacturers of clozapine were contacted for cases. Articles were then individually reviewed to find additional reports. RESULTS We identified 17 articles detailing 26 individual cases and 11 additional articles without individual case data. The mean age at time of diagnosis was 33.5 years. The mean dose of clozapine on presentation was 360 mg. Symptoms developed at an average of 14.4 months after initiating clozapine. The clinical presentation was generally consistent with heart failure: including shortness of breath (60%) and palpitations (36%). Echocardiography at presentation showed dilated cardiomyopathy in 39% of cases and was not specified in other cases. CONCLUSION There should be a low threshold in performing echocardiography in suspected cases of clozapine induced cardiomyopathy. Clozapine should be withheld in the setting of cardiomyopathy without other explanation. There is limited data on the safety of drug re-challenge in clozapine induced cardiomyopathy. Re-challenge may be considered in carefully selected cases but close monitoring and frequent echocardiography are required.
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Affiliation(s)
- Mohammed Alawami
- Department of Cardiology, Auckland District Health Board, Auckland, New Zealand.
| | - Cara Wasywich
- Department of Cardiology, Auckland District Health Board, Auckland, New Zealand
| | - Aleksandar Cicovic
- Department of Cardiology, Auckland District Health Board, Auckland, New Zealand
| | - Christopher Kenedi
- Department of Liaison Psychiatry, Auckland District Health Board, Auckland, New Zealand
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Serrano A, Rangel N, Carrizo E, Uzcátegui E, Sandia I, Zabala A, Fernández E, Tálamo E, Servigna M, Prieto D, Connell L, Baptista T. Safety of long-term clozapine administration. Frequency of cardiomyopathy and hyponatraemia: two cross-sectional, naturalistic studies. Aust N Z J Psychiatry 2014; 48:183-92. [PMID: 23985160 DOI: 10.1177/0004867413502089] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The antipsychotic drug (APD) clozapine (CLZ) is under-prescribed because of concerns about its safety. We evaluated in separate protocols the frequency of cardiomyopathy and hyponatraemia, which are adverse drug effects, where few comparative studies are available. METHODS Cross-sectional studies in subjects treated for at least 3 consecutive months with the same drug were conducted. Cardiomyopathy: Patients undergoing treatment either with CLZ (n = 125) or with other typical or atypical APDs (n = 59) were examined by a cardiologist who also recorded echocardiograms and electrocardiograms in order to diagnose cardiomyopathy. Hyponatraemia: Fasting sodium levels were assessed in patients receiving any of the following treatments: CLZ (n = 88), other atypical APDs (n = 61), typical APDs (n = 23), typical + atypical APDs (n = 11), and other drugs/drug-free (n = 36). RESULTS Cardiomyopathy: No case of cardiomyopathy was detected. The frequency of abnormal ventricular ejection fraction (< 55%) was similar in both treatment groups (p = 1). Hyponatraemia: The frequency of hyponatraemia (percentage; 95% CI) was: CLZ (3.4%; -0.7, 7.1); other atypical APDs (4.9%; -0.5, 10.3); typical APDs (26.1%; 8.2, 44.0); typical + atypical APDs (9.1%; -7.8, 26.0); other drugs/drug-free (0%). None of the CLZ hyponatraemia subjects were on monotherapy. CONCLUSIONS Our results are at odds with previous studies of CLZ-associated cardiomyopathy. However, they must be compared to further cross-sectional or prospective studies because most published data come from either case reports or pharmacovigilance systems. The frequency of hyponatraemia during CLZ administration was similar to that observed with other atypical APDs, and it was significantly lower than that recorded with typical agents. These results, along with numerous case reports on the effects of CLZ in patients with polydipsia and water intoxication, point to a safe or even positive profile of CLZ on electrolytic regulation.
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Affiliation(s)
- Ana Serrano
- 1Department of Psychiatry, Los Andes University Medical School, Mérida, Venezuela
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Clozapine-induced myocarditis: is mandatory monitoring warranted for its early recognition? Case Rep Psychiatry 2014; 2014:513108. [PMID: 24587933 PMCID: PMC3920926 DOI: 10.1155/2014/513108] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 12/11/2013] [Indexed: 11/18/2022] Open
Abstract
Clozapine is an atypical antipsychotic used for treatment resistant schizophrenia.
Its potential to induce agranulocytosis is well known but it can also cause myocarditis. Clozapine is the only antipsychotic known to induce this side effect, typically early in the treatment, and literature is scarce on this condition. We are presenting a case report of a 21-year-old schizophrenic male who developed myocarditis within 3 weeks of starting on clozapine for his treatment resistant psychosis. We then aim to review some of the available literature and raise awareness among physicians as this condition can potentially be fatal if not detected early.
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Ittasakul P, Archer A, Kezman J, Atsariyasing W, Goldman MB. Rapid Re-challenge with Clozapine Following Pronounced Myocarditis in a Treatment-Resistance Schizophrenia Patient. CLINICAL SCHIZOPHRENIA & RELATED PSYCHOSES 2013:1-11. [PMID: 24047759 DOI: 10.3371/csrp.itar.091313] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Clozapine is an atypical antipsychotic which is often effective in patients who fail to respond to other antipsychotics, but its use carries substantial risk. Myocarditis is one of the life-threatening adverse effects which occurs in about 1% of exposed patients. Re-challenge with clozapine is controversial, particularly shortly after the occurrence of the myocarditis and when there is clear and convincing evidence of cardiac damage. Aggressive use of clozapine, however, may be critical for the recovery of patients early in the course of their illness. Here we report a successful case of clozapine rechallenge following an initial aggressive dosage titration in an inpatient setting.
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Affiliation(s)
- Pichai Ittasakul
- Department of Psychiatry, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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38
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Ferri N, Siegl P, Corsini A, Herrmann J, Lerman A, Benghozi R. Drug attrition during pre-clinical and clinical development: understanding and managing drug-induced cardiotoxicity. Pharmacol Ther 2013; 138:470-84. [PMID: 23507039 DOI: 10.1016/j.pharmthera.2013.03.005] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 02/19/2013] [Indexed: 02/08/2023]
Abstract
Cardiovascular toxicity remains a major cause of concern during preclinical and clinical development as well as contributing to post-approval withdrawal of medicines. This issue is particularly relevant for anticancer drugs where, the significant improvement in the life expectancies of patients has dramatically extended the use and duration of drug therapies. Nevertheless, cardiotoxicity is also observed with other classes of drugs, including antibiotics, antidepressants, and antipsychotics. This article summarizes the clinical manifestations of drug-induced cardiotoxicity by various cancer chemotherapies and novel drugs for the treatment of other diseases. Furthermore, it presents on overview of biomarker and imaging techniques for the detection of drug-induced cardiotoxicity. Guidelines for the management of patients exposed to drugs with cardiotoxic potential are presented as well as a checklist for collecting information when a safety signal is observed in clinical trials to more effectively assess the risk of cardiotoxicity and manage patient safety.
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Affiliation(s)
- Nicola Ferri
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy.
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Ronaldson KJ, Fitzgerald PB, Taylor AJ, Topliss DJ, Wolfe R, McNeil JJ. Rapid clozapine dose titration and concomitant sodium valproate increase the risk of myocarditis with clozapine: a case-control study. Schizophr Res 2012; 141:173-8. [PMID: 23010488 DOI: 10.1016/j.schres.2012.08.018] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 07/20/2012] [Accepted: 08/27/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite the implementation of cardiac monitoring guidelines, clozapine-induced myocarditis continues to cause deaths in Australia, and the risk is a barrier to prescription of this effective drug for the treatment of schizophrenia. This study was designed to identify clinical and phenotypic risk factors for clozapine-induced myocarditis. METHOD Possible cases of clozapine related myocarditis occurring between June 1993 and November 2009 and a comparative group of controls taking clozapine for at least 45days without cardiac disease were documented from the patients' medical records. RESULTS 105 cases, with time to onset of 10-33days, and 296 controls were included in the study. In multivariate analysis, the risk of myocarditis increased by 26% for each additional 250mg of clozapine administered in the first nine days of clozapine titration (odds ratio 1.26; 95% confidence interval 1.02-1.55; p=0.03) and concomitant sodium valproate more than doubled the risk (2.59; 1.51-4.42; 0.001). Further, each successive decade in age was associated with a 31% increase in risk (1.31; 1.07-1.60; 0.009). Nevertheless, 33 cases received less than 920mg of clozapine during the first nine days of dose titration, did not take sodium valproate and were aged less than 40years; and nine control patients received sodium valproate and more than 920mg of clozapine in the first nine days without developing myocarditis. CONCLUSIONS Clozapine should be initiated by slow dose titration and sodium valproate is best avoided, if clinically feasible, during this period. All patients commencing clozapine should be monitored for myocarditis up to Day 28.
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Affiliation(s)
- Kathlyn J Ronaldson
- Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia.
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40
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Cardiovascular side-effects of antipsychotic drugs: The role of the autonomic nervous system. Pharmacol Ther 2012; 135:113-22. [DOI: 10.1016/j.pharmthera.2012.04.003] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 04/08/2012] [Indexed: 01/27/2023]
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Power B, Williams H, Shymko G. The difficulties of diagnosing clozapine myocarditis: damned if you do, damned if you don't. Australas Psychiatry 2012; 20:165-6. [PMID: 22529146 DOI: 10.1177/1039856211432482] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Manu P, Sarpal D, Muir O, Kane JM, Correll CU. When can patients with potentially life-threatening adverse effects be rechallenged with clozapine? A systematic review of the published literature. Schizophr Res 2012; 134:180-6. [PMID: 22113154 PMCID: PMC3318984 DOI: 10.1016/j.schres.2011.10.014] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Revised: 10/20/2011] [Accepted: 10/24/2011] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clozapine is widely prescribed for treatment refractory patients with schizophrenia, but its use is limited by potentially life threatening adverse effects. Rechallenge after these complications has been occasionally attempted in patients with severe psychotic symptoms. OBJECTIVE To review the outcome of clozapine rechallenge after potentially life threatening adverse effects. METHODS Electronic, all-language, literature search (1972-2011) followed by demographic and clinical data extraction. The outcome of rechallenge was considered favorable when the lower bound of the 95% confidence interval (CI) of the proportion of patients who could continue clozapine was >50%. RESULTS Altogether, 138 patients (mean age: 36.3years, 65.7% male, 57.6% Caucasian, virtually all with schizophrenia spectrum diagnosis) underwent clozapine rechallenge after developing neutropenia (n=112), agranulocytosis (n=15), neuroleptic malignant syndrome (NMS) (n=5), myocarditis (n=4), pericarditis (n=1) and lupus erythematosus (n=1). Rechallenge strategies were heterogeneous and not systematically evaluated. Clozapine rechallenge was successful in 78/112 patients (69.6%, CI: 60.6-77.4) after neutropenia, 3/15 (20%, CI: 7.1-45.2) after agranulocytosis, 5/5 (100%, CI: 56-100) after NMS, 3/4 (75%, CI: 30-95) after myocarditis, 1/1 after pericarditis, and 0/1 after clozapine-induced lupus. Successfully rechallenged patients were followed for 16-96weeks. None of the rechallenged patients died. CONCLUSIONS Although controlled studies are clearly needed, using a priori, confidence interval-based criteria, case reports/series suggest that in refractory patients who benefited from clozapine, careful rechallenge can be considered after neutropenia and NMS, but not after agranulocytosis and myocarditis.
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Affiliation(s)
- Peter Manu
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York,Hofstra North Shore – Long Island Jewish School of Medicine at Hofstra University, Hempstead, New York,Albert Einstein College of Medicine, Bronx, New York
| | - Deepak Sarpal
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York
| | - Owen Muir
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York
| | - John M. Kane
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York,Hofstra North Shore – Long Island Jewish School of Medicine at Hofstra University, Hempstead, New York,Albert Einstein College of Medicine, Bronx, New York
| | - Christoph U. Correll
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York,Hofstra North Shore – Long Island Jewish School of Medicine at Hofstra University, Hempstead, New York,Albert Einstein College of Medicine, Bronx, New York
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Usefulness of NT-pro-BNP and echocardiography in the diagnosis of subclinical clozapine-related cardiotoxicity. J Clin Psychopharmacol 2011; 31:712-6. [PMID: 22020348 DOI: 10.1097/jcp.0b013e318234ee66] [Citation(s) in RCA: 13] [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 Available information regarding clozapine-related cardiomyopathy is limited to reports of severe left ventricular dysfunction not rarely with fatal clinical evolution. A subclinical cardiotoxic effect might be diagnosed using echocardiography and N-terminal pro-B-type natriuretic peptide assay. METHODS Thirty-eight patients with psychotic disorder in chronic therapy with clozapine (24 male and 14 female subjects; mean age, 38.4 years) were enrolled. Left ventricular ejection fraction (LVEF) was measured by area-length method (average of 5 measurements). RESULTS Twelve patients showed a mild depression of left ventricular function (LVEF between 50% and 55%), 2 LVEF less than 50% and 1 less than 30%. The area under the receiver operating characteristic curve for N-terminal pro-B-type natriuretic peptide as a predictor of left ventricular dysfunction was 0.87. CONCLUSIONS A subclinical left ventricular dysfunction was found in 3 of 38 patients, whereas a mild impairment of the left ventricular systolic function occurred in 1 of 3 of young, previously healthy, clozapine-treated patients A prospective study in clozapine-naive patients may be useful to better understand cardiotoxic effects of clozapine.
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Affiliation(s)
- Amanda Bray
- Cumberland Psychiatric Hospital, University of Sydney, New South Wales, Australia
| | - Robert Reid
- Cumberland Psychiatric Hospital, University of Sydney, New South Wales, Australia
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Abstract
PURPOSE OF REVIEW Schizophrenia is associated with increased mortality and reduced life expectancy, with cardiovascular disease being the most frequent cause of death. Antipsychotics have detrimental effects on different risk factors for cardiovascular disease. This review will focus on the relationship between antipsychotic treatment and cardiovascular disease. RECENT FINDINGS The increased overall mortality and mortality from cardiovascular disease in schizophrenia are now well documented. Patients with schizophrenia are at risk of receiving less optimal treatment for cardiovascular disease. Patients with schizophrenia are at high risk of metabolic syndrome, a cluster of risk factors for cardiovascular disease. Some antipsychotics, in particular, clozapine and olanzapine, frequently cause weight gain, dyslipidemia and diabetes mellitus. Antipsychotics differ in their effects on body weight, lipids and glucose regulation. However, the long-term effects of these differences between individual antipsychotics on overall mortality and cardiovascular mortality are not well established. SUMMARY More research is needed to better understand the relationship between schizophrenia, antipsychotic treatment and cardiovascular disease. More effective treatment strategies need to be developed to reduce the burden of cardiovascular disease in schizophrenia.
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Layland JJ, Liew D, Prior DL. Clozapine-induced cardiotoxicity: a clinical update. Med J Aust 2009; 190:190-2. [PMID: 19220183 DOI: 10.5694/j.1326-5377.2009.tb02345.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Accepted: 09/02/2008] [Indexed: 11/17/2022]
Abstract
Clozapine is a valuable drug for patients with treatment-resistant schizophrenia. Myocarditis is the most publicised cardiac complication of clozapine treatment, but cardiomyopathy and pericarditis have also been reported. Myocarditis has heterogeneous and non-specific presenting features, making it difficult to identify patients with clozapine-related myocarditis clinically. A high index of suspicion is required. The gold standard for diagnosis of myocarditis is an endomyocardial biopsy, but this is not a practical initial approach. Transthoracic echocardiography is a valuable, reproducible and widely available tool to assist in diagnosis of clozapine-induced cardiotoxicity. The level of B-type natriuretic peptide, a hormone secreted in response to ventricular wall stress, may be useful for evaluating patients with clozapine-induced cardiac dysfunction and may in the future be useful for screening asymptomatic patients. The mainstay of treatment of clozapine-induced cardiotoxicity is cessation of clozapine and provision of supportive care.
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